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. 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.
Despite the worrisome increase of coronavirus incidence and death in the U.S. and the world, I am more optimistic this week, given the positive results of some recent vaccine trials. I finally feel like there is an end in site - even if that end is still 6 months away or more. So let's please all pull together in this final stretch to minimize the number of people who suffer and die needlessly.
In the early days of COVID-19, many of the Coronavirus cases were grouped around nursing homes. Things have changed, however. Researchers published an interesting study in the journal Nature: they used cell phone data to track people's movement to over 550,000 different locations (restaurants, religious venues, etc.) in 10 U.S. metropolitan areas. This information was correlated with a SARS-Cov-2 transmission model. As is so often the case, a minority of locations account for the majority of transmissions. Such locations included restaurants, gyms, and coffee shops - indoor venues where people congregate. Therefore, reducing the occupancy in inside public venues will be very helpful in making a significant impact in controlling the disease.
Collins English Dictionary just announced its "word of the year:" it's "LOCKDOWN." It is a verb and a noun that indicates "a unifying experience for billions of people across the world, who have had, collectively, to play their part in combating the spread of COVID-19." I rather like it that this global need to work together on combatting a global crisis is the philosophy of this word of the year...
Finally, on to Thanksgiving: I know many of us are planning travel and the traditional family gatherings. Please don't do it. The CDC - in their first news briefing in months! - strongly recommended yesterday to forgo travel and to limit celebrations to household members only. This recommendations was echoed "in the strongest possible terms" by the American Medical Association, the American Hospital Association, and the American Nurses Association and is based on the spiking coronavirus cases that are overwhelming hospitals.
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.
As treatments have been improving, the mortality associated with COVID-19 has been steadily decreasing over the last few months. An article from the Journal of Hospital Medicine found a death rate of hospitalized patients of 25.6% from COVID-19 in New York in March. In August, the death rate had declined to 7.6%. Indeed, it seems that the mortality associated with SARS-Cov-2 has dropped by a third! According to Dr. Christopher Murray, the director of University of Washington's Institute for Health Metrics and Evaluation (what a mouth-full!), the virus killed 0.9% of those known to be infected in the spring, while in now kills around 0.6%.
Another piece of good news came in a recent study in BioRxiv (which was NOT peer-reviewed): 185 people with past COVID-19 infection were studied and their memory B-cells (a type of white blood cell) analyzed. The result of the study suggested that an immune response to SARS-Cov-2 may last for many years. This would suggest that past infections as well as vaccinations will protect you for a long time indeed!
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.
The newest studies (published in the journal Science) suggest that the antibodies developed by people who have recovered from COVID-19 actually last for at least 5 months.
There has been a significant increase of Emergency Department visits of kids and teens for mental health reasons with the pandemic - increases of 24-37%.
As I mentioned in previous newsletters, doctors' practices have also suffered economically from the pandemic. A recent survey actually showed that 49% of respondent physicians either lost their jobs, were furloughed, or were subject to a reduction in pay due to the pandemic. Physicians in areas where the virus was rampant were/ are most affected financially.
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. Transmission via touch (touching a surface with the virus on it and then touching your nose, eyes, and mouth) is quite unusual.
Humans can transmit the Novel Coronavirus to dogs and cats but these animals don't get particularly ill. More importantly, these animals don't seem to be able to give the virus back to us!
There is some concern that minks can transmit the SARS-Cov-2 virus to humans. Mutations acquired when the virus jumps from one species to the next can also make a possible future vaccine less effective. Since June, Denmark has reported 214 human cases of COVID-19 that likely were transmitted from minks. Five other countries (the U.S, Italy, the Netherlands, Spain, and Sweden) have also reported SARS-COV-2 cases in farmed minks.
People are most infections the day prior to developing symptoms and then infectivity declines about one week after onset of symptoms.
A study published in the journal Virology in October unfortunately showed that SARS-Cov-2 can stay alive and infectious on surfaces much longer than we thought: at room temperature, it can live up to 28 days! A recent study found that SARS-Cov-2 can stay alive on human skin for up to 9 hours! So wash your hands frequently and use hand sanitizer often!
We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them
There are rumors that wearing of masks is associated with lower oxygen saturations in the blood, a fact that can be critical in vulnerable populations. However, a study published in JAMA studied 25 senior citizens in Canada, all of whom were given a three-layer mask. Then their oxygen was check at rest and with activity. Luckily, there was no clear drop of oxygen saturations associated with the wearing of masks.
It turns out that wearing a mask is not just protecting others from the virus if you are ill. The CDC has just announced that wearing the mask protects the wearer from the viruses of others also! Win-Win!
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.
Current estimates suggest that only 42 people have gotten COVID-19 from being in an airplane.
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.
About half the patients with COVID-19 have neurologic symptoms.
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.
JAMA Network Open reported on 11/19/2020 that many patients with COVID-19 - especially if they were older than 65 - presented with delirium (severe confusion). Indeed, more than 25% of older patients presented at the emergency department with delirium and 37% didn't have any of the more typical signs such as fever or shortness of breath.
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.
A study out of Michigan looked at patients who had been hospitalized for COVID-19 and recovered: two months after discharge, one third of people still had ongoing health issues such as a cough, loss of taste and smell, or shortness of breath.
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.
The CDC announced in mid October that people who are overweight have an increased risk of severe illness with COVID-19. This means that 75% of the U.S. population is at heightened risk.
A new study showed that pregnant women with COVID-19 were more likely to give birth prematurely (13% compared to 10% prior to the pandemic). Pregnant women were also more likely to end up in the ICU and needing to be put on a ventilator compared with non-pregnant infected women.
Incidence/ Prevalence:
To the best of our knowledge, only a handful of people world-wide have become re-infected with SARS-Cov-2, a tiny number given the prevalence of the disease. This is great news!
At this time, more than 3 million people in the United States have ACTIVE coronavirus infections, according to experts out of Columbia University and the University of Washington. This means that about 1.1% or the U.S. population is currently infected and actively shedding virus that can infect others.
The nationwide uptick in cases which started in September is now in its ninth week and is longer than the surge of cases in the Northeast in March/April or the June/July upswing in the Sun Belt. The entire country is now involved.
On November 10, the number of COVID-19 hospitalizations were above 60,000 for the first time - over 2000 higher than the previous record in April.
At this time, over 55.6 million people in the world have contracted the novel coronavirus. 1.34 million people have died worldwide (compared to 1.24 million two weeks ago). The United States has the highest number of cases. The U.S. also has the highest number of deaths (at 252,000) in the world (236,000 two weeks ago).
In the United States, more than 11.8 million people have now contracted SARS-Cov-2 (9.76 two weeks ago).
California is reporting that it now has more than 1.08 million people infected with SARS-Cov-2 (compared to 962,000 two weeks ago).
As of November 19, 2020, there have been 12,878 people in San Mateo County who have tested positive with the SARS-CoV-2 virus (compared to 11,710 people two weeks ago). 168 people in San Mateo County have died from the disease (compared to 162 people two weeks ago).
For the week ending in November 10, San Mateo had an adjusted case rate of 5.7 cases per 100,000 residents per day, which is twice as high as the previous week. Also, the county's test positivity rate rose from 1.3% to 2.1%. Though this increase is extremely worrisome, it is still well below the positivity rate of 5.2 of all of California.
Over 1 million children in the U.S. have now been diagnosed with COVID-19 - 11.5% of all cases.
As we discussed in the past, most children infected with the virus do not develop any symptoms. The current thinking is that this is due to the presence of antibodies to other coronaviruses. 43% of kids had antibodies to different coronavirus strains in a study done by the Francis Crick Institute.
The CDC announced this week that Black, Hispanic, and Native American people with COVID-19 are four times more likely to require hospitalization compared to others.
People with intellectual disabilities are three times more likely to die of COVID-19 than others.
Testing
On November 18, the FDA granted an emergency use authorization for the first rapid at-home test for COVID-19. This test is made by Lampira and uses a technology similar to the PCR tests available. This test can supply results within 30 minutes. Accuracy of positive and negative tests seems to be quite high (above 94%). The cost is projected to be about $50 and a doctor's prescription is still needed.
See also the notes (below)about what testing options are available through out office.
Treatment
On October 22, the FDA approved remdesivir as a treatment for COVID-19 and therefore took it out of the "experimental/ emergency use" category. It is the only medication COVID-19 treatment in the United States. At the same time, the WHO just recommended AGAINST using remdesivir for hospitalized patients, due to lack of evidence that the drug reduces risk of death or need for a ventilator....I know, it's confusing!
On 11/19/2020, the FDA granted emergency use authorization of the combination of remdesivir and the monoclonal antibody baricitinib.
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.
A very small trial (published in Jama Network on November 12) included 152 adult outpatients infected with COVID-19. They were treated with fluvoxamine, an anti-depressant closely related to prozac. It seems that this medication not only affects the serotonin system, but can also have some anti-viral effects. At any rate, none of the patients treated with fluvoxamine got worse, while 6 patients (8.3%) of the placebo patients deteriorated. These are interesting results, though they need to be validated in larger trials.
An inhaled medication that stimulates the immune system (interferon beta-1) helped hospitalized patients with COVID-19. Those patients who were given the inhaled medications were two to three times as likely to get better; The treatment group had a 79% lower risk of developing severe disease or dying. This was just a phase 2 trial, so phase 3 trials are still needed until such a treatment could be considered.
Vaccine development is ongoing.
In the U.S., 8 vaccine candidates have received federal support under Operation Warp Speed. Of these, 4 companies (Moderna, Pfizer/ BioNTech, Oxford/ AstraZenica, and Janssen) have entered phase 3 trials.
By the end of December, there should be enough vaccines available to protect up to 20 million Americans.
The Russian "Sputnik V" vaccine, which is in phase 3 trials, seems to be 92% effective with "no unexpected adverse events." Unfortunately, very little information has been made available to the public, so this success has been greeted with a dose of skepticism also.
Brazil has halted a late stage trial of a Chinese Vaccine on November 9 due to a "serious adverse" reaction. However, there are concerns that politics (rather than science alone) have figured into the trial being halted at this time.
On November 9, the vaccine produced by Pfizer/ BioNTech was shown, in an interim analysis, to be 90% effective in preventing COVID-19 disease. Just a week later, they announced that the data now suggests it is up to 95% effective. Also, both mild and severe disease seems to be prevented. Seniors as well as younger people respond well to the vaccine. This is still preliminary data, as the phase 3 trial is still ongoing. Also, the safety data looks good, but is not yet finalized. But, this 90% efficacy is fantastic, as most vaccines are not nearly this effective. There are still some stumbling blocks, however, if this vaccine comes to market: it has to be given in 2 doses, 3 weeks apart. More importantly, however, it has to be stored in -70 decrees C temperatures, which is much lower than most freezer can provide. So the logistics still need to be worked out... Pfizer hopes to apply for an emergency use authorization for their vaccine as early as today!
Moderna announced on 11/16/2020 that it's two-dose vaccine showed 94.5% efficacy in an interim analysis of its phase 3 trial. The trial has enrolled 30,000 U.S. participants. In the analysis, 5 people who had received the vaccine developed COVID-19 (none severe) while 90 people who received the placebo were sickened by the virus (11 of whom were severely ill). Moderna's vaccine does not have the deep-freeze requirement of the Pfizer vaccine.
On 11/19/2020, researchers at Oxford University confirmed that the COVID-19 vaccine produced by AstraZenica produced a strong immune response in older adults. The final findings of the last phase of testing are expected to be available in the next few weeks.
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.
J&J reported on October 23 that their vaccine trials would resume after having concluded that prior adverse events noted with the vaccine were unlikely to be a result of the vaccine administration.
HHS Secretary Alex Azar has announced that the government has come to an agreement with various large pharmacy chains (Costco, CVS, Kroger, Walgreens, and Walmart) to help distribute the coronavirus vaccine, once it becomes available. There will be no cost associated for the public. Various other public health agencies are also ramping up their efforts now to be able to provide the vaccine to people as soon as it becomes available.
Antibody therapy:
The FDA has issued an emergency use authorization for the monoclonal antibody "bamlanivimab" produced by Eli Lilly. The EUA is based on an interim analysis of a phase 2 trial of 465 patients. This treatment is indicated for people with mild to moderate COVID-19 not sick enough to be in the hospital or to require supplemental oxygen. Treatment consists of a one-hour intravenous infusion and should be given to outpatients as soon as possible after the diagnosis of COVID-19 is made. By doing this, the risk of hospitalization or emergency department visits can be reduced from 10% to 3%. Unfortunately, the logistics of administration of this treatment is not clear yet. As the medication needs to be given intravenously, it would need to be given in a hospital infusion center. However, people sick with COVID-19 are not currently allowed in the hospital infusion centers - this is also the place where cancer patients receive their chemotherapy! Similar concerns were raised in JAMA, when the authors opined about the limited availability of bamlanivimab, the complicated administration, and potentially high costs of the medication. At this time, tnei NIH's Covid-19 Treatment Guidelines Panel says that there is not enought evidence to recomend for or against the use of this medication. They say that the treatment should not be the "standard of care" at this time.
A recent study published in the British Medical Journal found that plasma from convalescent patients (i.e. those who had COVID-19 in the past) was NOT effective in treating active coronavirus patients.
Another new and interesting therapy comes in the form of a preventative nasal spray: in a trial involving ferrets (!!), researchers have inoculated ferrets with a daily nasal spray that blocks the absorption of the SARS-Cov-2 virus. This data is based only on a small number of animals tested and needs to be studied further. However, if this strategy proves effective in humans, then a daily nose spray of such a medication could function like a vaccine and keep us safe from COVID-19. Interesting...
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.
Ryan Stice, who oversees pharmacy services at Sutter Health, has been preparing for the cooling requirements for the Pfizer COVID-19 vaccine (minus 94 degrees Fahrenheit!!) since the summer. As you can well imagine, this could be a logistic nightmare. Now Sutter, like other local health care providers and local health departments, is moving quickly to acquire about a dozen large and several smaller portable freezers for vaccine storage. Sutter is still finalizing the exact location of the freezers.
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.
On November 17, San Mateo moved back into the more restrictive red tier. Though this is not good news, we are actually lucky, as 94% of Californians are now under the most restrictive purple tier. For San Mateo, the following changes will now apply:
Theme parks must close.
Zoos and museums must be at 25% capacity.
Bars that do not offer food service must close.
Indoor dining is limited to 25% capacity.
Houses or worship are limited to 25% indoor capacity.
Gyms are limited to 10% indoor capacity.
Movie theaters are limited to 25% capacity.
No fans are allowed at professional sporting events.
Only outdoor pools may be opened.
Santa Clara is now in the more restrictive purple tier. There, restaurants will only have outdoor dining and all worship services will need to be outdoors as well.
Starting tomorrow, November 21, there will be a curfew imposed on residents living in purple tier counties: residents are asked to stay indoors (except to buy essential foods and products or to walk their dogs) between 10 pm and 5 am. This curfew is expected to last until at least December 21. For now, at least, San Mateo is not in the purple tier...but over 90% of the state is!
Last week, health officials of 10 Bay Area jurisdictions issued guidelines for the holidays, advising people to keep gatherings small and short to prevent spread of the coronavirus. This is particularly important because the Bay Area still has a relatively low incidence of COVID-19. Traveling will increase your risk of contracting the disease and bringing it home with you.
On November 10, the San Mateo Board of supervisors approved nearly $6 million for the "Coronavirus Aid, Relief, and Economic Security Act" funding. Many businesses and households will continue to suffer as a consequence of the business restrictions inherent in the pandemic lockdown.
San Mateo is still offering free PCR testing for COVID-19:
Scheduled testing occurs at the San Mateo County Event Center. Testing here can be scheduled 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"
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."
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.
All of us in the office are healthy and doing well.
All patients coming into the office will be required to wear masks.
We have finally received more "regular" flu shots (i.e. NOT those for seniors). So if you are under 65 and have not yet received your flu shot, call our office and come on in! Unfortunately, we have run out of our flu shots for seniors, for now. We are on the wait-list to get more, but are not sure when that will be. We'll let you know as soon as we know. Until then, we encourage our senior patients to get their flu shots from a pharmacy.
In addition to the "regular" Covid-19 testing that we have had all along (nasal swab, PCR-based test with approx. 24-48 hour turn around) our office also has two other COVID-19 testing options available:
A saliva based PCR-test that can be done in a patient's home. It is then sent via Fed-Ex to a lab and usually gives results in 36 hours. This test is usually covered by insurances and is 100% sensitive and 100% specific. It is accepted as evidence of immunity for most travel (not including travel to Hawaii, which does not accept this test).
A rapid 15-minute test that is based on a nasal swab and performed in our office. This test is 85% sensitive and 100% specific. This test is perfect for people without symptoms or prolonged exposure to a COVID-10 patient who "just want to make sure" they are ok. This test is not covered by insurance and costs patients $30/ test. We hope to have this test available by early next week!
About Dr. Sujansky's Life in These Times
On a more personal note, my family and I continue to do well.
The new restrictions on travel and social interactions will allow me to have more time at home and to get a jump start on sending out holiday cards and decorating the house. Also, I am trying to come up with holiday gifts that are more home-made and more personal - another possible upside of the pandemic. I think that also means that everyone is getting something knitted from me...
Thanksgiving will be a low-key affair at the Sujansky household: we are planning on going up to our condo at Kirkwood and dining on a 16 lb turkey between the three of us. I look forward to a change of scenery! And I will try again to be thankful for the many things that we have that others are lacking: shelter, a warm bed at night, love, good food, and the occasional glass of wine. And it goes without saying that I am grateful daily for all of my patients and friends in these difficult times.
My older son Stefan is scheduled to return from Greece in mid December. I am so looking forward to that. From his accounts, we are living lives of luxury and health compared to the conditions of the refugee camps on Samos.
Some of you have mentioned that you send my newsletter to friends and family. I could not be more flattered. Please also note that I put each week's newsletter under the "blog" section of my website (www.SujanskyMD.com) in case you want to share the newsletter that way or look at previous editions. Also, anyone can just google "Dr. Sujansky" and "blog" and it should come up.
Finally, I wanted to let you know that we are having another "Obagi Event" on December 3: many of your are already familiar with the wonderful skin care products by Obagi that we carry at the office. On December 3, our Obagi rep will hold one-on-one meetings virtually (via phone, zoom, or face-time) with anyone who wants some good tips for healthier skin. And to tempt you even more: we are offering 20% off all Obagi products from November 30 through December 31. So call and make an appointment for this or just come in and treat yourself (and others in your family) to Obagi. I think we all deserve something special in these times.
I wish you all a wonderful weekend and coming week. I hope all of you stay safe and healthy. I am thinking of you often.
