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 some details on this topic from previous newsletters, as they remains important - new information will be in BOLD.
Vaccines are here! In the last week, people have started receiving the Pfizer/ BioNTech COVID-19 vaccine. And while the number of COVID-19 cases are still sky-rocketing and there are lots of challenges in getting the new vaccines to everyone, I finally feel like there is an end in sight....an end to social isolation, mask wearing, and an end to this newsletter :)
Alas, we are not there yet, so please continue to do the right (and hard) thing to stay safe!
General Information:
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%.
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.
There has been a significant increase of Emergency Department visits of kids and teens for reasons with the pandemic - increases of 24-37%.
Transmission:
The incubation period can be 14 days (or more), though most people develop symptoms within 5-10 days.
The CDC has reduced the duration of isolation of a person infected with SARS-Cov-2: the CDC decreased the isolation period to 5 days after onset of symptoms.
For people who have been exposed to the virus, the CDC has shortened the minimum amount of time they need to quarantine as well. The quarantine can end 7 days after exposure if such people have no symptoms and have had a negative COVID-19 test (done 5 days after exposure). Without the test, the quarantine can end at 10 days.
People with a severely compromised immune system (like those receiving chemotherapy for cancers) may actually continue to shed the coronavirus for 2 months or longer after getting infected (New England Journal of Medicine). The current isolation precautions may therefore need to be adjusted for such people.
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.
A recent review of studies shows that less than 10% of the spread of the novel coronavirus occurred outdoors (though it is possible!) and that we are 19-times more likely to contract the virus indoors vs. outdoors.
A recent study (Nature Communications) again showed that men tolerate COVID-19 worse than women: men and women are equally likely to get infected with the virus, but men are about 3-times as likely to end up in the ICU and 40% more likely to die.
We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them
The American Academy of Pediatrics just issued a new guidance recommending face masks for kids participating in most youth sports. They should be worn during training, competition, as well as on the sidelines. Luckily, these recommendations don't apply to swimming and diving (too hard to breathe through a wet mask!), to gymnastics and cheerleading (masks could get caught or obstruct vision), or wrestling (choking hazard).
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.
Although COVID-19 is associated with a wide array of symptoms, 96% of infected people have either fever, cough, or shortness of breath. About 45% of infected people have all three of these 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.
An increasing number of COVID-19 patients seem to have long-standing sequelae of their infection:
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.
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!
An article published in the journal Clinical Infectious Diseases looked at blood donations collected by the Red Cross between December 13, 2019 and January 17, 2020: 106 of the 7,389 samples studied showed antibodies to SARS-Cov-2. This strongly suggests that people were getting infected with COVID-19 as early as December, a month before the first person known to have been infected with coronavirus arrived in the U.S. from China on January 15.
At this time, about 33% of Americans live in an area where there is a critical shortage of ICU beds.
Across the U.S., hospitals are teeming with with record number of COVID-19 patients. New cases nationwide totaled 244,365, a record. California, Maine, and Tennessee each reported single day highs. Wednesday was the worst day in the U.S. since onset of the pandemic, with 3,607 people dying. In California, the San Joaquin Valley and Los Angeles County are particularly badly hit. In L.A. County, 2 people are dying per hour.
Some statistics:
San Mateo:
number of cases: 19,645 (15,040 two weeks ago)
number of deaths: 183 (170 two weeks ago)
number of people in the hospital: 120 (80 two weeks ago). Peninsula Hospital is not at capacity.
California:
number of cases: 1.76 Million (1.29 Million two weeks ago)
number of deaths: 22,150 (19,586 two weeks ago)
U.S.:
number of cases: 17.3 Million (14.2 Million two weeks ago)
number of deaths: 311,000 (276,000 two weeks ago)
World:
number of cases 75.1 Million (65.4 Million 2 weeks ago)
number of deaths: 1.67 Million (1.34 Million 2 weeks ago)
Due to this shortage of hospital staff and space, Medicare is now allowing hospitals to care for patients in their own homes. Such programs will offer around-the-clock electronic monitoring for Medicare patients who are sick enough to be hospitalized but don't need to be in an ICU.
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.
I saw a scary summary of "excess deaths" in 2020: these "excess deaths" are calculated in comparing 2020 to previous years. I suspect many of these excess deaths are attributable to people not seeing doctors regularly or going to the emergency room for fear of contracting COVID-19
Diabetes: 15% above normal
Alzheimer's: 12% above normal
High blood pressure: 11% above normal
Pneumonia and flu:11% above normal
Heart disease: 6% above normal
Testing
The FDA has authorized a new test that checks for both influenza and COVID-19. This test is saliva-based and can be collected at home. Once fully available, the test will be run through Quest labs and will provide results within 2-3 days. It still requires a doctor's prescription.
The FDA also authorized LabCorp's Pixel COVID-19 home collection kit. This kit allows patients to self-collect a nasal swab at home and then send it for testing to LabCorp. This kit can be purchased online or in a store without a prescription.
On 12/15/2020, the FDA authorized the first fully at-home COVID-19 antigen test. This test ("the Ellume COVID-19 home test" provides results in 20 minutes and can be purchased without a prescription. For those people with symptoms, the test accurately identifies 96% of positive cases and 100% of negative cases. For people without symptoms, the test identifies 91% of positive cases and 96% of negative ones. Results take 20 minutes to show up.
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.
On 11/19/2020, the FDA granted emergency use authorization of the combination of remdesivir and the monoclonal antibody baricitinib. Recent studies suggest that adding the baricitinib to remdesivir will speed up recovery by one day.
Vaccines:
The CDC Advisory Committee on Immunization Practices recommended on December 1 that health care personnel and residents of long-term care facilities should be the first to receive the upcoming vaccines (phase 1a). Phase 2 will likely include people with significant illness, "essential workers" who can't telework, teachers/ school staff, older adults, people in homeless shelters. Individual states will have the final say on allocation of vaccines and will tailor recommendations to the needs of their populations.
Pfizer/ BioNTech:
On December 13, the CDC officially recommended use of the Pfizer/ BioNTech COVID-19 vaccine for those aged 16 years and above. This recommendation is based on a randomized trial of 43,000 people who were followed for about 2 months. The Pfizer vaccine was not tested on pregnant women or people who are immunocompromised. This does NOT mean that these groups of people can't get the vaccine, but that the CDC plans on offering special considerations down the line. There is no reason to believe that the vaccine would be less safe in people with immune problems. However, the vaccine may not be as effective in them. We will need to await further studies about vaccine efficacy for such people in the future
Specifically, the American College of Obstetricians and Gynecologists recommended that the Pfizer vaccine should NOT be withheld from pregnant or lactating women.
The Pfizer vaccine was given to the first patients on 12/14/2020 and has been given to people in San Mateo this week also.
Studies suggest that the Pfizer vaccines "starts working" within 10-14 days after the first dose. It seems effective across age groups, race/ ethnic groups, as well as in obese and non-obese patients.
There have been two instances in Britain and one within the United States in which people who had received the Pfizer vaccine subsequently developed a severe allergic reaction. It is unclear how common such an allergy in general, though I suspect that we all will know more about that soon. All of the allergic reactions occurred within minutes of receiving the vaccine. For now, it is recommended that people with a history of anaphylaxis (when the circulation shuts down and people have problem breathing) be observed for 30 minutes after receiving their vaccines. People who have a history of bad allergic reactions (but not anaphylaxis) should be observed for 15 minutes. All others should be observed for 10 minutes. Also, no other vaccines should be given within 2 weeks of receiving the Pfizer/ BioNTech vaccine.
California's Western States Scientific Safety Review Workgroup has reviewed the data on the Pfizer vaccine and found it to be safe and efficacious in a statement from December 13. This advisory group is made up of "nationally acclaimed scientists with expertise in immunization and public health" from Oregon, Washington, Nevada, and California
Moderna:
An FDA advisory panel voted yesterday (12/17/2020) that the FDA issue emergency use authorization for the Moderna vaccine for people 18 and older; The actual authorization is expected today, 12/18/2020.
This vaccine showed 96% efficacy in people aged 18 to 64 and 86% efficacy in people older than 65. However, in all age groups the vaccine was 100% effective in preventing severe disease.
Moderna's vaccine does not have the deep-freeze requirement of the Pfizer vaccine.
Moderna will start testing its vaccine in adolescents soon.
Like with the Pfizer vaccine, people can get muscle aches and a fever after the vaccines. These side effects are more common after the second dose and usually last one day.
Though the Pfizer and Moderna vaccines seem to be very good at preventing severe disease, it is not yet clear if they keep people from getting infected at all. The latter is an important question, as infected, asymptomatic people can still transmit the virus and make others sick. So we have to wait and see to find out if people who have been vaccinated can still make others sick...and we have to continue to wear masks to prevent virus transmission, even if we have been vaccinated.
The Oxford/ AstraZenica vaccine:
This vaccine does not yet have emergency use authorization.
Preliminary results suggest that this vaccine is quite effective in preventing the symptoms of COVID-19 and is effective in young and old alike. However, older adults are less likely to have side effects.
The Russian "Sputnik V" vaccine:
Russian developers published new trial results for this vaccine on December 14 and reported that it was 91.4% effective. At this time, more than 200,000 people have already been vaccinated with this vaccine as part of a mass vaccination drive in Russia.
The United Arab Emirates issued the first government approval of a Chinese coronavirus vaccine on 12/9/2020, citing preliminary data that suggested an 86% effectiveness. Details on the data have not been released, however, so the effectiveness has not been verified by outside sources.
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.
On 12/6/2020, the federal government downgraded the number of COVID-19 vaccines that will be available until the end of 2020: now only 40 million doses (down from 300 million doses) will likely be forthcoming this month.
Antibody therapy:
The FDA has issued an emergency use authorization for the monoclonal antibody "bamlanivimab" produced by Eli Lilly. 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. On November 18, the NIH noted that there was insufficient information to recommend for or against this medication for people with mild to moderate disease.
In late November, the FDA granted emergency use authorization for two more monoclonal antibodies (casirivimab and imdevimab) that need to be administered together intravenously for the outpatient treatment of mild to moderate COVID-19. These too are recommended only for "high risk" individuals. This is the medication cocktail made by Regeneron.
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. ICU and acute care beds are still available and the surge capacity beds have not been activated yet. 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.
Our Community and Beyond:
California Governor Newsom announced the launch of a new COVID-19 exposure notification system, known as "CA Notify." The system was developed by Google and Apple and relies on an app that can be downloaded by all Californians starting December 10. The system is entirely voluntary and will alert users to potential exposures without storing or transmitting any data involving a person's identity or location. All the user has to do is to keep the Bluetooth on and they will receive an alert if they were in close contact with someone who tested positive for COVID-19.
On December 14, Gov. Newsom announced that California had received 33,000 doses of the Pfizer vaccine. The rest of the state's allotment of 393,000 doses will hopefully arrive within days. Unfortunately, there are 2.4 million health care workers and many more nursing home residents, that are in the first tier to receive the vaccine. By the end of December, California should have gotten 2.1 million doses, however.
San Mateo is scheduled to receive 6,000 doses of vaccine next week. Health care workers as well as nursing home residents are supposed to receive the vaccine first. However, there are over 24,000 health care workers in San Mateo County, so many doctors, nurses, and therapists will have to wait for future shipments to become vaccinated.
As of midnight on 12/17/2020, San Mateo has joined the rest of the Bay Area counties in a mandatory "Regional Stay At Home Order." The order is a result of the Bay Area now having less than 15% of ICU beds available. The order prohibits gatherings of any size (except for outdoor church services and political demonstrations). Restaurants can only provide take-out and delivery services. Many businesses, including salons and barbershops, must close. Retail is held to 20% capacity. The new order will stay in place for at least 3 weeks.
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." With the recent surge of cases, we are postponing most routine physical exams and minimizing most in-person visits. Patients who require physical evaluations to diagnose and treat their medical issues will always be seen in person.
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.
We have still are giving "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!
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 10-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.
Many patients have asked me when our office will receive our "allotment" of COVID-19 vaccines. Truth be told: I have no idea. No one has contacted me about this and I rather suspect that we won't receive any COVID-19 vaccines for distribution. The logistics of getting so many people vaccinated - but at different times based on their risk tier- is herculean. I suspect most of the vaccines will be given via hospitals, pharmacies, and County Health offices. I will let you know once I know more and point out where you can get your vaccines and when.
We will try to keep you updated as the epidemic evolves. Feel free to call or email with questions or concerns.
About Dr. Sujansky's Life in These Times
On a more personal note, my family and I continue to do well.
My oldest son, Stefan (20) is back in the U.S. and in our home. He arrived on Monday and is trying to adjust back to life in the U.S. along with the creature comforts that are afforded here. Believe me, I have been trying to spoil him rotten with said creature comforts all week! It is good to have him back.
Every year, my two college roommates and I meet in December and spend a day baking Christmas cookies together. At the end of the day, we have caught up on everyone's lives and have plenty of cookies for our own families as well as enough to distribute to a small city. Well, this year's pandemic threw a monkey wrench in our plans, of course. Instead of baking together, we each made several batches of cookies at home and then met in a Target parking lot to exchange the cookie tins. Then we met over Zoom an hour later for our taste testing. It was not like "old times," for sure, but it was pretty darn good...and we still have enough cookies to share with most of San Mateo. :)
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.
We still have the 20% discount on Obagi skin products through the rest of December. Check out the "Holiday Hydrate Special" which includes the hydrate luxe, retinol, travel sizes of foaming gel and toner, as well as travel size facial elastiderm and hand sanitizer).
Finally, I think this is my last newsletter for the year. I want to wish each of you Happy Hanukah, Merry Christmas, and a Happy New Year! 2020 has been challenging, for sure. Thank you for being there for me at every step along the way. I am so grateful for all of your encouraging words, interests in my personal life, and wishes for my wellbeing. I can't tell you how much you have touched me. I hope that part of the world does not change in 2021...though I am ready for other parts of the world to normalize in 2021!
Thank you.
