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! I received my first dose of vaccine about 10 days ago at Peninsula Hospital as part of their mandate to vaccinate all of their affiliated health care providers.
At this time, not all physicians and other health care personnel have been vaccinated yet. Also, not all nursing home residents and staff have been vaccinated either. The hope is for this to be completed within short order. For this reason, the next "tier" of vaccine candidates has not been called to receive their vaccination. This tier includes people over 75 as well as people in certain essential front line workers (see details below).
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!).
However, pharmacies will be on the front line for vaccine distribution: Safeway pharmacy is already accepting names for their wait lists for vaccinations (once this has been approved). Also, Walgreens and CVS will be distributing the vaccine, though I don't think they have started any wait list yet.
Overall, the vaccine distribution in the U.S. has gotten off to a slow start, with only 2.1 million people having received the vaccine as of 12/28/2020 (rather than the 20 million people that had been predicted). This delay is thought to be due to assigning state and local governments to vaccine distribution rather than advocating a national approach.
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 national survey indicated that the number of people willing to get the new COVID-19 vaccine declined since the onset of the pandemic: in early April, 74% of people said they were likely to get vaccinated, while only 56% of the U.S. population thought they would do so in early December, 2020. People with lower educational backgrounds were less likely to want to get vaccinated - sadly, this is a population that is most vulnerable to getting exposed and infected.
Transmission:
The incubation period can be 14 days (or more), though most people develop symptoms within 5-10 days.
A SARS-Cov-2 variant originally found in the United Kingdom seems to be much more infectious than other strains. South Africa has also seen a more contagious strain of the virus. Mutations are common in viruses, and SARS-Cov-2 has undergone multiple mutations since it surfaced on the world stage. Unfortunately, this strain has also been found in Colorado and California, and is likely more wide-spread in the United States overall. Luckily, there is no reason to believe that the new COVID-19 vaccines will not be effective against this strain.
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 study in Emerging Infectious Diseases looked at people in South Korea who had had COVID-19 with no or few symptoms: even 8 months later, over 90% gad positive antibodies! This finding suggests that people, once infected, are unlikely to get re-infected anytime soon. We don't yet know how long this immunity lasts, however...
Two other recent studies confirmed the very low likelihood of contracting COVID-19 once you have developed antibodies to the disease (from past infection).
Colleges have been trying to figure out how to keep their students and faculty safe during the pandemic. A recent study showed that extensive social distancing with mandatory mask-wearing is extremely effective in preventing transmission of the virus. Additional random testing of students several times per week would further quell 96% of infections.
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.
SARS-Cov-2 can survive on human skin for about 9 hours - wash your hands, people! It can be found for up to 28 days on surfaces such as glass, stainless steal, and paper currency. So try to avoid using cash and clean your cell phones frequently!
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 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.
When using a disposable (non-medical) masks, please remember to don a new one daily - or more frequently if the masks get wet or soiled.
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.
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:
The number of people dying of COVID-19 is at a record high. To put things in perspective, the number of people dying every day in the United States of COVID-19 is equal to those that perished in the September 11 attacks. It is also equivalent to 15 Airbus jetliners (each with 150 on board) crashing every day.
The journal JAMA Internal Medicine recently published a research letter looking at "excess mortality in California from March to August, 2020 and attributed to COVID-19: overall, California has a population of just under 40 million, which makes up about 12% of the U.S. population. From March through August, California had about 20,000 more deaths than expected (based on figures from previous years). Those populations most affected included Black and Hispanic residents, people over 65 years of age, and people without.
Coronavirus hospitalizations in the U.S. have hit an all-time high as of December 28, with more than 121,000 people hospitalized nationwide, according to the COVID Tracking Project. This number includes 22,592 intensive care patients, an increase from 16% capacity in September to 40%.”
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.
Some statistics:
San Mateo:
number of cases: 24,589 (19,645 two weeks ago)
number of deaths: 227 (183 two weeks ago)
number of people in the hospital: 174 (120 two weeks ago). Peninsula Hospital is not at capacity.
California:
number of cases: 2.31 Million (1.76 Million two weeks ago)
number of deaths: 25,963 (22,150 two weeks ago)
U.S.:
number of cases: 20 Million (17.3 Million two weeks ago)
number of deaths: 346,000 (311,000 two weeks ago)
World:
number of cases 75.1 Million (75.1 Million 2 weeks ago)
number of deaths: 1.82 Million (1.67 Million 2 weeks ago)
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 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
In the first 6 months of the pandemic, the mortality associated with COVID-19 decreased from 17% to 9%.
Remdesivir is the only medication approved for COVID-19 treatment in the United States.
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). The CDC advisory panel recommended on December 21 that the next tier (tier 1b) to receive the vaccine include adults aged 75 and older as well as frontline essential workers (e.g. police officers, firefighters, teachers and grocery staff). This second tier will amount to more than 51 million people! The hope and plan is to achieve vaccination of this group within 2 months.
Phase 1c will include adults aged 65 to 74 as well as younger folks with high-risk conditions. Finally, phase 2 will include everyone else.
At this time, the official recommendations say that people who have had COVID-19 in the past should still get the vaccine. This should be safe, as such people were included in the vaccine trials as well.
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!
Some scientists are suggesting that a single dose of the Pfizer or Moderna vaccine may be adequate in preventing COVID-19. This would indeed be great, as it would mean that we could vaccinated twice as many people with the current amount of vaccine available. But many questions yet remain, as the large studies looking at the efficacy of the vaccines looked at the two-dose-series. Also, other question include how long the efficacy of a single dose would last and if we need to give two doses for this reason. So: stay tuned. We should know more in short order.
Both the Pfizer/ BioNTech and the Moderna vaccines are "reactogenic," which means people often get achy, tired, and may have a fever after they get their dose. This does NOT mean that they are having an allergic reaction to the vaccine and it does NOT mean they have developed COVID-19 after getting the vaccine - the latter is not physiologically possible. These reactions are signs that the immune system is being turned on, which is what we want!
Pfizer/ BioNTech:
On December 13, the CDC officially recommended use of the Pfizer/ BioNTech COVID-19 vaccine for those aged 16 years and above.
The American College of Obstetricians and Gynecologists recommended that the Pfizer vaccine should NOT be withheld from pregnant or lactating women.
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.
At least 6 people in the U.S. have had severe allergic reactions (anaphylaxis) after receiving the vaccine. The CDC now recommends that people with past severe allergic reactions to other vaccines should have their risk assessed prior to getting the COVID-19 vaccine. If they do get the new vaccine, they should be monitored for 30 minutes afterwards.
The above allergic reactions notwithstanding, this vaccine is considered "very safe," according to Stanford professor Yvonne Maldonado, who serves on the Western States review panel for the COVID-19 vaccines.
Moderna:
This vaccine has also been approved for emergency use.
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.
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.
Novavax announced this last week that it “has begun a large late-stage study of its experimental COVID-19 vaccine in the United States..., after delaying the trial twice due to issues in scaling up the manufacturing process.” 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.
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.
The United Arab Emirates issued the first government approval of a Chinese coronavirus vaccine on 12/9/2020.
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.
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.
Our Community and Beyond:
California Governor Newsom announced the launch of a new COVID-19 exposure notification system, known as "CA Notify." The system 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 21, San Mateo County announced an investment of $4.5 million to provide an additional ten ICU beds at Sequoia Hospital in Redwood City. the agreement will cover the personnel needed to staff the additional ICU beds and the first 5-bed unit should be available within one week.
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.
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.