COVID-19: End of June Update

We want to share our perspective and give counsel as we reach the end of June in the COVID-19 pandemic. In this email/blog we talk about where we are with regard to our understanding of the illness and our recommendations for you, particularly as we approach the July 4th holiday. In the next emails/blogs we’ll talk about travel and school. These are big questions.

What do we know now? What’s new?

1. Prevention: This is the foundation of all. We still need to prevent folks from getting infected in the first place. This is critical. See below.

2. Transmission: we believe the main mode of transmission is from respiratory droplets. These can be expressed from a cough, sneeze or loud talking or singing. Or, if someone has a high burden of virus, even a close conversation is enough. The virus may be in the poop, so we’re recommending you close the lid before flushing. I even changed the toilet seat at the Hinsdale office to add a lid. Yes, me.

3. Infection: we initially thought that COVID-19 was primarily a respiratory illness: fever, cough, shortness of breath. Many other symptoms have been added to the list, including symptoms related to the intestinal tract and loss of smell/taste. While we encourage you to reach out if you have symptoms, the CDC has a “self-checker” to determine whether your symptoms fit.
   Children: It thought that children are less likely to get infected with the SARS-CoV-2 virus, and also less likely to express symptoms. It is also suspected that they may spread it less to others, which is uncommon for most respiratory viruses. While there are cases of Pediatric Inflammatory Syndrome in Children temporally associated with SARS-CoV-2 (PISC-TS), these cases are extraordinarily rare. It will be interesting to see what happens in the next few weeks as children and young adults leave quarantine. All of this has important implications for how we think about school in the fall. More to come on that.

4. Diagnosis: testing has become more available to us and easier to administer. We now have a kit that requires you to swab the inside of your nose with a Q-tip, which is much easier than the deep nasopharyngeal swab.The turnaround time is a few days, and in that time folks should quarantine. We are looking to acquire a machine by the upcoming flu season that will allow us to do tests in our own practice with an even quicker turnaround time for you. We’ll update you as we learn more.

5. Treatment: There still is no recommended outpatient treatment. If you get COVID-19 and you feel sick, all we can recommend are treatments for your symptoms, nothing that directly attacks the virus. Remdesivir is an option for sick folks in the hospital, and the steroid, dexamethasone, is an emerging option as well. We hope you don’t get that sick.

6. Immunity: We believe that folks who get sick with COVID-19 are immune for a while, maybe at least a couple of months. That data is still emerging. Vaccine trials are also ongoing. I’m bullish that we’ll have a vaccine to offer by the end of 2020.

Preventing Infection: When I look back at the emails I sent back in March I wish we were further along now than I anticipated we would be as a country. Here’s what I wrote back on March 17th, over three months ago:

“We need to take this social distancing thing seriously. The concept is based on the idea that the infection can only spread if you come into contact with people. The virus needs a human host. It doesn’t live in mosquitoes like malaria or in deer ticks like Lyme’s disease. If one person has it and spreads it to no one (R0 of zero for that person), that branch of the expansion of the virus ends. So, by isolating ourselves, we can neither give it to anyone if we have an early or mild case, nor can we get it from someone. And if we slow the spread, we flatten the curve.”

It seems, over three months later, that we’re still having the same conversation. What we didn’t know on March 17th but then recommended on March 30th , was the value of universal mask wearing. Exactly three months ago we said: “We now recommend that you put on a face mask when you leave home and may have contact with others.” The data for that recommendation have become only stronger, as I mentioned in the email from last week.

With regard to prevention, essentially nothing has changed with our recommendations to you: wear a mask when you’re out, limit your exposure to others, if you need to go out, stay six feet away from folks, keep your hands clean. This applies to the July 4th holiday weekend. I know the instinct will be to connect with friends and family. Be mindful! The virus is still out there and we are expecting a resurgence in Illinois as noted below. Best case: brats in the back yard with your quarantine pod. The rest has risk. We have a survey that can help you assess your personal risk and that of a particular activity.

So, why the surge in states such as California, Arizona, Texas, Florida, South Carolina and North Carolina? Why has almost every state seen an uptick in cases? The primary reason is people aren’t following recommendations to reduce the spread of the infection. I hate to say this, but I can almost guarantee that this WILL happen in Illinois. Out in DuPage County Dr. Meg is seeing people behave like everything is back to normal. A family we care for out in Glen Ellyn tells stories of a street fair-like atmosphere in their downtown. Chicago no different: bars open, young people in line. Virtually mask free.

When we recommended that you Shelter at Home back in on March 18th this is what we hoped would be the outcome of the order:

My hope is that during the time of social isolation and Shelter at Home we can:

1. Build up supplies that are desperately needed. This includes SARS-CoV-2 testing, personal protective equipment for those on the front line, extra ventilators in the event of a local epidemic, and the trained staff to handle all of this

2. Create a better and more comprehensive containment strategy. We’re learning that people can have the virus and be minimally symptomatic. That doesn’t mean they are minimally infectious. So, how do we identify people who are infected and isolate them from people at highest risk? Whom do we test? When do we test? How do we enforce isolation? Let’s figure this out

3. Delay our community’s impact until a vaccine is available…

4. Develop successful treatments...

5. herd immunity…

I bold one element that is, sadly, too far behind. Only yesterday did we get an email from Northwestern that talked about the State and Chicago’s recommendations for contact tracing, with a focus on nursing homes, correction facilities, etc. There is NO Federal approach/guideline for contact tracing, so each state/locality is having to figure it out on their own. We need to be testing often, isolating those who are infected, and tracking down those to whom that person was exposed. We, the system, need to do better! Over three months...

We’ve been keeping track of the hot spots for good reason. Many of our members spend winters down in Florida and Arizona. And I obviously care about California, with family in both the Bay Area and Southern California. Plus, my son goes to college in Los Angeles. This is all so concerning to me. In upcoming email/blog posts we’ll talk about travel and school.  

We need to be thoughtful as we consider the data coming out of the hot spots. We hear folks downplay the numbers saying, “We’re just testing more, and as you test more you’ll find more cases.” The data from Illinois has shown how increased testing doesn’t necessarily lead to an increase in cases: We dramatically increased our testing while we were in Phase 3 and saw a DECREASE in case positivity rate. An increase in testing didn’t find more cases, it found progressively fewer because we were still only partially open as a state. The next two weeks for Illinois will be critical. If folks don’t wear their mask, don’t social distance from strangers, the number of cases will rise just like in the current hot spots. We’re not off to a good start, sad to say.

Another comment I’ve read is, “Look, the death rates are declining.” The jury is out on that. Some of you are math/statistics folks and may appreciate the concepts of leading and lagging indicators (and I’ve been corrected on my statistics in the past, so have at it!)  A leading indicator is a measure that reflects the status of an issue early on. For COVID-19, the number of people with fever and other flu-like symptoms would be a leading indicator of infection. A hospitalization would be a later indicator of infections. Death, however, is a lagging indicator.

At the height of the surge in NYC, from the time of diagnosis to death was about five days. Now, later in the epidemic, with both a younger subset of the population who are ill and better treatment approaches it may take up to 14 days for someone to die, and then at least another seven days for this death to be recorded to public health officials. So, as we’re seeing these hot spots flare, we need to give it another couple of weeks to know whether the rise in cases is leading to bad outcomes: death, then, is a lagging indicator. A mid-range indicator, hospitalizations, is showing a significant increase in many areas, suggesting this isn’t just a statistical anomaly.

What’s up with the blood type?
In my prior email/blog I told you I’d follow up on the research on blood type. We’re only six months into this illness so clearly we still have a lot to learn, yet there are many more tools to use to learn than there used to be. One newer research tool is genomics. Genome-Wide Association Studies “involve scanning the genomes from many different people and looking for genetic markers that can be used to predict the presence of a disease. Once such genetic markers are identified, they can be used to understand how genes contribute to the disease and develop better prevention and treatment strategies.” In a study of 1980 severely ill COVID-19 patients in Spain and Italy published in one of our most respected medical journals, The New England Journal of Medicine, researchers identified a cluster of genes that conferred susceptibility to severe COVID disease. This cluster of genes is associated with the ABO blood-group system. They found that people with Type A blood were more susceptible to severe COVID-19 illness and those with Type O blood were less susceptible.

You then may ask, “What is my blood type?” In our practice we don’t regularly test folks’ blood type, as it practically doesn’t serve much purpose unless you’re donating blood. Even if you did know your blood type, would this change our recommendations on how you behave? Our recommendation has always been: do whatever you can to prevent getting sick from COVID-19. While people with type O blood may have a lower chance of severe illness, it doesn’t mean that this blood type provides immunity. That being said, we will add this as part of our routine assessment (or next time you're getting blood drawn), with the goal being to identify and counsel those who may be at higher risk if they acquire COVID-19: those with Type A blood. You only need to be tested once.

As we arrive at the end of June, despite all the doom and gloom in the email, I’ll tell you I’m feeling very blessed. I have had time to spend with my family that I otherwise wouldn’t have spent, and everyone remains healthy. The team here at Harper Health is likewise healthy, and we've come together nicely in this time of challenge. Dan's temporary location in Skokie is open, as well. I’m also on Day 4 of a 21 Day Abundance Meditation Challenge, nudged by a friend. We live amidst abundance, if we can take notice.

As I look back at our emails from the past four months, I land on the one from April 9th. I think it’s useful to go back to that. Let’s try and remember those sounds/smells/pictures/music that spark joyful memories. In that post we asked you to provide us with a sound/smell/picture/song/etc. that sparks a joyful memory for you. Among the responses, we received pictures of fish caught on a Wisconsin lake, the song “Don’t Stop Believin’” by Journey, and a quote, “And though she be but little she is fierce.”

If you didn’t get a chance to send us something back then, can you reply back today with a song/poem/book/photo that sparks a joyful memory for you? We’d love to hear from you.