Follow-up Q&A with Leigh Anne Hylton Gravatt, Pharm.D., BCPS

Leigh Anne Hylton Gravatt, Pharm.D., BCPS (Pharm.D.’03/P), associate professor and vice chair of education in the Department of Pharmacotherapy and Outcomes Science in the VCU School of Pharmacy, joined us on Facebook Live March 24 to answer questions from alumni about COVID-19, infectious disease and social distancing. Here are answers to all of the questions she wasn’t able to get to during the live broadcast.

From Lisa Nuckols Davis (B.S.’91/HP):

Working in health care, specifically home health, I would like to know what is my best way to protect myself? I am looking to find out which mask is fully protecting me. I am told I can wear a regular surgical mask with all of my patients although I do not know if they have been exposed, if they are a carrier, etc.

Answer:

Ultimately, the only mask that has been shown to prevent COVID-19 secretions 100% is an N95 mask. Now I would question, what type of contact do you have with patients and for what period of time? These are the recommendations for what you should do if you think you have been exposed.  

An alternative suggestion is to potentially get your patients to wear a mask, which would keep their secretions from potentially contaminating you. Oftentimes surgical masks are enough to prevent spread.  

From Meriam Senay (Pharm.D.’10/P):

Glad you will be talking! Besides in vitro data, are you aware of any recommendations for adding zinc and the dose to hydroxychloroquine for the treatment of COVID-19? Thank you!

Answer: 

Hi Meriam! She is one of my former students. Has zinc shown to be beneficial either with or without hydroxychloroquine for the treatment of COVID-19 specifically? No.

There is some in vitro data that suggests increasing intracellular zinc levels for SARS, another novel coronavirus, can hinder the replication of the SARS virus.  

From Lesha Albert: 

Does this particular virus have different strains? Once you develop this particular virus, what is the percentage of you developing it again?

Answer:

Originally they thought there were only two DNA variants of COVID-19; however, as this has progressed and they have gained more samples to analyze, the latest I have seen is that there may be as many as eight strains. They are all genetically related and at this point we don’t have enough data to see if there is truly a difference in symptoms or outcomes between those infected with different strains.  

From Brandy Thurston Billings:

Mirroring what everyone else is asking about how long until it’s safe. I’m 6 1/2 months pregnant and am worried I may not be able to safely go out and/or work if the one-month ban is lifted. Can I anticipate self-isolating for six months, including maternity leave?

Answer:

The answer is at this point we don’t know. Are pregnant females in general at a higher risk for acquiring infections? Yes. Do we know if this means they are more predisposed to acquiring COVID-19? Unsure. Do we know if pregnant females who acquire COVID-19 are more likely to have severe disease? Unsure.

At this point all we have are case reports and a couple of limited case series. It does appear that there seems to be low risk to the fetus overall in these published cases, which is good news. The largest concerns seem to be those who are likely at the highest risk, which would be pregnancy and other risk factors such as uncontrolled high blood pressure or uncontrolled diabetes.  

Otherwise at this point, they are still recommending social distancing if possible and just taking general precautions such as good hand hygiene. There are no recommendations at this point that pregnant females should remain in isolation for a longer period of time.  

From Sonya-Lee Constantino Zezza:

I live in Florida, and we are not in lockdown. Any thoughts on that? Most people are getting Vitamin D with outside activities. Is that still OK?

Answer:

Good news! Now Florida has been put on lockdown.I think everyone, no matter where you are living, should be practicing social distancing and avoiding crowds.

Do I think it is beneficial to get fresh air if possible? Yes, but also while maintaining a safe distance from crowds.  

From Cheryl Myers Johnson:

Do we really know how close to symptoms appearing that a person is contagious or shedding the virus?

Answer:

The incubation period, how long it has taken from the time you have been exposed to the virus until when you show symptoms, is about five to seven days. 

During which part of that period do you start shedding virus? We’re unsure, but based on some limited studies it seems like fairly early on in the disease before you even start showing symptoms, four days in this study. So that is what is scary. You may not even realize you have the disease, but could be passing it to others during this time.

Most individuals shed virus for up to 14 days, thus the recommended 14-day quarantine if you have been exposed, but for some individuals, it has been shown to be less or even longer.  

From Elaine Nguyen (M.D.’15/M):

A few studies have come out reporting that people who are at greatest risk for complications are older individuals with comorbid disease states. A big proportion of these patients have hypertension. I think of my parents who are in their late 50s who have hypertension, and I just wanted to know if the risk of complications are associated with individuals with unmanaged disease states or if it applies to individuals with managed chronic illnesses as well?

Answer:

It is hard to know at this point the level of control these individuals had prior to their illness, but it appears that the more uncontrolled their underlying disease states are, for both hypertension and diabetes, the higher at risk they are for developing complications.

That being said, we have perfectly healthy younger patients who are also having complications and deaths. So in general, prevention is the best option if possible.  

From Cheryl Schrier:

1. What is/are the biggest risk points to our hospital and retail pharmacists and pharmacy techs right now, and what can they and the public do to mitigate these risks for our providers?

2. Are community or hospital pharmacists currently experiencing shortages in availability of hydroxychloroquine and Z-Paks to your knowledge?

Answer:

1. I think the biggest risk to our pharmacists and pharmacy techs is being exposed to the public without proper protection. I think that most institutions, especially community pharmacies, are finally coming around to individuals wearing masks and putting up protective plastic barriers.

The CDC just released guidance for pharmacies for how they can minimize their exposure. If I am being honest, I don’t understand why they cannot better utilize other items such as curbside pickup or their drive-through option to protect our pharmacists. I do know many hospitals are working to minimize pharmacy members’ exposure to potentially infected individuals as well.  

2. Some generic brands of hydroxychloroquine are in shortage, but this is dependent on the manufacturer. Oral Z-Pak is not in shortage, but the IV version is.  

From Josh Zhang (B.S.’19/H&S):

How does the global death toll for this pandemic compare with the Spanish flu?

Answer:

Hello, Josh (a current student)! It’s hard to compare because you have to realize they didn’t have full access to testing back then, but based on what we know, over 500 million were thought to be infected with 50 million deaths worldwide, giving a mortality rate of 10%.

Currently, we have 1.1 million infected and 62,784 deaths, giving us a mortality rate of 5.7% worldwide, and it seems to be close to 2.5% in the U.S. Remember, we still don’t know how long this may last, so it is hard to say.  

From Don Ward:

Would you be able to speak to the “wet markets” that some suggest as the source of the virus in China?

Answer:

I will be honest, I cannot say that I am an expert on this, so I hesitate having an opinion.  

From Stefani Bonner (B.S.’15/H&S):

1. Should we be taking any extra measures when cleaning produce from the grocery store? Would the standard warm water and vinegar rinse/soak kill potential viruses that may have landed on oranges/apples from infected shoppers?

2. If I’m mildly sick and concerned that I may have COVID and I’m immunocompromised or elderly, should I go to the hospital before it potentially gets worse?

Answer:

1. At this point, there aren’t any extra measures recommended for cleaning produce outside what you would normally do prior to eating it.

2. If you are concerned about having COVID-19 now, there are more testing sites throughout Richmond and Virginia. 

If you are not having severe symptoms which would be trouble breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face, it is not recommended that you go to the ER. If anything, it is recommended to let your doctor know and monitor your symptoms.  

From Kara Fisher (M.S.’18/N):

Hi, Dr.Gravatt! When professionals recommend a 14-day quarantine, does that begin when a person suspects they’ve been exposed, or when a person develops symptoms?

Answer:

Hi Kara! Based on the CDC recommendations, it is 14 days from the time of suspected exposure, and if they are infected, then resolution of symptoms. 

From Mandy Kate Ellis:

When a patient tests positive for coronavirus, how long should they remain quarantined after they become asymptomatic?

Answer:

People with COVID-19 who have stayed home, or been home isolated, can stop home isolation under the following conditions:

  • If you will not have a test to determine if you are still contagious, you can leave home after these three things have happened:
    • You have had no fever for at least 72 hours (that is three full days of no fever without the use medicine that reduces fevers).
      AND
    • Other symptoms have improved (for example, when your cough or shortness of breath have improved).
      AND
    • At least seven days have passed since your symptoms first appeared
  • If you will be tested to determine if you are still contagious, you can leave home after these three things have happened:
    • You no longer have a fever (without the use medicine that reduces fevers).
      AND
    • Other symptoms have improved (for example, when your cough or shortness of breath have improved).
      AND
    • You received two negative tests in a row, 24 hours apart. Your doctor will follow CDC guidelines.

From Anastasia Krisik (Pharm.D.’04/P):

Dr. Gravatt, what are your thoughts on Plaquenil (hydroxychloroquine)?

Answer: 

I personally believe we don’t have enough data available to say that it is beneficial in all cases. In actuality, we have limited published data with a very low number of patients in open label trials that say it may decrease viral carrying capacity in those infected. The jury is still out on this one.  

From Kevin Taylor (B.F.A.’88/A):

I heard this morning that Advil is bad for you to take if you have the virus. Is that true?

Answer:

This has not proven to be true.  

From Sarah Ibinson (Pharm.D.’15/P):

Hi Dr. Gravatt! Can you discuss the data that shows that approximately 80% of people have mild/moderate symptoms? Also, of the pediatric patients who have tested positive, have there been hospitalizations or deaths? Thank you!

Answer:

Hi Sarah (also a former student)! Yes the data show that up to 80% of those infected have mild to moderate symptoms, 15% require hospitalization and 5% are severe and need ICU level of care. The CDC has a great place where you can see up-to-date information that is pieced out based on age. Based on age, the rates of hospitalizations have been:

  • 0-4 YO: 0.2/100,000 individuals
  • 5-17 YO: 0.1/100,000 individuals
  • 18-49 YO: 2.5/100,000 individuals
  • 50-64 YO:  7.4/100,000 individuals
  • 65+: 13.8/100,000 individuals

So the risk has been very, very low for pediatric patients. In the U.S., based on confirmed numbers, there have only been two confirmed COVID-19-related pediatric deaths. 

From Kristen Sloskey (Pharm.D.’13/P):

What kind of specificities/sensitivities do these (COVID-19) tests have?

Answer:

This is tricky because some places are using different tests and these have been found to be variable in their sensitivity and specificity.  

From Tricia Tarrance (B.S.’11/MC):

What vitamin supplements do you recommend?

Answer:

At this time no specific vitamin supplements are recommended outside of just a healthy diet and lifestyle. No other vitamins have been shown to decrease the rate of transmission or severity of illness at this time.  

From Merone Tibebu Zewde:

When the COVID-19 vaccine becomes available, would it be required for everyone or would it be an option? Considering the fact that many people are still hesitant in getting the flu vaccine and other vaccines.

Answer:

I think if a COVID-19 vaccine would become available, I don’t know that they would require it. I say this because the flu vaccine prevents infections and deaths yet is not a mandated vaccine.  

From Larry Powell (B.S.’85/MC):

How long does the virus stay airborne? If you see someone cough without covering their mouth how do you protect yourself?

Answer:

Based on the data I have seen, it can be airborne up to three hours potentially. I think the biggest thing is to make sure you are a great distance from other people, especially those sneezing and coughing and decide to not walk toward that individual.  

From Sarah Crews (M.B.A.’17/B):

Can you get CV19 multiple times? Or if you have it now, will you be immune once your symptoms have passed?

Answer:

The quick answer is we don’t know. We think immunity is being built post-infection, but we don’t know for how long either.  

From Jeannette Gendre:

Have you covered ride shares? Many students are taking advantage of the lack of public transportation by using their vehicles for Uber/Lyft. Should ride shares also be halted? Thanks!

Answer:

My personal thoughts on this goes back to limiting your exposure to others in general during this time. This includes public transportation and using ride shares. I would definitely say to make sure that you are trying to not touch surfaces while in the vehicle and immediately washing your hands after being in another individual’s vehicle. Overall, we should be limiting our exposure to the general public outside of those who we live with on a daily basis.  

From Renee Farkas:

What are your thoughts about antimalarial hydroxychloroquine and the antibiotic azithromycin as helpful in treating the virus?

Answer:

See above!