This activity has been designated for CME and ABIM MOC credits and is being recorded Today’s Activity Code: 14608

Agenda for 2/10/21 • Covid updates • News • Sharp specific • Miscellaneous/Open Discussion TEXT YOUR ATTENDANCE Its important that we know you are participating

Text Attendance Number: (858) 247-3111

Today’s Activity Code: 14608

Teleconference Etiquette • Mute your phone and computer during the call, as severe echoes can occur. Mute using either a mute button, or *6 which toggles mute on and off. • Do not place the on hold, as many hold line play music or narratives which disrupts the call • Once done talking, re-mute • The chat box is monitored if you would like to submit questions or issues • TAC is available for technical problems at the physician line 858-672-5202 Coping with Stress

• People have been living in a storm of stress during the pandemic, and when prolonged, stress can have negative impacts on our health via inflammation and elevated cortisol. This can include cardiovascular disease, diabetes, depression, Alzheimer's disease, cancer and others like weight gain, GI issues and hypertension, fatigue and sleep disorders • Coping mechanisms can include: – Meditating and mindfulness decreased stress markers in a study 2017 – Hobbies, can occupy yourself and distract from the event of the day – Schedule daily movement or exercise breaks – Boost intake of stress relieving foods like salmon, trout, sardines, green peppers, oranges, kiwi, yogurt, kambucha, sauerkraut – Sleep hygiene (cool, dark room, no devices, reg schedule) – Enjoy nature, listen to music, yoga, avoid caffeine and strict diets More Good News!

• New Covid cases continue to drop • Nationally, new cases dropped 21% from the prior week, according to HHS • It is too early to see effects from early vaccinations, and is more likely to be from the population seeing rises in infections, and possibly someone they know. In addition, the desire to avoid the newer variants may be a factor • The caveat, is the concern over Super bowl last Sunday, which could be another super spreader event • An Inland North regional center for Covid is located at the old Palomar downtown, does testing, vaccinations, and infusions of monoclonal (in selected patients). It requires a referral from their PCP (does not need to be submitted to SCMG) Covid Updates 2/10

• Can Over-the-counter pain relievers interfere with the Covid vaccine? some people pre-medicate with OTC pain meds prior to inoculation, to blunt side effects. However the side effects are an indication that the response is doing what it should. • In the Journal of Virology, 1/19, they reported taking ibuprofen could blunt the antibodies and other elements of the immune system to the Covid vaccine. A 2016 study looked at children who took pain meds prior to a vaccine, had fewer antibodies than those who did not. • This mechanism is tied to the anti-inflammatory effects while trying to induce a controlled inflammation via the vaccine. • A 2020 mega analysis however, did not show decreased effectiveness to in children, taking acetaminophen, placebo, or ibuprofen. The study did not report actual antibody levels but only that the antibodies exceeded the seroprotection level. • The CDC and WHO recommend against taking OTC meds prior to vaccine, but OK to take for symptoms after the vaccine COVID Updates 2/10/21

• In a pre-print, non-peer reviewed article, Regeneron’s antibody combo was found to neutralize the variants B1.1.1.7 (UK), and B 1.135 (So Africa), whereas the response to the vaccine was reduced in B 1.135. More to come as this is peer-reviewed • CDC guidelines for reopening schools expected to come out this week • Sharp has developed a special, interactive event focused on what self-care looks like, and techniques to encourage it in children. It is Friday, Feb 19th, 11:00am-12:00pm. You can register HERE until 24 hr prior to the event • The Diabetes, Obesity, and Metabolism journal published a study of a global analysis showing of those hospitalized with Covid-19, 14% will develop diabetes. The study included 3,700 Covid-19 patients, but a direct cause-effect relationship is unknown. The ACE2 receptor is found on beta cells, that supports this idea, but research is inconclusive • The FDA issued an EUA yesterday for the plus etesevimab for OP treatment of Covid and decreased hospitalization or death from 7% to 2% (70% reduction) More Covid Updates 2/10

• When patients who had Covid should get the vaccine (Uptodate.com): – Pre-vaccination is not recommended – Individuals with recent, documented SARS-CoV-2 infection should have recovered from the acute infection and met criteria for discontinuation of isolation precautions before receiving the vaccine (10 or 20 days post onset) – It is reasonable to delay the vaccine due, and allow others to get the vaccine – The CDC also recommends individuals who received the monoclonal or convalescent plasma therapy for COVID-19 should delay for at least 90 days (also for monoclonal COVID therapy given after the first vaccine dose) • Interlukin-6 inhibitors target the pro-inflammatory mediator that gives rise to the cytokine storm. Early studies were not hopeful. Later RCT studies showed tocilizumab decreased progression to a vent, and death, from 19.3% to 12%, and the NNT was 13 to prevent one death. Recommended if on HFNC/BIPAP CMS update

• Scams: The Office of Inspector General is frequently updating this web page on scams related to Covid. – They advise against posting photos of your vaccination card online, because it shows a name, and DOB and can lead to identity theft – The vaccines are free, except for some administration costs. Those asking for money for the vaccine are potential fraudulent – Be suspicious of unsolicited calls or requests for information • CMS compiled information from various sources that are relevant to Covid, and published them in a Covid-19 Partner resources Page and the HHS COVID Education Campaign page. The latter one focused on “the movable middle”, those who want to protect their health, but hesitant to get the vaccine I’ve Been Vaccinated, Now What?

• Following full immunization for Covid, what do you and patients need to know: – No passport doesn’t exist yet – No changes to current recommendations for mitigation strategies – A mask is your new best friend. Vaccines are not 100% protection, the best ones up to 95% effective (compare to oral contraceptives at 91-96% effective) – Some patients mount a more robust immune response, some are non-responders – The virus is mutating, as is typical with viruses, making vaccines less effective – You could be a silent spreader (think Typhoid Mary). We don't yet know if being vaccinated means you can’t be a carrier – The lasting effect of an immunization is unknown – Outdoor activities are fairly safe after being vaccinated, but indoors still carries a small risk of exposure, and becoming a carrier HID 2/10/21

• Inpatient numbers at Sharp continue to decline, and ICU capacity is down to 92% from 96% last week • Covid nasal swab test positivity rate is down to 8.2% from 11% last week in SD • County reporting to SDIR has improved, working with Sharp IT, with total vaccinations and those fully vaccinated have both improved • Johnson & Johnson vaccine is expected to have final review and approval by the FDA Feb 26th • AstraZeneca is not expected for use in the US until April. Its a 2 shot regimen and only requires refrigeration • There is concern that the B117 variant may cause another spike in new cases next month, due to its high infectiousness • Sharp has delivered 106,000 vaccines to date HID 2/10/21

• A new community site is expected to open on the SMH campus soon, at which point, Sharp will be able to deliver 100,000 inoculations/week • Much confusion remains over vaccine distribution, with eligible groups changing from the state guidance • Sharp hospitals are around 70% vaccinated • For patients with Covid infection, after 20 days, and prior to 90 days, they can have elective surgeries without new testing, and can also start their vaccination regimen • Concerns exist over variants with high mutation rate and increases in morbidity • We have B1117 (UK) in SD, which binds better to the target receptors, and the B1135 (South African) transmits better, and not susceptible to vaccine. The Brazil variant is similar to the B1.135. A cluster of a California variant has little clinical concern. Sharp is now providing 100-200 specimens a week to a lab that detects variants. Our first sample was 2% B1117, and new sample now between 5-10%,doubles q 10d Vaccine Info

• One dose of the Pfizer vaccine gives up to 90% immunity at 21 days, per MedRxiv, and awaiting peer-review • Sharp CME department is presenting a webinar tomorrow, 2/11 from 12:30pm- 1:30pm on a vaccine update. To join the meeting: http://bit.ly/SGHGR2021 event # 701 443 249#, or call in 858-573-1718 • Helpful information if someone is hesitant to get the vaccines. It gives good information in lay language to the common questions of: “I don’t know what’s in the vaccine”, “the vaccine was developed too quickly”, “the side effects can be severe” Local Vaccine Rollout – updates 2/3/21

• Now inoculating phase 1b tier 1, to all patients 65 and older, depending on vaccine availability. Following this, should be those in occupations likely to have exposure, such as teachers, childcare, emergency services, and agriculture. It depends on local vaccine availability • If a patient got a vaccine at a county site, like Petco, add that to your records so we do not include them in the vaccine roll out (CONNECT users) • Vaccinations for influenza and pneumococcal pneumonia in the inpatients diagnosed with Covid are being delayed. This is due to inflammatory cascade, and possible use of steroids which blunts the response to the flu/pneu vaccines • Sharp has been vaccinating only those over age 65

Sharp Specific Info 1/27

• SCMG is in discussions with Vons/Albertsons and SharpCare for vaccine administration to SCMG patients, updates to follow. The county sites are open now • Sharp Employees will get vaccines through the Employee health Department. They can call 858-499-4180 • Vaccination Appointments throughout the county can be accessed here • Sharp Health Plan is opening a 2-day vaccination clinic starting Friday for SHP members 65+ • Volunteer vaccinators are needed at many sites: – Click here to volunteer as a vaccinator at the Chula Vista site – Click here to volunteer at the Grossmont Healthcare District Reminder this activity Serology SARS CoV-2 is being recorded • Antibody test results can be helpful in diagnosing the MIS-C (Multisystem inflammatory Syndrome in Children, and detecting infections with few or no symptoms where initial PCR Is negative but the clinical course suggests Covid • In the setting of potential plasma donation with prior diagnosed or suspected COVID Other than that, the role of serology is only appropriate for epidemiological studies at this point and has very limited use in a typical outpatient clinical setting. • None of the FDA approved assays have been approved for the diagnosing of disease • Negative results does not rule out Covid infection, the PCR molecular diagnostic test (nasal swab) should be used for acute infections (CDPH) https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html https://www.theatlantic.com/health/archive/2020/05/coronavirus-antibody-test-immunity/611005/

New Cases last 12 days

Reported 2/9/21, overall positivity rate 6%

County Health Department testing sites

COVID-19 Resources

More than 100 community testing sites also offer free, confidential testing: Find a COVID-19 Testing Site. Another site that shows all the sites is available through the 211SanDiego site For more information about what Californians can do to prevent the spread of COVID-19, visit Coronavirus (COVID-19) in California. California continues to issue guidance on preparing and protecting California from COVID-19. Consolidated guidance is available on the California Department of Public Health's Guidance web page. Additional Resources – Recently Added

•Behavioral Health Resources Flyer (September 2, 2020) •Hands-Only Adult CPR During COVID-19 Safety Bulletin (September 1, 2020) •Mental Health Action Guide (August 27, 2020) •Dental Requirements Summary (August 26, 2020) •Dental-Specific Frequently Asked Questions (August 26, 2020) •Caring for your Mental Health During COVID-19 for Healthcare Personnel (August 13, 2020) •NIH Covid treatment guidelines Resources

• Clinician On-call Center is a 24 hr hotline with trained CDC clinicians standing by to answer healthcare personnel questions, at 800-CDC-INFO (800-232-4636) • National Institutes of Health: Coronavirus Disease 2019 (COVID-19) Treatment Guidelinesexternal icon • California epidemiologist on call # 916-328-3605 • Guidelines for healthcare worker exposure at work • https://www.sandiegocounty.gov/coronavirus.html • California Health Alert Network (CAHAN) • Sharp specific coronavirus site (sign in with your citrix (Cerner) password • The reopening continues, with the following, while observing physical distancing: • https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/commun ity_epidemiology/dc/2019-nCoV/reopening.html Reminder this activity Open Forum and Questions is being recorded TEXT YOUR ATTENDANCE Its important that we know you are participating

Text Attendance Number: (858) 247-3111

Today’s Activity Code: 14608