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. 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.
Local cases of COVID-19 remain high: rates are 10+ times higher than they were in September and October. Deaths are about 10 times higher as well. At the same time, the number of cases, hospitalizations, and deaths is now going down! Also, vaccinations are slooooowly opening up for people over 65... definitely very good news and very bad news at once.
This is what I know:
The new presidential administration has laid out a very detailed plan on dealing with the novel coronavirus. It is hoped that this more centralized approach will help expedite the vaccination process and also help prevent disease spread in other ways. This plan includes:
increased vaccination centers
federally supported help from FEMA and the National Guard
mobilization of more personnel to administer the vaccine (I myself have added my name to a list in San Mateo to offer help with vaccinations if they need it...)
more federal help to counties to help with their vaccination efforts
increased production of PPE (which is currently still in short supply!)
emphasis on vaccinating populations that are more vulnerable and/ or disenfranchised.
This week, Gov. Newsome announced a new flexibility in California's vaccination tiers, in an effort to accelerate the process. At this time, priority will be given to people over 65. Unfortunately, the vaccine supply is not sufficient to vaccinate all Californians over 65 and the distribution infrastructure for such a huge vaccination process is not yet in place.
At this time, over 23 million doses of vaccine have been administered in the U.S. More than 3 million of those doses are second doses. At this time, about 6% of the American population has received at least one dose of vaccine.
With few exceptions, only Phase 1a ( workers and residents/ staff) are currently receiving the COVID-19 vaccine supplied directly by San Mateo county. People older than 75 are eligible to receive vaccines through Sutter and people older than 65 can receive vaccines via Stanford.
Health officials have created a "COVID-19 Hotline" that is open seven days a week who can advise people on eligibility issues etc.: 1-833-422-4255.
Sutter Health has started allowing patients older than 74 to sign up for the COVID-19 vaccine via their "myhealthonline" site. To sign up for this site, you can go to www.sutterhealth.org to register or call 844-987-6115.
Please let me know if you get a COVID-19 vaccine, so I can add it to your medical chart.
As of next week, Sutter will a vaccination clinic at the San Mateo Event Center and will be open to Sutter patients aged 75 and older. You still need to make an appointment (via the above phone number or "myhealthonline") but hopefully this venue will streamline the process more.
As mentioned above, Stanford is vaccinating people in their system who are older than 65. This can be done via the Stanford "healthonline" website or by calling them. However, they are not offering vaccines to patients outside of their system at this time.
Some states and communities are running low on vaccines. These shortages are occurring as states have recently significantly increased their vaccination efforts.
Some people who have received their fist vaccine dose are worried that their second dose may be delayed. While the CDC does urge people to get the second dose as close as possible to the ideal interval, they also say that "there is no maximum interval between the first and second doses for either vaccine."
At this time, there is simply not enough vaccine available to meet demands. Also, vaccine supply routes are unlikely to increase beyond previous production estimates before April. This is due to the lack of manufacturing capacity. However, more vaccines may become available with improved coordination of local and federal vaccination efforts. In addition, other strategies are being employed, like increasing production of certain needles and syringes that allow an extra dose of vaccine to be derived from each vial of Moderna vaccine.
Finally, there is hope for new vaccines to come on the market soon. At this time, there are at least three other vaccines in late stage clinical trials. If any one of them is successful, we will have millions of extra vaccine doses coming to the U.S. market in the coming months. One such such vaccine is produced by Johnson & Johnson. Others are by Novavax and AstraZenica.
With desperation growing in the population, we are now seeing scams that prey upon people's eagerness to get a vaccination. Beware of:
offers to move you ahead in the vaccination cue for a fee.
offers to sell you a spot on the vaccination waiting list.
someone that is not the County or a health care provider trying to offer you a vaccine.
any calls about vaccines where people ask for your financial information of social security information. Never give such information out over the phone.
ads for miracle cures involving supplements or vitamins.
General Information:
As treatments have been improving, the mortality associated with COVID-19 has been steadily decreasing.
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.
A recent study in the journal Science suggested that COVID-19 will continue to be with us in future years. However, once we have reached her immunity via vaccinations and infection, it will not be worse than the common cold.
Deaths nationwide were 18% higher from March, 2020 to December, 2020 than in a "normal" year.
The World Health Organization now recommends that people dealing with COVID-19 outside of the hospital use a pulse oximeter (that little gadget that goes on your finger and reads how much oxygen is in your blood) to help gauge disease progression. These are readily available and cost about $20.
Transmission:
At this time, it is estimated that no more than 14% of the U.S. population has been infected by SARS-Cov-2. Unfortunately, that is a long way from heard immunity...
A January article in the Annals of Internal Medicine suggested that at least one third of SARS-Cov-2 infections are asymptomatic. If you don't have any symptoms and test positive for the virus, you have only a 25% chance of developing symptoms down the road...though you are still contagious!
A SARS-Cov-2 variant originally found in the United Kingdom seems to be much more infectious than other strains.
Some have raised concerns that the British virus variant was more dangerous than the others. This is far from clear, however. The United Kingdom has been slammed with coronavirus infections in recent weeks and the increased mortality may well be due to hospitals working at excess capacity and with limited personnel.
The variant first noted in Britain (aka the "B.1.1.7 variant") is likely to become the most prevalent strain in the U.S. by March, 2021. Experts are concerned that the increased transmissibility will translated to new phase of exponential growth in cases...This variant has now been reported in at least 20 U.S. states and 60 countries world-wide.
South Africa has also seen a more contagious strain of the virus. These more contagious variant have now been found in the U.S. as well as in multiple other countries.
The South African variant is now dominant in the southern half of Africa.
Another new highly-contagious variant has originated in Brazil.
Unfortunately, a U.S. patient with this SARS-Cov-2 variant was just diagnosed in the Minnesota. This variant is very similar to the one noted in South Africa.
It looks like California has recently developed its very own SARS-Cov-2 mutant. This variant, known as CAL.20C was first found in July, but didn't start to spread much until November. There is no signs to suggest, as yet, that this new variant is more lethal (or even more contagious) than other strains. It has spread to 10 states so far
There is a new travel ban on non-U.S. citizens entering the country from countries with these more contagious variants: the United Kingdom, South Africa, and Brazil. Also, 26 other European countries are effected, as these allow travel over open borders and may therefore also have increased incidence of these more contagious strains.
The CDC has issued a new requirement for people flying into the U.S. from abroad: effective January 26, all travelers boarding flights from abroad must now have evidence of a negative COVID-19 test within 3 days of travel. The CDC also recommends that passengers get re-tested 3 to 5 days after arriving in the U.S.
Yet another study, this one published in MMWR, shows that the risk of transmission of SARS-Cov-2 is actually quite low in K-12 schools, as long as people wear masks, honor social distancing, and avoid indoor sports.
Face masks are extremely important and effective in protecting the wearer as well as the people around them
The most effective cloth masks are multilayer - these can block 50-70% of droplets and particles. Materials like silk may also help repel moist droplets and reduce fabric wetting.
If you only have a rather flimsy mask, then doubling up with two masks (or more!) can actually provide very effective protection from the coronavirus.
Symptoms and Risk Factors:
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.
An increasing number of COVID-19 patients seem to have long-standing sequelae of their infection: three quarters of people previously hospitalized with COVID-19 have at least one ongoing symptom 6 months later (The Lancet). Such symptoms usually included muscle weakness or fatigue, sleeping issues, and anxiety/ depression.
I know there were lots of concerns early in the pandemic about ACE-inhibitors and ARB's (both of which are blood pressure medications) possibly making people more susceptible to COVID-19. Since then, several studies did NOT find a correlation. Most recently, an article in JAMA looked at 700 adults on these blood pressure pills and, again, found that there was NO correlation between taking/ stopping them and developing COVID-19. One less thing to worry about!
Incidence/ Prevalence:
On 1/19/2021, the United States exceeded 400,000 deaths due to COVID-19. Only one month earlier, we had hit 300,000 deaths.
California has become the first state to record more than 3 million cases of COVID-19.
The above notwithstanding, it appears that the current coronavirus wave has peaked. While another surge is possible, the number of new daily infections appears to be decreasing in most states for the last several weeks. There has been a 21% drop in new cases in the last week. All but one state found a decline in new coronavirus infections. The numbers are also looking better in most of Europe. And the western part of the United States is seeing the largest reduction of COVID-19 cases nationwide, with a reduction of 43% in the new case overall. Yeah!
As of January 14, over 2.5 million children in the United State have tested positive for SARS-Cov-2. Between January 7 and January 14, 211,000 were diagnosed, the single highest increase since onset of the pandemic. The death rate for children is still between 0.00% and 0.06%, thankfully.
Some statistics:
San Mateo:
number of cases: 34.957 (30,196 two weeks ago)
number of deaths: 356 (268 two weeks ago)
number of people in the hospital: 149 (188 two weeks ago).
California:
number of cases: 3.26 Million ( 2.9 Million two weeks ago)
number of deaths: 39,211 (32,239 two weeks ago)
U.S.:
number of cases: 25.8 Million (23.4 Million two weeks ago)
number of deaths: 433,000 (389,000 two weeks ago)
World:
number of cases 101 Million (93.3 Million 2 weeks ago)
number of deaths: 2.19 Million (2 Million 2 weeks ago)
Testing
The BinaxNOW rapid antigen test, developed by Abbott labs, found that it could accurately predict infection with SARS-Cov-2 in people with symptoms 64% of the time. If you didn't have symptoms and were infected, then the likelihood to pick up the disease was only 36%. However, if the test did show a positive result, then the likelihood of being infected was 100%.
Treatment
Remdesivir is the only medication approved for COVID-19 treatment in the United States.
A medication being used for people hospitalized for COVID-19 called tocilizumab may actually make you worse! However, a different trial published only 10 days previously showed that it helped with the disease. If you guys are feeling confused and frustrated, then join the club....unfortunately, this kind of contradictory data is not uncommon early in an investigation looking for new treatments for diseases. This is why doctors usually don't rely on one trial or study alone to make major treatment decisions. More information will be forthcoming!
Lots of other medications are being tested aggressively in the treatment against SARS-Cov-2. Indeed, over 200 possible treatments are in clinical trials. One such drug is called Aplidin. A study published in the journal Science showed that this drug drastically prevented replication of the virus and may indeed be 30-times as effective as remdesivir. However, we are still in the early part of trials, so nothing conclusive can be said as yet.
Vaccines:
At this time, there are 64 vaccines in clinical development and another 173 vaccines in pre-clinical trials world-wide.
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).
Scientists are still waiting to learn if people who have been vaccinated can still spread virus to others...though early data on this topic is promising. So you still need to wear a mask, even if you have been vaccinated!
Both the Pfizer and Moderna vaccines should not be given to people with an allergy to polyethylene glycol or polysorbate. People with such possible vaccines should be cleared by an allergist prior to vaccine administration and have the vaccine administered in a setting where advanced medical care is available - just in case!
The CDC has recently made some changes to the timing of the vaccines: the interval between vaccines (3 weeks for Pfizer/ BioNTech and 4 weeks for Moderna) remains the same. However, if this is not possible, the second dose can be given up to 6 weeks after the first dose. In fact, even after 6 weeks the second dose can be given and people do NOT need to restart the entire vaccination process.
Pfizer/ BioNTech:
Good news: initially, the number of severe allergic reactions to the vaccine were on the order of 11/ million, based on studies done in December. Now, including the data from January, it looks like the likelihood of an allergic reaction to t he Pfizer vaccine is closer to 5/ million.
A new study (in bioRxiv) suggests that the Pfizer vaccine can neutralize the B.1.1.7 (British) variant of the virus as well as the one from South Africa. However, the efficacy for the South African variant is "only slightly reduced."
Moderna:
Moderna announced that their vaccine did protect against the two virus strains first found in Great Britain and South Africa, though the response to the South African variant was not as strong as against other variants. Now Moderna is looking at developing special booster shots to the South African variant, should that become needed in the future.
Studies show that severe allergic reactions to the Moderna vaccine are quite rare, on the order of 3 in a million.
Johnson & Johnson is in the late stages of their new COVID-19 vaccine development: recent results show that the vaccine generated an immune response in nearly all volunteers, with minimal side effects. Antibodies were detected in at least 90% of the people who got the vaccine. The advantage of the J & J vaccine is that it requires only one shot of vaccine. Also, the vaccine can stay stable in a refrigerator for months. Unfortunately, it may yet be another few months until this vaccine is further vetted and comes to market...
The Oxford/ AstraZenica vaccine:
On December 30, Britain became the first country to grant emergency use authorization for this vaccine, opening the door to production of a vaccine that is inexpensive and easy to store.
This vaccine does not yet have emergency use authorization in the U. S. and is unlikely to receive such authorization before April, 2021.
Merck just announced that it was halting trials on two of its vaccine candidates, as they didn't work very well. Instead, Merck announced that they will be focusing their efforts on developing two medications that may be helpful in treating COVID-19.
Novavax announced that it “has begun a large late-stage study of its experimental COVID-19 vaccine in the United States...” This vaccine is protein-based (not RNA-based like the Moderna and Pfizer vaccines). One advantage of this type of vaccine is that it can be manufactured on a large scale quickly.
A second vaccine (called Coronavac) produced by China has been studied in Brazil and was said to be effective at a rate of 78%. Unfortunately, subsequent studies suggested that the efficacy rate was just over 50%...
India is starting a large vaccination campaign using the vaccine developed by AstraZenica as well as a locally developed vaccine from India.
Sanofi reported on 1/27/2021 that it would help manufacture 125 million doses of the Pfizer/ BioNTech vaccine in Europe. At the same time, Sanofi is also still developing two vaccines of its own.
Antibody therapy:
COVID-19 patients who receive convalescent plasma containing high numbers of antibodies did better than those receiving plasma with low levels of antibodies...makes sense.
A recent trial gave the antibody treatment bamlanivimab to staff and residents of nursing homes in England. These people had not contracted the virus yet. Those people that were treated with the intravenous prophylactic medication were 80% less likely to later develop COVID-19.
Similar to above, it seems that the antibody cocktail (casirivimab- imdevimab) produced by Regeneron can also help prevent infections and disease in people when given PRIOR to them getting sick. This is great news, of course. The bad news is that this "drug cocktail" requires an intravenous infusion and this is not easy to administer in the outpatient arena.
Treatment with bamlanivimab combined with etesevimab was helpful in treating outpatients with COVID-19, but bamanivimab alone was not effective.
Some data suggests that these antibody treatments are not as effective against the more contagious variants we are seeing out of Britain, South Africa, and elsewhere.
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.
Our Community and Beyond:
As of this week, the California Department of Public Health ended its state-wide shutdown. County-based restrictions will again determine what activities are allowed and where. We are back to the color-coded tier used previously. At this time, all but 4 California counties are in the most restrictive purple tier. Sadly, San Mateo is one of the purple counties. In this purple tier, restaurants, wineries, movie theaters, and gyms may operate outdoors. Also, personal care services may reopen with strict limits on occupancy.
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.
I have been contacted by a number of you about when they can come into my office to get their vaccine: our office has not been given any COVID-19 vaccine, and it is not clear that we will ever be given a shipment. I suspect this is due to both logistical requirements in accounting for vaccine distribution as well as the very real issues related to vaccine storage (including freezers that can store vaccine at -100 degrees F!).
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."
All of us in the office are healthy and doing well.
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.
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.
All is quiet at the Sujansky household. My older son has moved back to Washington, D.C. to share an apartment with two friends while he takes college classes remotely. So now the house is quieter and my grocery bills are smaller and the laundry is more manageable. Life is easier, but I miss him like crazy.
So with fewer mouths to feet, I have paradoxically thrown more efforts into baking. The result last weekend consisted of home made cinnamon rolls (pictured below) and two loaves of chocolate chip banana bread. If I gain weight, I will blame my son for his absence...
I have also been cuddling more with our dog Mala as she misses my son seemingly as much as I do, and walks into his room several times a day wondering where he is.
We are going up to Kirkwood this coming weekend to take advantage of the new snow. This is why I am sending out this newsletter a day early...now I can "get a jump" on our weekend and start packing! The snow should be amazing...
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.
Sincerely,
Ulrike Sujansky, MD
