Updates on the Novel Coronavirus (aka COVID-19): What You Need to Know
Information about the spread and about the safety concerns of the novel coronavirus (aka "SARS-Cov-2"), and the disease it causes, COVID-19, is evolving on an daily basis. You may have noted some flip-flopping on recommendations from the government and scientific community in the last 7 months. Some of this is certainly due to the novelty of the virus: early on, we had very little information about the disease and this uncertainty was reflected in the changing recommendations. It is also clear that politics has played a major role in the information that has been distributed and the recommendations made. So I wanted to try to bring you unbiased, non-political information about the of the virus in our community and in general. I will include details on this topic from previous newsletters, as they remains important - new information will be in BOLD.
As most of you will know, President himself was found to be infected with the COVID-19 virus last week. This occurred despite the very frequent testing of the president himself as well as testing of those that have contact with him. The moral of the story? The COVID-19 tests are not 100% accurate and can be negative even if someone is infected. This is especially true for the "rapid" tests, that provide results within 15 minutes. So please don't rely on a negative test result too much, and continue to take other precautionary measures such as social distancing and wearing a mask.
General Information:
Pandemics are not new to our civilization and each pandemic is unique. What makes SARS-Cov-2 different and more challenging is the high degree of infectiousness as well as transmission from people who have no symptoms at all or only mild symptoms.
An article published in the Annals of Internal Medicine on Sept 2, 2020 calculated the mortality rate of COVID-19 by randomly testing people (with and without symptoms!) for COVID-19 in Indiana in late April, 2020. residents were not included in the testing. The researchers found that the incidence of death increased with age: people older than 60 had a mortality rate of just under 2% - a mortality rate that is about 2.5 times as high as influenza. People younger than 40, however, had a mortality rate of 0.01%.
COVID-19 has had negative health impacts on many people who don't contract the virus: 40% of U.S. adults surveyed in late June reported at least one or behavioral health problem associated with the pandemic. In general, young adults, Hispanic and Black people, as well as essential workers and unpaid caregivers had the highest rates of issues. The prevalence of in the U.S. population is three-times higher now during the pandemic than several years ago.
A study from September 18 in JAMA suggests that the incidence of illicit drug use has about doubled since onset of the pandemic.
The Department of Health and Human Services will start testing the waste water of 36 million people for SARS-Cov-2. This testing will cover about 10% of the U.S. population and occur over six weeks in October and November. The result will provide a more complete picture of local COVID-19 trends. Sounds like a great idea...but I must admit I am happy I don't have that job!
The COVID-19 pandemic has also affected physicians and their practices. A recent survey found that 4% of physicians didn't plan on re-opening their practices due to personal health concerns associated with the virus. In addition, another 4% of physicians had closed their offices during the pandemic for other reasons. And 43% of doctors have reduced their staff in the setting of the the COVID-19 crisis.
The CDC has extended its ban on passenger cruise ship travel through the end of October. Between March and September, 2020, there have been at least 3700 people who fell ill with COVID-19 that they contracted while on a cruise. 41 people have died.
The World Bank warned this week that the coronavirus pandemic could push over 100 million people into extreme poverty worldwide. Extreme poverty is defined as living on less than $1.90 per day
Transmission:
The incubation period can be 14 days (or more), though most people develop symptoms within 5-10 days.
Transmission occurs predominantly via respiratory droplets. Transmission is more likely the longer you are close to an infected person, the closer you are, and the worse the air ventilation is. It is rare to have pregnant mothers transmit the virus to their fetuses. Transmission via touch (touching a surface with the virus on it and then touching your nose, eyes, and mouth) is quite unusual.
People are most infections the day prior to developing symptoms and then infectivity declines about one week after onset of symptoms.
Eyeglasses may help prevent the spread of the coronavirus.
The popular wisdom until recently has been that the virus mainly spreads from person-to-person via "droplet spread." However, it seems that SARS-Cov-2 may also be spread via aerosols, which are much smaller particles that can stay suspended in the air for hours (somewhat like pollen).
On 9/18/2020, the CDC changed its guidance on coronavirus transmission, noting that it could be spread through the air. This statement is in line with the beliefs held by the scientific community. However, this CDC position was redacted on 9/21/2020. Then, on October 5, The CDC again reversed course and stated that the virus can indeed spread beyond a 6 feet distance, especially in poorly ventilated spaces. This is thought to be an acknowledgement of the airborne spread of the novel coronovirus.
Although it seems likely that COVID-19 can be transmitted via both droplets and aerosols, preliminary research suggest that droplet spread is much, much more common.
It now seems likely that re-infection with SARS-Cov-2 does occur.
A study by the CDC just showed that adults who tested positive for SARS-Cov-2 were twice as likely to have eaten at a restaurant in the prior two weeks compared to people with negative results. So either restaurants themselves are likely places of virus transmission, or people who eat in restaurants also engage in other "high risk" activities.
The journal Science published a study of 85,000 people in India with COVID-19 and looked at over half a million contacts of these patients - a HUGE study. The surprising results included the fact that 71% of people don't seem to have infected anyone! This implies that a minority of infected people seem to be passing on the virus to others - so called "super-spreaders!" Similarly, a separate paper looked at experiences in Hong Kong, which had extensive contact tracing done also and found that 19 % of cases were responsible for 80% of transmissions.
Researchers reported in MMWR that a 13 year old girl ended up spreading SARS-Cov-2 to a total of 12 family members during a family reunion. These relatives came from five households in four different states. The girl had tested negative for COVID-19 prior to the gathering, again proving that the tests are not 100% accurate.
There is an excellent article published in the Atlantic about SARS-Cov-2 transmission. It focuses on how many "super spreader events" have been responsible for transmissions of the virus and how this could explain why, for example, Northern Italy was an early focus of the disease, while Central Italy wasn't. In addition to some people being "super-emitters" of the virus, other circumstances (large indoor events, crowding, poor ventilation) also play a large role. This is why events with large congregations of people - like weddings, large church gatherings, restaurants - are likely to become hot spots of transmission, especially if there is loud talking or singing involved. The article is worth reading in its entirety:
https://www.theatlantic.com/health/archive/2020/09/k-overlooked-variable-driving-pandemic/616548/
We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them
Please, folks, wear the face masks properly! I see so many people walking about wearing face masks with their noses not covered. This doesn't protect anyone!
Some people are worried about using face masks, thinking they can decrease the amount of oxygen people inhale while increasing toxic levels of carbon dioxide. Luckily, a recent study (from the Annals of the American Thoracic Society) measured these gases in people wearing face masks - some of whom had significant underlying lung disease! - and found that oxygen and carbon dioxide levels were not worrisome!
The latest estimates from the scientific community suggest that at least 70% of the population needs to become immune from Sars-Cov-2 (either by vaccination or by infection) before we reach "herd immunity," a state where the virus essentially dies out because there are not enough people to transmit the infection. At this time researchers estimate that about 9% of the U.S. population has been infected by SARS-Cov-2.
A study published in JAMA in mid September looked at the transmission of the novel coronavirus within the walls of a hospital. I know many of us are worried about going to the emergency room or to other areas in the hospital for fear of contracting COVID-19. Well, this study looked at one academic medical center and examined a 12-week period, during which 697 people were admitted to the hospital with COVID-19. Only 2 patients subsequently came down with COVID-19 due to an exposure from the hospital itself.
More of us are traveling by airplane again these days. An interesting article from JAMA looked at the risk of flying and getting infected with SARS-Cov-2:
The risk of getting COVID-19 during air travel is lower than from an office building, classroom, or supermarket.
The low infectivity has to do with the relatively low airflow between rows.
Half of the airflow in a plane is from fresh air from outside - the other half is recycled through HEPA filters similar to the ones used in an operating room.
Current estimates suggest that only 42 people have gotten COVID-19 from being in an airplane.
if you want to see more details, please refer to the article itself at:
https://jamanetwork.com/journals/jama/fullarticle/2771435?guestAccessKey=95853d41-d229-4c8c-ac3f-fcb9eeab76dd&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_term=mostread&utm_content=olf-widget_10022020
Symptoms and Risk Factors:
People with COVID-19 usually develop achy muscles and a fever, as well as shortness of breath. A small number are also nauseated and have diarrhea. Loss of taste and smell is common. Severe cases usually involve a pneumonia that may lead to hospitalization and the use of a ventilator to allow the lungs to adequately transfer oxygen into the blood.
SARS-Cov-2 has been found not only in the lungs and airways, but also in the brain, heart, liver, kidneys of patients.
About half the patients with COVID-19 have neurologic symptoms.
More than 50% of the patients who died of COVID-19 were found to have the SARS-Cov-2 virus infecting their brains.
Most children who get infected do not exhibit any symptoms. However, a small percentage who end up in the hospital have symptoms of "vasculitis," which is an inflammation of the blood vessels. This syndrome, called "pediatric multisystem inflammatory syndrome (MIS-C)" is still rare, but can be very serious.
An adult version of the multisystem inflammatory disease of children has now been described as well: a total of 27 adults with COVID-19 have been found to have signs of inflammation of the heart, digestive system, and nervous system. Three patients have died. It also seem possible that this disease is not actually caused directly by the SARS-Cov-2 virus, but by our body's inflammatory response to it.
An increasing number of COVID-19 patients seem to have long-standing sequelae of their infection:
persistent lung disease is common, with people experiencing cough and shortness of breath 12 weeks after hospitalization. Nonetheless, most people do recover.
A study looked at heart function in 25 college athletes who had recovered from COVID-19 after a mild or asymptomatic infection. 15% had signs of inflammation of the heart muscle (by MRI) and an additional 31% had signs of past heart muscle injury. These findings gain in importance as the college sports seasons are set to resume.
Certain underlying conditions make you more prone to get sick with COVID-19. These include emphysema, diabetes, and heart disease. Also, obese people as well as smokers and people with kidney damage are also at higher risk.
Adults with vitamin D deficiency are at greater risk for severe COVID-19 disease and death.
In the United States, Black people and Hispanic people are three times as likely to become infected with COVID-19 compared to Caucasians. Moreover, Black and Hispanic people are twice as likely to die of the disease compared to White people.
Incidence/ Prevalence:
Dr. Robert Redfield, the director of the Centers of Disease Control and Prevention, said that the number of Americans infected with SARS-Cov-2 was probably 10-times higher than the number reported.
Dr. Michael Ryan, the WHO's head of emergencies (what a title!) estimates that about 10% of the world's population has been infected with SARS-Cov-2 to date. This would indicate that the vast majority of people are still at risk.
At this time, over 36.7 million people in the world have contracted the novel coronavirus. 986,000 people have died worldwide (compared to 986,000 two weeks ago). The United States has the highest number of cases, followed by India and Brazil. The U.S. also has the highest number of deaths (at 213,000) in the world.
In the United States, more than 7.68 million people have now contracted SARS-Cov-2. The states with the highest new cases include Alaska, Indiana, Kansas, Kentucky, Minnesota, Montana, North Dakota, Utah, and Wyoming.
California is reporting that it now has more than 848,000 people infected with SARS-Cov-2 (compared to 804,000 two weeks ago).
As of October 8, 2020, there have been 10,452 people in San Mateo County who have tested positive with the SARS-CoV-2 virus (compared to 9785 people two weeks ago). 155 people in San Mateo County have died from the disease (compared to 150 people two weeks ago).
San Francisco has maintained one of the lowest death rates from COVID-19 compared to other major U.S. cities.
Between August and September, the number of people aged 18 to 22 years who were infected with SARS-Cov-2 has increased by 55% in the United States (according to the MMWR).
Teenagers are about twice as likely to become infected and transmit SARS-Cov-2 as compared to younger children.
At this time, about 100 children and teenagers have died of COVID-19 in the U.S. (compared to over 200,000 fatalities overall). A study done in the journal Science Translational Medicine hypothesizes that children's immune system has evolved to better protect against unfamiliar bacteria and viruses - a characteristic that is lost as people mature. Therefore kids are better able to destroy the coronavirus before it causes too much harm in their bodies.
Testing
The CDC plans on publishing new guidelines for testing people without symptoms, having withdrawn a previous statement that stated that almost no one without symptoms needs to be tested. Details of these guidelines have not yet been released.
On September 28, President Trump announced a plan to distribute 150 million rapid coronavirus tests in the coming months. These tests had been purchased by the government previously and can deliver results within 15 minutes. The tests will be distributed to the individual states based on their population.
Treatment
As treatments have been improving, the mortality associated with COVID-19 has been steadily decreasing over the last few months.
The drug remdesivir is being used in severely ill patients with COVID-19.
Recent results showed that administration of remdesivir to patients requiring oxygen reduced the recovery time of COVID-19 by 5 days compared to placebo.
The NIH has launched a late-stage trial looking at the efficacy of remdesivir together with anti-coronavirus hyperimmune intravenous immunoglobulin for hospitalized patients.
An article in late September from JAMA Internal Medicine investigated whether hydroxychloroquine was effective in preventing COVID-19 in health care workers. It was not.
Low doses of the steroid "dexamethasone," given intravenously, have been found to reduce death rates by 33% in people with COVID-19 who are on a ventilator.
Vaccine development is ongoing. In general, the development of any vaccine occurs in 3 phases: In phase 1, small groups of (usually young and healthy) people receive the trial vaccine. In phase 2, the vaccine is given to people that are similar in age and health to the target vaccine populations (in the COVID-19 case, those are people who are older and have chronic medical conditions). Finally, in phase 3, the vaccine is given to thousands of people and checked more thoroughly for efficacy and safety.
There are more than 200 COVID-19 vaccines under development overall.
In the United States, two vaccine candidates have reached phase 3 trials and another phase 3 vaccine was put on hold.
Both Pfizer and BioNTech have entered phase 3 trials. The mRNA technology for vaccine development is new and could usher in a new era of faster and safer vaccine development in general. Fingers crossed!
AstraZenica had halted its vaccine trial and started a safety review after one of the participants came down with a disease similar to transverse myelitis.
On September 12, AstraZenica resumed its vaccine trials in the United Kingdom; trials outside the U.K. remain on hold. An independent review of the trial found that the neurologic events may not have been related to the experimental vaccine.
The FDA has expanded the scope in its investigation of AstraZenica to include prior trial so similar vaccines. This will likely mean that the vaccine will be delayed further.
Johnson & Johnson has launched phase 3 trials for it's vaccine. This vaccine candidate is good because it requires only one administration dose and does not have to be kept frozen.
Invio Pharmaceuticals have had to put a hold on their final vaccine trials as the FDA tries to obtain some answers related to the novel delivery method of the vaccine. The hold was not due to any adverse effects seen in earlier investigation.
On October 6, the FDA announced new guidelines that call for extensive safety data to be gathered for the final stage of vaccine trials prior to vaccine approval. As a consequence, it is highly unlikely that a coronavirus vaccine will be approved before election day. WHO Director-General Tedros Ghebreyesus hopes that a vaccine will be available by the end of the year.
Unfortunately (but understandably!), all the vaccines being tested at this time are not being tested on children. This means that children would NOT be eligible to receive such a vaccine, once it is approved otherwise.
HHS Secretary Alex Azar stated that there could be adequate amounts of coronavirus vaccine for "everyone who wants one" by April, 2021.
China has started administering unproven coronavirus vaccines to tens of thousands (or even possibly hundreds of thousands!) of its population, a move that has confused and concerned global infectious disease experts.
California officials have announced that the state will conduct its own independent review of any potential COVID-19 vaccine to guarantee its safety.
Antibody therapy:
Eli Lilly has developed an experimental treatment involving SARS-Cov-2 antibodies. Eli Lilly has now requested emergency use authorization from the FDA for mild to moderate COVID-19, based on phase 2 trials.
Regeneron Pharmaceuticals, the company responsible for the experimental antibody medication administered to President Trump, has asked for emergency authorization for use of its medication. Preliminary results have shown reduced viral levels in patients treated outside the hospital. Supplies are limited and only 50,000 patients could be treated at first.
Mills-Peninsula Hospital:
Peninsula Hospital continues not to be full and is managing its share of COVID-19 cases as well as could be hoped for. Plenty of beds are still available in case more people fall ill and all the treatment modalities we discussed above are available here.
Our Community and Beyond:
The State of California has come out with a new color-coded system to guide reopening of different parts of the state: this system has 4 tiers: certain criteria such as each region's number of positive COVID-19 tests, hospitalizations, and Intensive Care Unit admissions will dictate what tier is appropriate for each region. Also, each region needs to be in a certain tier for at least 21 days and have improved their COVID-19 metrics for this time period prior to being able to "advance" to a higher/ better tier. The lower the tier, the more likely the region can open services.
on 9/22/2020, San Mateo moved up to the second (red) tier, allowing more more businesses to re-open. These include
Indoor restaurants (max capacity of 25% or 100 people, whichever is fewer)
All indoor retail (max 50% capacity)
Shopping centers (max 50% capacity)
Hair and nail salons as well as barber shops
Museums, zoos, and aquariums (max 25% capacity)
Places of worship (max 25% capacity or 100 people, whichever is fewer)
Indoor movie theaters (max 25% capacity or 100 people, whichever is fewer)
Gyms and fitness centers indoors (max 10% capacity)
San Mateo County continues to report improved standing within the state's re-opening framework. At this time, there are 4.3 new cases per 100,000 residents and the positivity rate has fallen to 2.6%. To enter into the next (less restrictive) tier, we will need to have a case rate of 3.9% for at least 2 weeks. In addition, San Mateo is not meeting a different benchmark set by the state: a new state mandate also requires improvement in positivity rates in disadvantaged communities; currently San Mateo has a disparity in positivity rates in its poorer neighborhoods and communities of color. This disparity could delay San Mateo's advancement to a higher tier of reopening.
On September 23, San Mateo announced a plan to significantly increase testing opportunities. The county's strategy involves a three-pronged approach:
Scheduled testing at the San Mateo County Event Center. Testing here will occur Tuesdays through Saturdays from 8 am to 3 pm - all without a cost to the patients. Appointments are required and can be made at "projectbaseline.com/COVID19"
Mobile testing in under-served communities.
Targeted neighborhood testing.
The CDC has recommended that children NOT trick-or-treat this Halloween, considering this a "higher risk" activity. Boo-hoo!
Our Office: What We Are Doing to Keep You Safe:
All patients seen in person will be screened for COVID-19 exposure and symptoms prior to coming into the building.
We disinfect all exam rooms and medical equipment as well as all door handles after EVERY patient visit, regardless of the medical issues involved.
We are also using tele-health options that allow you to have video as well as audio interactions with us as part of a "remote office visit." Tele-health is one change associated with the COVID-19 crisis that is likely to remain long after this pandemic is over. However, video visits can never replace in-person visits in our ability to make diagnoses and to really get to know our patients.
For those patients seen in the office, we ask that friends and family members stay in the car (or elsewhere outside the office) during the visit. Of course we do welcome caregivers into the office with the patient if they are needed for improved safety or communication. Other office guidelines will be based on recommendations of the American Medical Association and local public health ordinances. We have installed Plexiglas screens in the front office. We will do everything possible to make sure you feel safe to come back to our office.
All of us in the office are healthy and doing well.
All patients coming into the office will be required to wear masks.
As in previous years, our office will be offering both quadrivalent flu shots as well as the flu vaccine for "seniors." We have received our shipment for the senior flu shots already and you are welcome to stop by the office any time (no appointment needed!) to get yours. We also have a limited supply of influenza vaccine for the under-65-crowd. More of those are expected to arrive in our office shortly!