Perspectives

Do You have Your "COVID Card?"

Welcome to the new normal. Living and practicing during a pandemic.

Sharon Pollick, D.D.S.

It’s the question we may be asked in the course of everyday exchanges in the future. And we may be requesting the same from our patients once normal commerce has returned. The coronavirus pandemic has brought new challenges around the world, including for healthcare workers everywhere.

Healthcare workers have the innate capacity to adapt and use the knowledge we have gathered through evidence-based medicine. We do this to change the way we analyze and treat a patient’s disease, all for the betterment of the public and their health. During this pandemic, experts 1 from around the world and in all specialties are leading the way in educating the rest of us who will be following in their footsteps. 2 We are using evidence-based dentistry, because that’s what we have been taught. It is the new buzz phrase, synonymous with “Tell/ Show/Do.” 3

Proof and Importance of Immunity

Americans may one day be asked to show their immunity certificate 4 for access to public activities. By, essentially, declaring “I have COVID-19 immunity,” they will be allowed entrance to shopping malls, theaters, cruise ships and into our offices. Such a measure would, at least for the short term, attenuate transmission.

The most vulnerable population—those with co-morbidities and over age 65—have accounted for 8 out of 10 deaths in the United States. 5 Freeop.org reports that, according to the Centers for Disease Control and Prevention, 2.1 million people live in nursing homes or residential care facilities, representing 0.6% of the U.S. population. And, yet, residents in such facilities account for 42 percent of all deaths from COVID-19, in states that report such statistics.” 6

Countries like Sweden, with a large nursing home population, have weathered the high mortality rate associated with this virus in the elderly, 7 while avoiding a stay-at-home order and quarantine 8 like what was implemented in New York and many other states.

New York State has seen a high mortality rate, 9 with at least 5,596 confirmed and presumed COVID-19 nursing home deaths, 10 which excludes those who were transferred to hospitals and died. Conversely, Florida, with a high elderly population, has had a much lower mortality rate, comparatively speaking, and their nursing home population has had 1,230 deaths. 11 This difference may be attributed to state policies enacted during the pandemic. On the other hand, Swedish epidemiologists predicted that their approach would propel them over the top of the curve to, ultimately, achieve herd immunity in the near future, 12 a status no other country has achieved. As of reports from early June, Sweden continues to maintain its plateau.

It’s important to understand that in the absence of personal and herd immunity, infection can’t be prevented; quarantining just delays it. This is what many have called “flattening the curve,” or postponing infection and deaths into the future, a measure that would potentially prevent a large spike of cases all at once, which would overwhelm our hospitals and result in higher mortality. Sweden avoided a stay-at-home measure and kept schools and businesses open with social distancing and other measures. Other much smaller countries, like Iceland, with approximately 19 million fewer people than New York State, have been successful in controlling the COVID-19 outbreak. Their approach included identifying and tracing people who were infected and instituting a two-week quarantine. They never imposed a stay-at-home-order, nor did they enforce mask wearing or closing schools or businesses. However, if you visit these countries, evidence of immunity is required.

Detecting Infected Patients

Just a couple of months ago, before there was evidence that this virus was a pandemic, there were millions of asymptomatic COVID-19 carriers gathered in public spaces and using public transportation. During this latent period, before symptomatology occurred, the virus had an opportunity to spread. 13 It was and is where many other countries focused their enforcement of social distancing. For this reason, some Asian cultures reported they had the ability to control the spread during this latent phase by “monitoring” their citizens and ejecting sickly people from public arenas. Their governments use heat sensing technology from hand-held or overhead monitors through an infrared thermal detection system (ITDS), which scans citizens as they enter the public transportation system. Sensors screen their bodies to determine if they are febrile. 14 These systems have been perfected and are very sensitive and accurate. 15 However, this technology can’t determine the cause for a person’s fever and determine if he or she has COVID-19.

The United States has not instituted such measures, which may be considered an act against civil liberties if done without people’s consent and uses the information obtained to remove people from public. Yet, it is a measure that could prove helpful in reducing the spread now and in future epidemics.

Personal Protective Equipment

Data from Singapore suggest that wearing masks has drastically eliminated spread, particularly among healthcare workers. 16 Caution should be used in extrapolating this statistic to the general population, because this is a multifactorial problem. Wearing a surgical mask while outside in the open air is much different than wearing a surgical mask in an enclosed car with the windows up or in a face-to-face setting positioned just a couple of feet from an infected person, or in a hospital setting with COVID-19 infected patients in a room. Additionally, comorbidities like lung and heart disease or advanced age put this population in a much higher risk category.

Surgical masks are used primarily in an operating theater to protect the patient from the healthcare provider, whereas respirators, such as the N-95, are worn to protect the provider from the infected patient. 17 Currently, the CDC recommends the use of surgical masks in enclosed public domains, where social distancing is not possible.

Dentists Want to Test Their Patients

Serological testing of IgM, acute response antibodies, and IgG, latent response antibodies to the coronavirus antigen, determines a person’s immunity status and is critical for outbreak response efforts. 18 Dental professionals are in one of the highest risk categories for exposure, and for that reason, some have advocated testing patients at the point-of-care (POC), before treatment is initiated. 19 A certificate from Clinical Laboratory Improvement Amendments 1988 (CLIA) is a requirement for any testing. Two certificates are available during this COVID-19 emergency: an Emergency Use Authorization (EUA) waiver from the FDA, a Certificate of Waiver (COW); and a Certificate of Compliance (COC), required for laboratories performing moderate- to high complexity testing. 20

Once the (COW) application is complete, additional information is required, including proof of practice ownership, dental license number, Tax ID and IRS forms. A (COC) certificate for laboratories performing more complex tests requires a 20-hour course and a director pathologist. The three tests currently available are for use in commercial labs only and not in dental offices.

Newer iterations of tests are being evaluated that provide (POC) results, mainly for hospitals or urgent care facilities. These tests are less sensitive and have higher false negative results, and as of this publication are not FDA-approved. 21 Note that two viral strains have been identified with limited knowledge about their activity. 22 Data from the FDA 23 and China 24 show a significant number of false negative tests in patients exhibiting mostly mild symptoms and in some severely ill patients. The viral testing process, referencing to the steps involved in obtaining the sample and then testing the sample must be performed accurately and skillfully and is the primary cause of false negative results. 25

Understanding the Immune Response

Immunity occurs after infection in most immunocompetent patients. Once inoculated with the virus, patients either become ill by showing signs of the disease, with most of them recovering, 26,27 while other patients become carriers. 28,29 Either way, most healthy individuals without comorbidities ward off the infection. And even among those who do become sick, over 99% recover. Evidence reported by the CDC shows improving weekly mortality rates as more data is collected. 30

Practice Guidelines

Practicing dentists, acting as the team leader, have a duty to follow what are scientifically proven policy and procedures. The New York State Dental Association (NYSDA) 31 and the American Dental Association (ADA) 32 have been working closely to monitor and ameliorate the situation. The team leader, the dentist, and his or her staff are on the front lines protecting our patients and each other while delivering urgent care as safely as we can.

Screening Patients before Their Appointment

The CDC, 33 the ADA and NYSDA have made available guidelines for providing urgent care safely during this pandemic, while elective care is put on hold. When patients call the office, the reception staff should be asking the following questions to assess the potential for infection and transmission:

- What is your temperature now?

- Are you experiencing coughing or symptoms of upper respiratory infection?

- Have you traveled to countries (Asia, Far East, etc.) with this viral infection?

- Have you been in the presence of a COVID-19 infected or symptomatic individual?

- Have you been within close proximity—less than six feet—to an infected person, unmasked for 10 minutes or more?

Determine and document the patient’s medical history with “yes” or “no” answers. If it’s determined that the patient may be infected, he or she is to be triaged to the hospital emergency room. Advise the patient to wear a face covering before heading out into public.

How has this changed the way we approach healthcare and our lives today and possibly in the future?

- Social distancing and quarantining are behaviors most Americans have only read about in history books. 34 They have been crucial in mitigating the transmission of this virus. Historically, quaranta giorni, or quarantine as the Italian phrase implies, is 40 days, and it was imposed on sailors to protect against imported disease, like the coronavirus.

- Just a f ew weeks ago, New York State was one of 45 states 35 under a state-of-emergency, with only essential businesses 36 operating, as per Gov. Cuomo’s decree. Initially, the stay-at-home order was to be used to “flatten-the-curve” or when the number of hospitalizations remained steady or declined.

- Dentists had their offices shuttered for over two months and were advised to triage dental emergencies accordingly. The governor allowed dental offices to reopen on June 1, following all CDC, OSHA and ADA guidelines. Prior to that date, patients requiring high-risk procedures or intervention to stop bleeding or a traumatic emergency were told to go to the hospital, where adequate infection-control and other measures were more readily available.

- All patients are prescreened by phone, eliciting their temperature, how they are feeling and triaging them to your office or the ER based on their answers.

- Grocery stores are better stocked now but were limiting customers to no more than two of particular items, to prevent hoarding. In addition, when smaller or popular grocery stores are filled to capacity with patrons, they prohibit more shoppers from entering until they fall below that crucial number of occupants.

- There have not been any published cases of infection related to dental care.

Follow all Guidelines

1. Wash your hands often especially after touching surfaces like doorknobs, pens, signage pads, phones and clipboards.

2. A void touching your face.

3. Disinfect frequently used items and surfaces.

4. Use a face covering while in public and unable to social distance.

5. Follow all CDC 37 and state and local guidelines.

6. If you feel sick, stay home to prevent spreading.

7. Utilize social distancing.

8. Do temperature checks of you and your staff.

9. Develop a policy for workforce contact tracing.

Salient Points about Transmitting Coronavirus

- One in every five New York City residents were positive for antibodies. 38

- Research shows that certain ultraviolet light, like sunlight, kills the virus on contact. 39

- Proper handwashing kills the virus.

- Social distancing is a beha vior that has slowed the transmission of the disease.

- Shielding facial mucus membranes with a mask and eyewear reduces spread.

We are all doing the best we can, complying and enforcing the recommendations set forth by local state and federal agencies. As days and weeks pass, more information is available, which is used by NYSDA and the ADA to set guidelines that we are to follow. 40

Widespread testing is an important tool and needs to continue. Clinical trials with new coronavirus vaccinations are in progress, but they take time. It took until November of 2019 for an Ebola virus vaccination to be approved for widespread use, almost five years from the start of the most recent outbreak. Many experts say that was lightning speed for a vaccine to be studied, created and approved. In the meantime, knowing a patient’s immunity status, along with behavior modifications, are the tools we have to fight this disease and remain safe.

Queries about this article can be sent to Dr. Pollick at girldoc@aol.com.

REFERENCES

1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html

2. https://success.ada.org/en/practice-management/patients/infectious-diseases-2019-novel-coronavirus

3. https://girldocdds.blogspot.com/2020/01/9-steps-to-double-implant-case.html

4. https://www.usatoday.com/story/news/health/2020/04/16/covid-19-fauci-says-immunity-certificates-possible-what-they/2987765001/

5. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html

6. https://freopp.org/the-covid-19-nursing-home-crisis-by-the-numbers-3a47433c3f70

7. https://www.statista.com/statistics/1107913/number-of-coronavirus-deaths-in-swedenby-age-groups/

8. https://en.as.com/en/2020/05/18/other_sports/1589796373_875369.html

9. https://nypost.com/2020/05/29/new-yorks-nursing-home-horrors-are-even-worse-thanyou-think/

10. https://www.health.ny.gov/statistics/diseases/covid-19/fatalities_nursing_home_acf.pdf

11. https://floridahealthcovid19.gov

12. https://www.nature.com/articles/d41586-020-01098-x

13. https://www.livescience.com/coronavirus-undiagnosed-spread.html

14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3294528/

15. https://www.sciencedirect.com/science/article/pii/S0033350615002838

16. https://www.weforum.org/agenda/2020/04/should-we-be-promoting-the-widespread-use-of-masks/

17. https://www.cdc.gov/niosh/nppt/pdf/UnderstandDifferenceInfographic-508.pdf

18. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-updateserological-test-validation-and-education-efforts?utm_campaign=041820_Statement_ FDA%20COVID-19%20Update%3A%20Serological%20Test%20Validation%20and%20 Education%20Efforts&utm_medium=email&utm_source=Eloqua

19. https://www.perioimplantadvisory.com/clinical-tips/best-practice/article/14174339/covid19-serology-tests-and-the-role-of-the-dental-office

20. https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-andpolicy-framework/emergency-use-authorization#covidinvitrodev

21. https://www.cdc.gov/coronavirus/2019-ncov/downloads/OASH-COVID-19-guidancetesting-platforms.pdf

22. https://academic.oup.com/nsr/article/doi/10.1093/nsr/nwaa036/5775463

23. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-updateserological-tests

24. https://www.medrxiv.org/content/10.1101/2020.02.11.20021493v2

25. https://www.fda.gov/media/136525/download

26. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html

27. https://www.livescience.com/coronavirus-updates-united-states.html

28. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html

29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7128959/

30. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html

31. https://www.nysdental.org/news-publications/novel-coronavirus-(covid-19)

32. https://www.ada.org/~/media/CPS/Files/COVI/ADA_Int_Guidance_Mgmt_Emerg-Urg_ Dental_COVID19.pdf?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cvpm-ebd-interim-flowchart&utm_campaign=covid-19

33. https://www.cdc.gov/coronavirus/2019-ncov/index.html

34. https://www.sciencedirect.com/science/article/pii/S0163445304000544

35. https://www.wsj.com/articles/a-state-by-state-guide-to-coronavirus-lockdowns-11584749351

36. https://esd.ny.gov/guidance-executive-order-2026

37. https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html

38. https://www.livescience.com/covid-antibody-test-results-new-york-test.html

39. https://news.columbia.edu/ultraviolet-technology-virus-covid-19-UV-light

40. https://pages.ada.org/return-to-work-toolkit-american-dental-association?utm_ campaign=covid-19-Return-to-Work-Toolkit&utm_source=cpsorg-alert-bar&utm_ medium=cpsalertbar-virus&utm_content=covid-19-interim-return-to-work

Sharon Pollick

Sharon Pollick is an oral and maxillofacial surgeon who, as liaison from the Suffolk County Dental Society Executive Board, serves as the director of member benefits at AAWD and chair of the NYSDA Council on Governmental Affairs. She is a member the NYSDA Information Technology Committee, chief of dentistry, Long Island Community Hospital, and author of the blogs Girldocdds. blogspot.com and GirldocDDS.com.