COVID-19: End of September Update

Here we are at the end of another month – about seven months since the pandemic started here in the U.S. If I look back to when this all began, I was worried. Northern Italy was going through a very tough time with many people dying and the whole country shut down. Countries across Europe were showing dramatic increases in cases and deaths. Then there was New York. The pictures and stories out of NYC were horrifying, with refrigerated trucks being used as temporary morgues.

We didn’t know about how easy it was to catch the virus. We also didn’t know what the true death rate was if you got it. And the doctors in the hospital caring for sick people were learning on the fly. Many of the people who died early on may have survived if they got the disease today. We’ve learned. The ICU doctors are putting people on ventilators less frequently, and they have medications that have been proven to be helpful in really sick people.

Our overall goal is for our patients to stay healthy and avoid significant illness, hospitalization, and death. This is true for COVID and for other issues such as stroke, heart attack and cancer. With regard to COVID, let’s review where we are in a number of different areas.

1. Prevalence: Recall that the purpose of our quarantine efforts at the beginning was to flatten the curve so hospitals would not be overwhelmed by cases like they were in places such as Northern Italy. This worked. In cities and states like ours, hospitals got very busy, but their resources never got tapped out.So, the curve was flattened but the virus is not going away. Until we have herd immunity, the virus will continue to make its way through the population. At our peak so far, in July the US had over 70,000 daily
 
Aside from these regional spikes, the concern is what will happen as we head into cold and flu season. SARS-CoV-2 is just one of several coronaviruses; the others are known to cause the common cold. Coronaviruses tend to be seasonal, with peaks in the wintertime. So, some predict that as we enter Fall and Winter a second spike will occur.

2. Transmission: One of the big changes since the beginning of the pandemic is the understanding of transmission. While there still is a lot to learn, it is now believed that the virus can be transmitted through aerosols. As a reminder, we initially thought that the primary way the virus was transmitted was through droplets. Virus gets carried in the droplets from a cough, sneeze, singing voice, etc. to a person who is within about a six-foot distance. This is still true. However, live virus has been found suspended in the air in smaller particles, aerosols. The concept of an aerosol is like that of perfume. If you walk into an elevator after someone who has worn heavy cologne, you can still smell it. That’s an aerosol. 

The important factor with aerosols and COVID-19 is the “infectious dose” of virus. How much virus do you need to inhale in order to get infected? If you’re exposed to a droplet, it’s easier to achieve an infectious dose because there’s more virus in a droplet. Since the concentration of virus is lower in an aerosol, though, it’s likely that you need a higher concentration of aerosol for a longer period of time in order to get infected. A corollary to this is that the severity of illness is dictated by the infectious dose of virus: if you wear a mask you may still get exposed to virus, but perhaps not at the same level that will make you sick, or even kill you.
 
The role that surfaces play in COVID-19 transmission has been de-emphasized. Initially we thought the virus survived for a long time on surfaces leading to recommendations to clean with disinfectant all items coming into the house. Further studies have shown that the risk of fomites in COVID transmission is low in real-life situations.
 
3. Illness:  Over the summer many younger people got infected with the virus and the public impression of the illness was that it may not be as severe as we thought. It is still true that there are factors that increase an individual’s risk of severe illness. Age is probably the most important.

What about the severity of the illness? What do we know? According to CDC data, those aged 50-64 are 30X more likely to die of COVID than those in the 18-29 year-old age group. So, while young adults may not care if they get infected, they should care if they give it to their parents.
 
With over 200K deaths attributed to COVID-19, the case-fatality rate in the U.S. sits at 2.6%. However, the true death rate from COVID-19 could be less than that (1% maybe?), since many people have had disease but haven’t gotten a confirmed diagnosis. On the other hand, some deaths may not be properly attributed to COVID-19, since testing for COVID-19 may not be done for people who die at home. Even with a death rate around 1%, this is still 10X more deadly than the seasonal flu.
 
As outlined by the CDC, other factors aside from age can increase the risk of severe illness. These can be personal factors or environmental. A lot of our patients fit into these categories! Do any apply to you?

1. Illnesses - Known: Certain personal factors are CONFIRMED through research to be higher risk of severe illness. Obesity (body mass index [BMI] of 30 or higher) is enough to put someone into the higher risk category. Unfortunately, that is true for a lot of us. Same with Type 2 diabetes mellitus. Others: Cancer, Chronic kidney disease, COPD (chronic obstructive pulmonary disease), Immunocompromised state (weakened immune system) from solid organ transplant, Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies, and Sickle cell disease.

2. Illnesses – Suspected: Other personal factors are SUSPECTED to be a risk, though the research is ongoing. A few to highlight include Asthma (moderate-to-severe), Hypertension or high blood pressure, and Smoking.

3. Other Individual factors. I’ll highlight a few here: One’s race and ethnicity is a risk due to disparate access to healthcare, jobs, housing and other factors. Individuals with developmental and behavioral disorders (such as ADHD) may be at higher risk because they may not be able to identify or describe symptoms very well. Pregnancy may be a risk for adverse outcomes, as well.

4. Where you live can have an impact, too. We know the role that nursing homes and longer-term care facilities have played. Same is true of group homes for people with disabilities such as Misericordia here in Chicago. Because of lack of access to healthcare, primarily, people living in rural communities are at higher risk, as are people experiencing homelessness and newly resettled refugee populations

Our understanding of the illness, itself, has evolved. At the beginning we felt it was just a respiratory illness: fever, cough, shortness of breath. We know now that it can affect the intestinal tract with nausea, vomiting and diarrhea. Upper respiratory symptoms are also common with sore throat, congestion and loss of taste or smell.
 
In severe cases, those who are hospitalized, we worry about blood clots that can influence the kidneys, heart and brain. Earlier in the summer we learned about a rare, devastating, illness in children, Multisystem Inflammatory Syndrome in Children (MIS-C). The same syndrome has recently been identified in adults: MIS-A. Worrisome.
 
Recovery from COVID-19 in most people is full. There are some patients, however, who just don’t get back to 100% after the illness. One patient (healthy, in his 40s) said to me, “I have felt a little different ever since Covid…I have more frequently felt something that is chest/heart related since I contracted Covid.” We’re working him up for COVID-19-related myocarditis, a complication of COVID-19 that can happen in even mild cases. Worrisome.

4. Diagnosis: I spent a lot of time at the end of last month reviewing the testing for COVID-19. Since that time, a new antigen test has hit the market, the Abbott Binax-Now. While it’s not a good test for diagnosing sick people, it would be a good test for surveillance of populations (testing groups two or three times a week). The Federal government bought all 150,000,000 of them and how they’re going to be distributed for use is unknown.  

Another innovation I read about yesterday is testing based on Crispr gene-editing technology. Gene editing using Crispr has been primarily used to prevent infections and treat genetically driven illnesses such as a genetic form of blindness.  Here, it’s used for diagnostics not treatment.  “When used as a diagnostic tool…the Crispr technology latches on to a set of letters of a gene carrying the signature of the novel coronavirus, highlights it, and gives a read-out on a piece of paper.” India has developed a Crispr-based test that has been shown to be reliable and cheap. We shall see. Promising.

5. Treatment: I believe that the Holy Grail for COVID-19 is not a vaccine. It’s a treatment that providers such as us can give patients at the point of diagnosis that reduces the risk of hospitalization, death and severe complications. If we find this and can turn an illness of mystery into a common cold, we can get back to “normal.” Are we there yet? No, but there is hope.  

As all of you know, our President was diagnosed with COVID-19 this week. A couple of medications he was given are new to the regimen and can be highlighted.

a. Famotidine (Pepcid®): Research has suggested that this medication used for heartburn may be helpful for patients with severe cases of COVID-19. A VERY SMALL study (10 patients!) of high-dose famotidine in outpatients showed improved symptoms. More to come on this drug, as we need good, randomized, controlled trials. Promising.

b. Antibodies: I mentioned the Regeneron trial back the end-of-July email. The President received this under “compassionate use” because he’s not part of a trial and the drug isn’t yet FDA approved. The Phase 3 studies have been completed and Regeneron is applying for Emergency Use Authorization for the drug. This is a cocktail of lab-produced antibodies that tag the virus for destruction by our immune system. This is extremely promising as it is a medication that has been studied and seems effective for OUTPATIENTS. So, it could be a tool that we could use for you if you get sick. More to come on this.

c. Dexamethasone: A study from the New England Journal of Medicine demonstrated that the steroid dexamethasone could be used for very sick people on oxygen. When used in this select population of patients, they did better. When it was used on less sick COVID patients, it didn’t help and, in fact, could have made their illness worse.

6. Prevention: We still strongly recommend modifying your personal behavior to protect yourself from getting infected, particularly if you or someone you live with is in a high-risk group. Do you live with an elderly relative? Is your spouse pregnant? Do you have a disabled child?  

REMEMBER: You can’t tell by looking at someone if they’ll have a fever tomorrow! You can get infected by someone who looks and feels well. So:

a. Wear a face covering if you’re going to be in a public space where you could encounter someone who is sick and could infect you. The research is incontrovertible. If you’re out for a walk in your neighborhood, no need for a mask until you pass folks. If you accidently cough or sneeze as you go by and you are infected unknown to you, you could expose them. Hopefully they’ll have a mask on, too. Wear a mask in a store where you might reach for the same bunch of broccoli another shopper is. Wear a mask if you’re going to be in an enclosed space, as if you are unknowingly infected you reduce the number of aerosols in the air that could infect others. Similarly, you reduce the number that could infect you if you are not infected.

b. Aim for six-feet of social distance. I played golf with a patient last week. He knew my stance on this and I had my own cart and kept six feet of distance. (I was in the woods, the sand, the rough, so no one was around me anyway.)

c. Keep your hands clean. We sent pocket-sized hand sanitizer out a couple of months ago. Need a refill? Come on by! We're happy to fill you up. 

d. Outdoors is better! A meal al fresco with a mild breeze, that should be just fine. Paddle tennis outside? Probably okay. Fitness in a gym with no outside ventilation? I’d be concerned. A crowded Supreme Court Justice announcement with a large crowd, no masks, no social distancing, and little wind? Could be a super-spreader event.  

e. Vaccines: Please refer to my post from last week that provided updates on the vaccine. Progress, but nothing definitive yet.

This was a long post and I appreciate you making it to the end. Please stay safe and let us know if you have any questions.