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.
"Herd Immunity" occurs in any population, when a certain percentage of the people becomes immune to an infection - either because they have had the infection already or because they are vaccinated. This percentage is different for each infectious disease - for COVID-19 the epidemiologists guestimate that the herd immunity lies at about 50-67%. At this time researchers estimate that about 9% of the U.S. population has been infected by SARS-Cov-2.
On October 4, three scientists (one from Harvard, one from Stanford, and one from Oxford University) presented the "Great Barrington Declaration" to provide an alternative strategy to the current lock-down strategies set up to prevent COVID-19 spread. These scientists argued that most younger people do fine with SARS-Cov-2 infection and do not suffer significant harm. At the same time, ongoing social isolation causes increases in depression, anxiety, and substance abuse and also devastates the economy. So the scientists suggested allowing the lower-risk individuals to go back to normal socialization (no masks, no social distancing, etc), with the understanding that they would likely get infected. Meanwhile, higher risk groups would continue to stay isolated. This way, they argue, a rapid herd immunity could be achieved as the younger people will become immune (after being infected) and can not spread it to the vulnerable.
This concept certainly has its appeal, but - in my opinion - the devil is in the details and there are some issues that need to be addressed:
20% of the deaths of COVID-19 occur in people younger than 65.
A large number of people who survive COVID-19 go on to have chronic symptoms that can last months.
What happens in the many households that include grandparents, parents, and children - how are the elders safe-guarded if the children and parents allow themselves to become increasingly exposed?
What happens to the front line workers like doctors and nurses: they are more likely to get their vulnerable patients ill if they are more likely to become ill themselves.
We are unclear how long any immunity from past COVID-19 infections lasts...
Subsequently, the so called "Snow Memo" followed the Great Barrington declaration. In it, over 6,200 scientists, researches, and health care professionals have disavowed the Great Barrington proposals, calling it reckless and ill-advised. They argue that ongoing care with masks, distancing protocols, and (hopefully soon) vaccination will achieve the same herd immunity, but at a lower social cost. We have yet to see which philosophy will be adopted by the country.
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. 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%. Looking at the experience of New York between March and June, 2020, researchers found the mortality rate to be 1.4% overall. However, for adults between 65 and 74, the mortality rate was 4.9% and those over 75 had a mortality rate of 14.2%.
The United Kingdom announced on October 20 that it will start infecting healthy volunteers with SARS-Cov-2 as part of a clinical trial, so that scientists can better understand the amount of virus that is needed to cause illness. In a later phase of a trial, volunteers will be vaccinated for SARS-Cov-2 and then exposed to the virus itself.
COVID-19 has had negative health impacts on many people who don't contract the virus: 40% of U.S. adults surveyed in late June reported at least one or behavioral health problem associated with the pandemic. In general, young adults, Hispanic and Black people, as well as essential workers and unpaid caregivers had the highest rates of issues.
Anxiety is rising during the pandemic: 62% of respondents in a recent poll reported increased anxiety. Prior years' polls found anxiety at 32% to 39%....at the same time, if 62% of people are now feeling more anxious, what about the other 38%?? Isn't everyone more anxious these days...just saying...
The CDC has extended its ban on passenger cruise ship travel through the end of October. Between March and September, 2020, there have been at least 3700 people who fell ill with COVID-19 that they contracted while on a cruise. 41 people have died.
The World Bank warned this week that the coronavirus pandemic could push over 100 million people into extreme poverty worldwide. Extreme poverty is defined as living on less than $1.90 per day.
To help prevent the spread of misinformation related the pandemic, the World Health Organization has partnered with Wikipedia to provide accurate information on the website. This joint effort allows Wikipedia to use the WHO published information, graphs, and video free of charge.
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. The virus can also be spread through the air beyond a 6 feet distance, especially in poorly ventilated spaces. 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.
The CDC has re-defined what it means by "close contact" vis-a-vis the coronavirus: in the past, a "close contact" of a coronavirus patient had been in continuous contact with the patient for 15 minutes and was therefore thought to be at risk of getting the disease themselves. Now, however, a "close contact" is someone who has been within 6 feet of a patient for at least 15 minutes spread out over 24 hours...so they could have had 2 minutes of contact here, 5 minutes of contact there - as long as it totaled to at least 15 minutes over 24 hours. This too will put them at risk of contagion.
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!
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! In comparison, the influenza virus can stay alive on surfaces for 17 days. Glass surfaces (such as smart phone covers!) are particularly likely to carry the virus, so please clean your smart phone surfaces frequently!
It now seems likely that re-infection with SARS-Cov-2 does occur, but is rare
A study published in the journal Pediatrics suggests that child-care centers do NOT hasten the spread of SARS-Cov-2, even if the infectious rates are high in the community. This finding will be important as our country is once again grappling with decisions as to what schools and centers can open safely.
There is an excellent article published in the Atlantic about SARS-Cov-2 transmission. It focuses on how many "super spreader events" have been responsible for transmissions of the virus and how this could explain why, for example, Northern Italy was an early focus of the disease, while Central Italy wasn't. In addition to some people being "super-emitters" of the virus, other circumstances (large indoor events, crowding, poor ventilation) also play a large role. This is why events with large congregations of people - like weddings, large church gatherings, restaurants - are likely to become hot spots of transmission, especially if there is loud talking or singing involved. The article is worth reading in its entirety:
https://www.theatlantic.com/health/archive/2020/09/k-overlooked-variable-driving-pandemic/616548/
We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them
Please, folks, wear the face masks properly! I see so many people walking about wearing face masks with their noses not covered. This doesn't protect anyone!
On October 19, the CDC issued a "strong recommendation" that all passengers and employees on airplanes, trains, buses, taxis, subways, and ride-share vehicles wear a face mask. In addition, people in airports or trains stations are also asked to wear facial coverings.
More of us are traveling by airplane again these days. An interesting article from JAMA looked at the risk of flying and getting infected with SARS-Cov-2:
The risk of getting COVID-19 during air travel is lower than from an office building, classroom, or supermarket.
The low infectivity has to do with the relatively low airflow between rows.
Half of the airflow in a plane is from fresh air from outside - the other half is recycled through HEPA filters similar to the ones used in an operating room.
Current estimates suggest that only 42 people have gotten COVID-19 from being in an airplane.
if you want to see more details, please refer to the article itself at:
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.
An adult version of the multisystem inflammatory disease of children has now been described as well: a total of 27 adults with COVID-19 have been found to have signs of inflammation of the heart, digestive system, and nervous system. Three patients have died.
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.
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 (but not obese) have an increased risk of severe illness with COVID-19. This means that 75% of the U.S. population is at heightened risk as 75% of the U.S. population is overweight or obese.
Adults with vitamin D deficiency are at greater risk for severe COVID-19 disease and death.
In the United States, Black people and Hispanic people are three times as likely to become infected with COVID-19 compared to Caucasians. Moreover, Black and Hispanic people are twice as likely to die of the disease compared to White people.
Incidence/ Prevalence:
To the best of our knowledge, only about 5 people world-wide have become re-infected with SARS-Cov-2, a tiny number given the prevalence of the disease. This is great news!
COVID-19 illnesses and infections have been increasing in recent weeks, suggesting that the long-dreaded fall spike of cases is beginning. In the last week, the U.S. has confirmed an average of 54,000 new cases per day, an 25% increase compared to the previous week - a change that can not be explained by increased testing alone. Hospitals across the U.S. are facing an increase of COVID-19 hospitalizations. Hospitalizations have risen by at least 5% in 37 states as of last Sunday. At this time, more than 41,000 people are in the hospital with COVID-19 in our country, an increase of 40% in the last month. This increased need for hospitalization has turned into a significant issue in parts of rural America, where hospitals tend to be further away and smaller in size.
At this time, over 42 million people in the world have contracted the novel coronavirus. 1.14 million people have died worldwide (compared to 986,000 two weeks ago). The United States has the highest number of cases. The U.S. also has the highest number of deaths (at 223,000) in the world.
In the United States, more than 8.49 million people have now contracted SARS-Cov-2. The current rise in nation-wide cases is driven by the rapid transmission in Midwestern states.
California is reporting that it now has more than 897,000 people infected with SARS-Cov-2 (compared to 848,000 two weeks ago).
As of October 22, 2020, there have been 10,961 people in San Mateo County who have tested positive with the SARS-CoV-2 virus (compared to 10,452 people two weeks ago). 157 people in San Mateo County have died from the disease (compared to 155 people two weeks ago).
A bit of good news: even as coronavirus disease is spiking throughout most of the country, the incidence of COVID-19 infection and deaths has been flat or decreasing in California.
Teenagers are about twice as likely to become infected and transmit SARS-Cov-2 as compared to younger children.
At this time, about 100 children and teenagers have died of COVID-19 in the U.S. (compared to over 200,000 fatalities overall).
Some more bad news: a recent study published in JAMA looked at the per capital death rate in the United States and compared it to 18 other countries with populations larger than 5 million people and a per capital GDP of more than $25,000 per year. This "all-cause" mortality takes into consideration those fatalities that may have been related to the coronavirus, but were never confirmed. Overall deaths in the U.S. in 2020 are more than 85% higher than in places such as Germany and Israel. Even if we look at the deaths clearly due to COVID-19, the number of people dying of the disease since May 10 is about 50% higher than every other country in the study. Possible reasons for this excess mortality is assumed to be weak public health infrastructure and a decentralized, inconsistent US response to the pandemic. Also, the U.S. population has more associated underlying disease (such as diabetes and obesity) compared to many other countries.
Testing
On September 28, President Trump announced a plan to distribute 150 million rapid coronavirus tests in the coming months. These tests had been purchased by the government previously and can deliver results within 15 minutes. The tests will be distributed to the individual states based on their population.
Another rapid COVID-19 test has been approved by the FDA. This one is called "CareStart" and functions much like a home pregnancy test. I only hope that small physician's offices like mine will have access to such testing in the near future....other rapid tests have been on back-order and not available to small private practices.
Also, another saliva test ("SalivaDirect") has been approved by the FDA and will be distributed to laboratories - hopefully soon!
Treatment
As treatments have been improving, the mortality associated with COVID-19 has been steadily decreasing over the last few months.
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. Unfortunately, recent reports on the efficacy of remdesivir have been mixed:
On October 8, the New England Journal published the final report on the NIH trial of this medication: although use of remdesivir significantly improved the time to disease improvement with this drug, mortality rates were not affected.
On October 15, the WHO released interim trial results of a 30-country randomized trial of the drug, suggesting that remdesivir (as well as hyddroxychloroquine, lopinavir, and interferon) had little or no effect on hospitalized COVID-19 patients.
Other recent results showed that administration of remdesivir to patients requiring oxygen reduced the recovery time of COVID-19 by 5 days compared to placebo.
A new trial found that the combination of remdesivir with baricitinib improved the time to hospital discharge from 8 days to 7. Also, this regimen increased the survival of patients with COVID-19.
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.
On October 8, the New England Journal of Medicine published a randomized study on hydroxychloroquine, suggesting that patients on this medication were actually LESS likely to be discharged from the hospital alive.
Plasma therapy (using blood plasma of people who had been infected with SARS-COv-2 previously) also did not show a survival benefit (Clinical Infectious Diseases, October 10)...however, it seems that patients older than 65 may have benefitted more than others.
Vaccine development is ongoing.
Dr. Fauci was "cautiously optiministic" this week that we will have a safe and effective vaccine for the novel coronavirus by November or December.
There are more than 200 COVID-19 vaccines under development overall.
Both Pfizer and BioNTech have entered phase 3 trials. The mRNA technology for vaccine development is new and could usher in a new era of faster and safer vaccine development in general. Fingers crossed!
Pfizer announced in mid October that it would not apply for an emergency authorization of its COVID-19 vaccine prior to the third week of November, citing the need to collect additional safety and manufacturing data.
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.
Unfortunately, the J&J trials have been paused on 10/13/2020 due to one unexplained illness in one participant.
Invio Pharmaceuticals have had to put a hold on their final vaccine trials as the FDA tries to obtain some answers related to the novel delivery method of the vaccine. The hold was not due to any adverse effects seen in earlier investigation.
An October article in the New England Journal of Medicine explains why a 2 month follow-up requirement for vaccines is appropriate:
Most adverse events occur within 6 weeks after receiving a vaccine.
The two month post-vaccination time frame allows scientists to make sure that the immune response doesn't wane after one month.
The WHO actually requires a 3 month follow up of COVID-19 vaccines; other vaccines (like the shingrix shingles vaccine) required a follow up of 3-4 years.
The FDA has approved Pfizer to include children over the age of 11 in its late-stage vaccine trials. This will let us know how children respond to the vaccines and hopefully allow for children to receive the vaccines as well - especially children that are particularly vulnerable due to underlying health conditions.
Antibody therapy:
Eli Lilly has developed an experimental treatment involving SARS-Cov-2 antibodies.
On 10/13/2020, Eli Lilly had to pause their clinical trials due to "a safety concern." Although it is understandably frustrating that this treatment may ultimately be proven to be risky, it is good that the safety procedures are alive and well and we know that vaccines and treatments that will eventually come to market will likely have been adequately vetted.
Regeneron Pharmaceuticals, the company responsible for the experimental antibody medication administered to President Trump, has asked for emergency authorization for use of its medication. Preliminary results have shown reduced viral levels in patients treated outside the hospital. Supplies are limited and only 50,000 patients could be treated at first.
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.
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.
People hospitalized at Peninsula Hospital for reasons other than COVID-19 may now have one visitor per day during visiting hours (10 am to 5 pm daily). Visitors will be screened for symptoms and asked to provide their name and phone number for contact tracing purposes. Also, visitors must wear specific face masks provided by Sutter.
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 October 19, San Mateo mandated a new compliance unit that will monitor businesses on issues related to compliance with county-related health orders. Specifically, businesses must implement social distancing protocols, require face coverings, and provide hand sanitizer or soap and water. If businesses are not in compliance, they will first be issued a warning. If the issues continue, civil penalties will be implemented (such as fines between $250 and $3000 per violation). Finally, the state reserves the right to criminally prosecute repeat offenders.
Santa Clara County has closed pro sporting events and amusement parks for the foreseeable future
On October 19, Gov. Newsom announced his plans to launch a scientific working group to examine the safety of any coronavirus vaccines that receive federal approval.
California is also preparing to launch a massive vaccination campaign, according to plans released last week. The details of the plan, which presumably include information on where the vaccine will be distributed and stored as well as what populations will be prioritized, have not been released. Given the size of California's population, such a vaccination campaign is a huge undertaking and requires careful planning.
On September 23, San Mateo announced a plan to significantly increase testing opportunities. The county's strategy involves a three-pronged approach:
Scheduled testing at the San Mateo County Event Center. Testing here will occur Tuesdays through Saturdays from 8 am to 3 pm - all without a cost to the patients. Appointments are required and can be made at "projectbaseline.com/COVID19"
Mobile testing in under-served communities.
Targeted neighborhood testing.
The CDC has recommended that children NOT trick-or-treat this Halloween, considering this a "higher risk" activity. Boo-hoo!
Our Office: What We Are Doing to Keep You Safe:
All patients seen in person will be screened for COVID-19 exposure and symptoms prior to coming into the building.
We disinfect all exam rooms and medical equipment as well as all door handles after EVERY patient visit, regardless of the medical issues involved.
We are also using tele-health options that allow you to have video as well as audio interactions with us as part of a "remote office visit." Tele-health is one change associated with the COVID-19 crisis that is likely to remain long after this pandemic is over. However, video visits can never replace in-person visits in our ability to make diagnoses and to really get to know our patients.
For those patients seen in the office, we ask that friends and family members stay in the car (or elsewhere outside the office) during the visit. Of course we do welcome caregivers into the office with the patient if they are needed for improved safety or communication. Other office guidelines will be based on recommendations of the American Medical Association and local public health ordinances. We have installed Plexiglas screens in the front office. We will do everything possible to make sure you feel safe to come back to our office.
All of us in the office are healthy and doing well.
All patients coming into the office will be required to wear masks.
As in previous years, our office will be offering both quadrivalent flu shots as well as the flu vaccine for "seniors." We have received our shipment for the senior flu shots already and you are welcome to stop by the office any time (no appointment needed!) to get yours. We also have a limited supply of influenza vaccine for the under-65-crowd. More of those are expected to arrive in our office shortly!