On the Front Lines: A Physician’s View of the Pandemic
April 16, 2020
By
Tina Eshleman
Dr. Jennifer Primeggia ’02 was in elementary school when she learned about Ryan White, an Indiana teen with hemophilia who faced discrimination because of his AIDS diagnosis and died just before he would have graduated from high school.
That’s when Primeggia decided she wanted to be a doctor specializing in infectious diseases. The idea that a 13-year-old could be infected with the AIDS virus through a blood transfusion astonished her, and she wanted to learn more.
Today, she is among the vanguard of medical professionals battling a different pandemic.
In early February, while most Americans were still going about their usual daily routines, she and her fellow physicians working in infectious diseases at Virginia Hospital Center near Washington, D.C., were preparing for an influx of patients with coronavirus disease 2019 (COVID-19).
They watched what was happening as the novel coronavirus took hold in China, then Italy, then Washington state, New York and California.
“My partners and I were reading constantly, trying to learn about the virus,” Primeggia says. “A lot of people are driven by fear, so it’s important for us to stay calm and rational in our decision making.”
They considered the logistics: who would receive diagnostic tests and how they would be conducted, how much personal protective equipment was available, how many respirators might be needed, what treatments could be used and the level of staffing required.
Soon, the number of patients with the respiratory illness increased. Most of them came in with similar issues: a dry, severe cough and flu-like symptom.
With limited tests available initially, guidelines on testing for the coronavirus meant calling the local health department to discuss the case, obtaining state approval, then collecting a sample and sending it by courier to Richmond and waiting two or three days for results.
“It’s been very frustrating,” Primeggia says. When she was on call the weekend of March 14-15, there were 26 patients who came to the Northern Virginia hospital’s emergency room with possible COVID-19 symptoms, but the hospital was unable to test them. Most were sent home, but some later returned when their conditions worsened.
On March 18, Virginia Hospital Center partnered with Arlington County’s health, police and fire departments to open one of the region’s first drive-through testing sites for patients showing symptoms of the virus. By that time, coronavirus cases had spread to all 50 states and the District of Columbia.
As of April 13, there were 77 patients in the hospital with confirmed cases of COVID-19 and another 14 who were being evaluated for the illness. About 100 people each day are being tested at the drive-through site, Primeggia says. The hospital is also able to complete rapid tests in-house now.
Fifteen of the hospital’s patients have died since the outbreak began. Some were elderly; others had been in good health before contracting the virus.
“People can become short of breath and get sick so fast,” Primeggia says.
A biology and Spanish major at William & Mary, she applied to Eastern Virginia Medical School after her freshman year, securing her path toward medical practice.
As a physician, she frequently draws on the Spanish language skills she developed as an undergraduate, while spending two summers working with now-retired Hispanic Studies professor Jonathan Arries as a medical interpreter for migrant farm workers on Virginia’s Eastern Shore.
One of her recent patients was a 48-year-old auto mechanic. She spoke with him in Spanish on March 27, and he told her that he had vacationed at home with his family before becoming ill, visiting local parks where he was around crowds of people.
“He was coughing a lot when we were talking and told me that his lungs hurt,” she says. “Every time he tried to take a deep breath, he had uncontrollable, painful coughing fits. I told him that we would watch him closely and support him.”
A few hours after they spoke, his condition worsened and he was placed on a ventilator in the intensive care unit. Sadly, the man did not survive, Primeggia says.
In an effort to improve patients’ prospects for recovery, Virginia Hospital Center enrolled in a clinical trial for the experimental antiviral drug remdesivir, produced by California biotech company Gilead Sciences. A shipment of the drug arrived on April 8.
As a co-investigator of the study at the hospital, Primeggia will identify moderately and severely ill patients who qualify for the study, obtain their consent and assess them for adverse reactions and side effects.
“We’d like to enroll as many patients as we can,” she says. “We are very excited about the trial.”
Developed as a possible treatment for Ebola, the new drug is considered promising for COVID-19 patients because of its success in treating related viruses SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) during laboratory tests. The drug is designed to work by disrupting the virus’s ability to replicate itself.
Gilead CEO Daniel O’Day wrote in a message posted April 4 that the company is making 1.5 million doses available for clinical trials, “compassionate use” for children and pregnant women, and expanded access for severely ill patients who can’t take part in clinical trials. Other Virginia sites participating in remdesivir trials include the medical centers at Virginia Commonwealth University and the University of Virginia.
Primeggia says another treatment with potential is plasma infusion from people who have recovered from COVID-19, because their blood contains antibodies that can fight the virus. Virginia Hospital Center has partnered with the Mayo Clinic and the American Red Cross to make this available to patients.
“We enrolled our first patient this week and are waiting to receive plasma,” she says.
While waiting to begin those treatments, Primeggia and her colleagues have been treating COVID-19 patients with Plaquenil, also known by the generic name hydroxychloroquine. It’s mostly been used for people with malaria or lupus, but the Food and Drug Administration recently approved it as a treatment for the coronavirus. Although small studies in France and China reported benefits, she says there’s not enough data to confirm its effectiveness.
“We’ve been using it for a couple of weeks,” she says. “We’re doing that mostly because we haven’t had have anything else. There’s not much treatment out there.”
As Primeggia and the rest of the infectious diseases team fight to save lives, the pandemic is putting a strain on the hospital’s supplies and health care workers. The number of COVID-19 patients now exceeds the 55 ventilators on site, although she notes that it’s possible for one machine to be used with multiple people. The hospital also has been receiving donations of personal protective equipment to augment its supply.
“The biggest issue is with staff,” she says. “Only so many people are trained in intensive care.”
Dr. Rohit Modak, one of Primeggia’s colleagues in the hospital’s infectious diseases group, describes her as collaborative, bright, calm under pressure and mindful of the effects of a decision on all stakeholders.
“During this pandemic, we’re all stretched thin,” Modak says. “It’s not just patient care, it’s taking care of hospital staff. We’ve had to lean on each other more. If I was busy in a meeting, she’d step up and take care of my patients. We really worked as a team to say what needs to be done and who has to do each role on each given day.”
Twelve-hour days are typical for Primeggia, and those can stretch to 18 hours on weekends when she’s on call. Health care providers at the hospital so far have avoided contracting the illness, she says, but many are scared and anxious. Her husband and two daughters, ages 2 ½ and 4 ½, are adjusting to the new demands on her time.
“My family tries to stay very supportive,” she says. “The last thing they want to do is talk about how worried they are about me.”
Primeggia remains hopeful that the spread of the virus will slow and that the new treatments will bring relief to patients.
“It’s going to be a couple more weeks before we see if the social distancing is really working,” she says. “Hopefully in the next few weeks, we’ll see an improvement.”