By Orly Avitzur April 16, 2020

A neurologist with the CDC discusses what's known to date about COVID-19 and what neurologists should be especially alert to.

On March 19, Neurology Today caught up with AAN member, James J. Sejvar, MD, a neurologist and epidemiologist at the US Centers for Disease Control and Prevention (CDC), who has been working on COVID-19 since early January when the first reports of illness were announced in China. In 2009, Dr. Sejvar he asked the AAN to collaborate with the CDC in reporting cases of Guillain-Barr syndrome (GBS), and any adverse events that were suspected of being associated with vaccines in general or the 2009-H1N1 vaccine.

Over the past eleven years, Dr. Sejvar has been deployed to regions of the United States to track the West Nile virus outbreak (2012), to remote villages in central Africa to investigate the Ebola outbreak (2014), to South America to track the Zika pandemic (2016), among numerous other urgent infectious disease epidemics.

I have worked with a number of worrisome viral outbreaks over the years, but none have frightened me as much as COVID-19 from the standpoint of spread of the disease, apparent ease of transmission, and associated morbidity and mortality, Dr. Sejvar told Neurology Today.

We reached Dr. Sejvar, who has been working 19-hour days, after his return from an extended trip to Rhode Island to engage in a special study examining the risk of contracting the 2019 novel coronavirus after exposure. Back in Atlanta on a mandated 14-day quarantine, he shared his current knowledge and advice on COVID-19.

We are continuously understanding more and more but there is still a lot we do not know: First, how long is someone contagious, and second, how easy it is to spread. We do know that people of older age and those with underlying conditions are at highest risk. People who have impairments that cause difficulty in clearing secretions such as those with Parkinson's disease, severe multiple sclerosis, GBS, or other chronic neuropathies are among those at higher risk. We are also concerned about people with seizure disorders. Although there is nothing specific about their condition that places them at risk, we know that seizures can be triggered in the setting of a febrile illness.

People with those conditions or of older age groups, as well as those taking immunosuppressants or immune-modulating medications, should adhere to the CDC guidelines and HHS advisories to minimize contact with others, both asymptomatic individuals and those who are symptomatic. They need to take these messages to heart.

While most neurologists are not currently on the front lines of directly working with COVID-19, they are clearly seeing people with neurologic diseases associated with aging, such as Alzheimer's disease and Parkinson's disease. Clinicians need to be fastidious in terms of infection control and whenever possible, place symptomatic patients in face masks and make sure that contact is limited. If a patient has known respiratory symptoms, neurologists should try to use full protective personal equipment (PPE) before examination to minimize exposure.

Admittedly, we are in the midst of a very difficult situation in terms of PPE. Quite frankly, there are health departments without adequate PPE. If possible, limit the exposure of someone with respiratory illness or signs of COVID-19 and keep them isolated. The government has worked with industry to ramp up the manufacturing of N95 masks, surgical masks, gowns, and eye shields. In lieu of masks, some people are using bandanas on both the physician and the patient to try to minimize the transmission of respiratory droplets. We know this is not ideal, but the CDC says that it's better than nothing.

In Rhode Island, we have set up tents that cars can go through and people can get swabbed after a brief history of present illness and past medical history is attained. The provider is outside the car and the patient is inside the car. This is being replicated in Massachusetts, New York, and other places. It's possible that a neurologist may be able to test someone and get an accurate assessment while minimizing exposure in waiting rooms and reception areas, by setting up systems that minimize patient contact.

There is a serologic test that the CDC developed for people who had been infected. In January, a group of students from a school in Rhode Island visited Italy, France and Germany before returning home. A teacher came down with COVID-19 and the students were all exposed. We are now conducting a sero-survey to look at how many kids exposed are sero-positive. The serology test is not yet Clinical Laboratory Improvement Amendments (CLIA)-approved and it still needs to be validated with positive- and negative-predictive value. We also don't know whether mounting an antibody response in IgG and IgM confers protection as it does with other viruses. As this is a new virus, we cannot assume that getting ill and recovering provides absolute protection.

One of the most alarming concerns is that COVID-19 transmission in the hospital is orders of magnitude higher than in the community. My biggest fear is that we incur a situation in which we end up with a limited availability of ventilators for people who are elderly or have underlying medical conditions. While the overall fatality rate is about 0.8-1 percent, recent age-stratified data suggests a rate of 9.5 percent for those over the age of 70 years. I am also very worried about the attitude of some young people we are seeing on the news who are ignoring warnings, congregating on beaches and in bars on spring break. Although there are fewer cases, we are definitely seeing people under the age of 45 with pneumonia.

Read more:
COVID-19: Advice from CDC Neurovirologist and... : Neurology Today - LWW Journals