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.

The air is finally clearing from the recent wildfires. If you felt poorly, you have good reason to have suffered: The smoke from the wildfires made for the dirtiest air in the last 35 years in some places. On 9/12/2020, the air quality index (AQI) in Salem, Oregon, measured in at 512 - this number is even more worrisome when considering that the AQI was only supposed to go from zero to 500! Moreover, AQI have only been kept for the last 35 years...

Also, not related to COVID-19 but worthy of comment: people with advanced cancer seem to do better and live longer if they drink coffee. As a coffee-drinker myself, I am always pleased to find any medical articles touting its benefits!

Finally, I wanted to share a joint press release from the American Medical Association, American Hospital Association, and the American Nurses Association from 9/24/2020: "By scale and raw numbers, COVID-19 has had a devastating impact on our country, affecting Americans at a rate that represents a nearly worst-case scenario. As autumn begins and as we continue working to minimize the suffering and death of this pandemic, we urge all Americans to get their flu shot early. With no end to COVID-19 in sight, a bad flu season has potential to cause additional strains on our health system that is still battling the pandemic. America's physicians, nurses, and hospitals and health systems thank you for doing your part."

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. Nursing home 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%.
There is more than one SARS-Cov-2 variants ("versions") circulating in the world. The "delta-384 variant" seemed to cause more illnesses in younger patients and could cause symptoms for longer. However, it was associated with less severe disease and a lower mortality rate.
A recent study out of Iceland found that antibodies produced from a COVID-19 infection can last at least 4 months - this is contrary to a previous study that suggested that antibodies were usually found only up to 3 months after infection. This study also found that in Iceland, at least, that 0.3% died of SARS-Cov-2 infections. However, in people who are older than 70 years, the mortality rate was 4.4%.
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 mental 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 depression in the U.S. population is three-times higher now during the pandemic than several years ago.
Analysis of federal data shows that more people have died from dementia since the onset of the pandemic. This is presumably due to the mental decline of people with memory issues in the setting of social isolation. It is just so sad....

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. Cats and ferrets can get the virus and give it to each other, but there are no cases of these animals giving the virus to humans. 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.
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.
We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them
Although we know that face masks help other people from getting infected, new information suggests that they will protect the wearer as well! Even if face masks don't filter out 100% of the viruses in the air, they can reduce the number of viral particles inhaled and keep people from getting sick - or at from getting least very sick.
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! Would you use an umbrella with a giant hole in it? I could use more colorful examples, but I am too much of a lady to go into details...I think you get the idea!
Household exposures are still the most common way that SARS-Cov-2 is transmitted while exposures on public transportation seem less common.
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.
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: the first person was likely exposed by their pre-symptomatic spouse (the study looked at a time when you could still visit your spouse in the hospital). The second person developed symptoms 4 days after being hospitalized for 16 days for an unrelated reason. It is unclear where (of even if) the exposure occurred in the hospital. So I think it is quite safe to go to the hospital for a procedure or for a study or for emergency care, if this is needed.

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.
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.
Of the young adults (aged 18 to 34) who required hospitalization, about 21% needed to be admitted to the Intensive Care Unit and 3% died. The highest predictors of poor outcome were obesity, diabetes, and high blood pressure.
One study (looking at only one medical center - so unclear how predictive this study is...) found that children with COVID-19 are just as likely to end up in the ICU as children infected with influenza.
Pregnant women with COVID-19 are less likely to have symptoms compared to their non-pregnant counterparts. However, they are also more likely to end up in the intensive care unit and on a ventilator. In addition, preterm births are more common in pregnant women with COVID-19 than pregnant women without the disease.
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.
About 60% of hospitalized people have decreased heart function - even six weeks after discharge. However, this heart dysfunction tended to improve over time.
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.
According to a report in JAMA, a gene that allows SARS-Cov-2 to enter into the cell ("transmembrane serine protease 2") exists in higher concentrations in the nasal cavities of Black people than other racial groups. It is possible that this genetic variation is partially to blame for the increased incidence of COVID-19 in the African American population. In addition, African Americans are also more likely to be front-line workers and therefore face higher exposure to the virus.

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.
The worldwide incidence of COVID-19 is still rising. At this time, over 32.4 million people in the world have contracted the novel coronavirus. 986,000 people have died worldwide (compared to 911,000 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 203,000) in the world. The second highest country is Brazil, with 140,000 deaths. However, Europe is also experiencing a resurgence of it's COVID-19 cases and is implementing new quarantine measures:
Octoberfest will be different in Munich this year, as gatherings of more than 5 people will be prohibited.
All bars and restaurants will be closed in Marseille, France.
London is having people stay home from work again.
In the United States alone, more than 203,000 people have died of COVID-19 and over 7.04 million Americans have been infected.
U.S. cases surged in the Northeast in the spring and in the South and West in early summer. Now, in late summer, we are seeing infections soar in the Midwest. North and South Dakota, Missouri, and Iowa now are adding more cases per capita than the other states.
California is reporting that it now has more than 804,000 people infected with SARS-Cov-2 (compared to 753,000 two weeks ago).
As of September 24, 2020, there have been 9785 people in San Mateo County who have tested positive with the SARS-CoV-2 virus (compared to 8966 people two weeks ago). 150 people in San Mateo County have died from the disease (compared to 139 people two weeks ago).
A new study from the CDC highlights how the median age of people in the U.S. infected with SARS-Cov-2 has dropped: in May, the median age was 46; in August, the median age had dropped to 38. At this time, Americans in their 20s make up the biggest group of people getting infected, likely due to their frequent disregard for social distancing guidelines.

Testing

According to the Government's General Accounting Office (9/21/2020), states are still facing a shortage of personal protective equipment and testing supplies, 6 months into the epidemic.
U.S. manufacturers are sharply increasing the production of fast and cheap (but less accurate) COVID-19 tests. The goal is to have 100 million such tests produced per month by the end of 2020.
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.
Finland is launching a new experimental protocol for coronavirus testing at its main airport: virus-sniffing dogs! We know that dogs' noses are sensitive enough to be able to detect various infectious diseases and even cancers. In this pilot program in Finland, dogs have been trained to sniff out COVID-19 and can accomplish this feat in 10 seconds or less! Human participation is voluntary for now...

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.
A medication developed for the treatment of rheumatoid arthritis, called "Olumiant," when taken together with remdesivir, may further speed recovery in COVID-19.
Infusion of an experimental drug, a monoclonal antibody, early in the course of COVID-19, has been found to reduce the likelihood of hospitalization. However, this statement (by the drug manufacturer Eli Lilly) has not been verified by independent experts yet and the results have not been published in a peer-reviewed journal, so the results are not yet confirmed...
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. Overall, steroids reduced the death rate in such patients by 20%.
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.
Currently 8 separate vaccines are in the final phase of mass testing.
Both Pfizer and BioNTech, who are developing a vaccine based on a mRNA (messenger RNA) model, 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.
Scientists at Oxford University and Imperial College in London are also investigating whether an inhaled version of their vaccine may work equally well (or better!) than the injected version.
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.
Understandably, many Americans are concerned that a U.S. SARS-Cov-19 vaccine will be similarly fast-tracked (for political purposes) and therefore not adequately tested. The FDA plans on releasing stricter guidelines on emergency vaccine authorization soon. Details are still unclear, but the guidance will require that people in phase 3 trials will be followed for a median of 2 months AFTER their last vaccine dose. In addition, an independent panel of experts will need to review each vaccine's detailed information prior to an authorization being considered.
At this time, 58% of the U.S. populations reports that they would take an upcoming COVID-19 vaccine, while 31% are not sure, and 11% would refuse a vaccine.
The Administration has announced on 9/16/2020 that a future COVID-19 vaccine will be administered to all Americans free of charge.
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.
Eli Lilly has developed an experimental treatment involving SARS-Cov-2 antibodies. The trial is looking at people with COVID-19 not sick enough to require hospitalization and is still ongoing. Nonetheless, an interim analysis is promising: those patients that received the antibodies had a 1.7% chance of being admitted to the hospital or to go to the emergency room, while 6% of those that did not get the treatment met that fate. Stay tuned.

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)
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 incidence of influenza this season is much reduced so far! We have seen this especially in the southern hemispheres of our globe. The reasons for this decrease likely lies in the measures of social distancing and increased hygiene that most of us have adopted. These measures not only help prevent COVID-19, but also influenza. That's one silver lining to the pandemic, I guess!
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 hope to get the flu shots for the non-seniors in short order.

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.

I have completed my most recent knitting project - an infinity scarf - just in time for fall! As you can see, I favor projects that are not encumbered with details like pesky sleeves or collars :).

Also, some friends and I visited the Filoli Gardens in Woodside last evening. It was breathtaking! The flowers were beautiful and the entire setting enchanting. See the pictures below. I was also so mesmerized by some of the amazing sculptures. I highly recommend a visit before the weather turns wet.

My older son Stefan (age 20) is still on the Greek island of Samos working with an NGO for a refugee camp. He completed his 14 days of quarantine, only to be re-quarantined 2 days later after some people in the refugee camp tested positive for SARS-Cov-2. For the last 3 days, however, he is out and about again and loving it.

Markus (age 17) is spending his days doing schoolwork and working on college applications, as he is a high school senior. I am proud of him for putting his nose to the grind-stone and just plowing through this work for now (mixed metaphors notwithstanding...).

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.

Our air is clean once again and autumn has arrived. There is a lovely nip in the air and I am looking forward to the smells and other pleasures of the new season. I hope you will all have a chance to enjoy the lovely weather this weekend. I recommend a nice walk during the day and a warm bed at night!

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.