A lot has changed over the past two months since the last update on our pandemic. We have now surpassed over 145,000 American COVID-19 deaths. This includes 7,170 in Pennsylvania, 401 in Lancaster County, and 80 in York county. By comparison, South Korea which is a country 1/7 the size of the U.S. has yet to reach 300 total deaths. Interestingly, South Korea and our country each had of their first diagnosed cases on January 21. Proportionately, we as the USA should have lost less than 2,200 total Americans to this illness. 145,00 is a larger number than 2,200. It frustrates me that we have done such a horrible job saving American lives compared with how South Korean has saved the lives of its citizens.
Let me state that there will be nothing political about this discussion. Everything that I have written here is the latest medical information from our nation and the world’s most recognized experts in infectious disease, virology, epidemiology, and public health. Those of you wishing to believe bogus conspiracy theories (e.g. QAnon), stop reading this article now, and instead please research the legitimacy of your beliefs from medically legitimate sources, as I have done. As has been said by a famous person whose name I cannot at the moment remember, “Everyone is entitled to their own opinions, but not their own facts.”
First of all, we are ALL at risk of catching this virus. It is even becoming evident that the possibility exists for someone who has initially recovered from infection with COVID-19 to become infected a second time.
The second infection may be more severe than the first. The number of people that this has happened to is very small, and there is some question as to whether they truly were second infections or just faulty serial testing over a protracted first infection. At any rate, experts are concerned that the immunity which occurs after a primary infection may not be durable. It may last only a few months or even less in some cases.
This brings up an extremely important point. In my practice, I have encountered many people who are discouraged by the rapidly shifting and evolving knowledge about the SARS-CoV-2 virus which causes the disease we know as COVID-19. Please understand that in early December of 2019, NO ONE knew ANYTHING about this particular coronavirus. Understand that most of what we know about everything else in the universe we have slowly learned over tens of thousands of years. How can any of us be surprised that in the span of just eight months, with all of the world’s best scientific and medical minds focused on this one virus and the disease it causes that there are new revelations coming out about it every single day? This pandemic is an especial interest of mine. I have a medical degree. I have a basic understanding of microbiology, viruses, public health, routes of infection, the physics of droplet dispersion, air purifiers, masks, contact tracing, vaccines, and risk factors in different populations. Many people do not have as comprehensive a background for understanding these things and may even not have the same degree of interest that I have about this subject. So, if you are not conspiracy-minded, just sit back, sip on your favorite beverage, and learn what you can from what follows to see if any of it is new to you. And if you knew all of this already, I would like to spend some personal, at a respectful and mutually masked distance, time with you, in order for you to educate me. (And I thank you in advance.)
For starters, who is at risk?
All of us who have not just recovered from COVID-19. Are there any exceptions to this? No. Now that was simple, wasn’t it? The rest of this is more complicated…
Are we all at the same risk? Not by a long shot! The person at greatest risk is an obese diabetic hypertensive male over age 70, with type A blood, and underlying heart, lung, kidney, and liver disease. This person had the ill fortune to have become infected with a large inoculum of virus particles. To make his outlook as bad as it could possibly be, he also has skin of darker color, poor emotional support, and no perceived reason to live. The chance that this individual would survive his COVID-19 infection is extremely small. So, who is the least likely to be personally affected by a similar viral load causing the infection?
The answer is a child less than age 4 with absolutely no underlying health issues. Whether or not the gender of the child at this age is significant in this setting is not yet known. I personally doubt it, since they are at this age pre-puberty and therefore have similar hormone profiles but eventually this will be studied and clarified! You see everyone is still learning about all of this! That is a big part of today’s message.
What has been learned about optimizing treatment for this disease in the hospital setting? Gosh, a lot of things actually. It is important to NOT put very sick patients on the ventilator if at all possible. It turns out that the initially life-saving pressurized oxygen delivered to the virus-ravaged pulmonary tree by a ventilator ends up causing further injury to the lungs because of the pressure of the ventilator itself! This is called “barotrauma” and in some cases this is just enough to push severely ill COVID patients from being just barely alive to now being suddenly dead. So, what is done instead? Placing patients in the prone position. This is called “proning.” High flow supplemental oxygen via nasal prongs has been shown to be very helpful, but if possible, it should be given without additional supplemental pressure. If the patient’s lungs still cannot supply adequate oxygen to meet the metabolic needs of the body, and if the hospital has this capability, then ECMO (extracorporeal membrane oxygenation) can be used. Also utilized is the intravenous medication Remdesivir. The glucocorticoid steroid dexamethasone has proved beneficial for those in the intensive care unit. And varying levels of anticoagulation are often used with beneficial effects to prevent or treat the multiple blood clots that can occur throughout the body with a severe COVID-19 infection.
What has not panned out as helpful in treating COVID-19 infections? Hydroxychloroquine, with or without azithromycin has been of zero benefit, and in some patients, it has contributed to arrhythmia induced complications. See this excellent article explaining five RCTs (randomized controlled trials) that clarify this for us.
How close are we to effective vaccines?
Much closer than I would have ever thought possible. This whole area is extremely exciting. On July 27, 2020, Moderna is started its Phase 3 mRNA vaccine trial in this country! Pfizer is also starting Phase 3 for its vaccine within the next few days. In fact, at least 19 vaccine manufacturers are in the midst of clinical trials already. And there are another 60+ companies right behind these two. By comparison, the fastest ever that a vaccine has been developed in the past, from initial conception to public implementation was for the mumps vaccine. And that took four years. There are several reasons to be optimistic about a much shorter time course for SARS-CoV-2 vaccines. Never before have so many great medical minds been trying to achieve the same goal, simultaneously, from all around the planet. Never. And we now have the most advanced technology that has ever existed. And, for the first time ever, these vaccines are being made AT RISK. And, even more striking, there will probably be some vaccines that will complete Phase 3 testing utilizing the CHALLENGE trial methodology. At-risk means that large amounts of vaccine are being built up during phase 3 before the results of that phase are even known. This is a huge financial gamble for the manufacturer, but the worldwide need is tremendous and urgent. A phase 3 “challenge” trial means that all of the study participants will INTENTIONALLY be infected with SAR-CoV-2. You can immediately see the ethical implications of this technique. It means that by study design there will be severe illness and possibly even death among the trial participants. This will be a given. It also means that the answer to the question of whether or not a particular vaccine will be safe and effective in large populations will come in just weeks instead of a great many months or even years! Can you believe it? Tens of thousands of people around the planet have already volunteered to be included in challenge trials! These are indeed brave and society-saving minded souls. God bless them all.
Finally, how can each and all of us best protect ourselves and our loved ones?
I find it helpful to view situations like this from the extremes. In that way, what is realistic for each of us becomes clearer. Let me say first off that there is no scenario that is truly zero risk, just as there is no scenario that is 100% risk, except perhaps being in a challenge trial and then having the bad luck of being in the arm of the trial that is NOT given the vaccine! This is not to say that being given the infection means death. Not at all. It is just that the expression of clinical illness for this disease is so highly variable that any one’s chances of living, dying, or having a permanent disability is a complete crap shoot! There have already been otherwise healthy baby girls who have died from this illness, and 100 year old obese men with diabetes who have lived! Go figure. No one can predict what will happen to them once they are infected. There are no guarantees.
This suggests to me that some precautions are in order. As of this moment, the following things are known. Most of this illness is transmitted through the air. It was thought at one time that much of the disease spread came from touching surfaces that were contaminated. This has been found to be not very common. We also used to think that most of the transmission occurred from larger respiratory droplets that were carried in the air from infected people (either symptomatic or not) who coughed, sneezed, shouted, sang, or at least talked loudly. Now we know that it also occurs from infected people just BREATHING near you! Darn, right?
So, what about masks?
MASKS AND PHYSICAL DISTANCING ARE THE SINGLE MOST IMPORTANT BEHAVIORS TO ADHERE TO IN ORDER TO LESSEN THE RISK OF PERSONAL COVID-19 INFECTION. Period. The best masks cover the nose and mouth simultaneously and should be worn whenever people are closer than 6 feet apart. Is 6 feet safe? Outside in a strong wind, yes. Otherwise, the answer is maybe. If you and the other person have just had 100% sensitive SARS-CoV-2 testing done and both of you tested negative, then you could even be French kissing and heavy breathing upon each other and the risk for both of you would be zero. But you see, we don’t have 100% sensitive tests, and we cannot get this answer in one hour or less. Abbot has a test that will give you an answer in 15 minutes, but it is not extremely accurate. Rats! So, you see, everything about this situation is a compromise. As far as masks themselves go, generally N95, or KN95 masks are about the best you can get to protect both the wearer and the persons in front of the wearer. N99 or N100 masks are the best of all to protect people in both directions. A high-quality gas mask protects the wearer better than anything but does very little to protect the people in front of them. On this topic, any mask with a “valve” in it to lessen the heat build-up in the mask and make exhalation for the wearer more comfortable will have almost NO PROTECTIVE value for the people in front of that mask wearer. I have heard experts say that these masks have NO PLACE in a pandemic. Please note and act accordingly.
A final word about testing. We do not do nearly enough, and we do not get the test results back quickly enough. The Harvard Public Health people relate that in order to best understand and control the spread of this disease we need to be doing between 3.5 and 5 million tests in our country each day. And we need to get the results back in 24 hours or less. We have always been, and we are still, way behind in both of these respects. All of the many countries who have done a good job with COVID-19 control have excelled at testing and even at this late date, we continue to fail miserably. My physician colleagues and I are appalled at our failings in this regard. I personally see it as criminal negligence by our government.
So, how much risk are you willing to take for yourself? For your family? For society?
How much inconvenience can you tolerate? Can you tolerate a mask and physical distancing in order to protect the lives of yourself and those you love?
Understand that it is 15-20 times safer to be outside among people than inside with the same spacing and number of people. Understand also that the number of people in the group affects your risk, with the more people, the higher the risk. It’s a numbers game about the percentage of infected people among the numbers of people present. It is becoming increasingly clear that there are more “super-spreading” events than there are super-spreading people.
Another important factor is the exposure time to a person or a group of people. Try to minimize the time of exposure. The idea is to reduce the number of virus particles that you encounter in any given situation.
Make your “aerosol and droplet gang” as small as possible. If you have to share air with any other people, keep that group as small as possible. Ideally, the group you share air with shares air with no one else, or else also an extremely small group. These things minimize your risk.
Other than being a hermit in a distant cave (without other people and certainly without bats!) we ALL are at some risk of becoming infected. Please do your best to not become infected. There is a Russian roulette aspect of this virus which can kill even the least likely among us. Our greatest chance of not eventually becoming personally infected is for humanity to create effective, and widely utilized vaccines.
Short of that, we at Medical Cosmetics are doing all that we possibly can to minimize YOUR and OUR risk of infecting each other. Please arrive with a mask covering your nose and your mouth and we will treat you in the safest way possible from the moment you enter the office and throughout your brief contact time with us.
Most sincerely, and in the spirit of sharing knowledge while lessening risk,
William A. Carter, M.D. at Medical Cosmetics
P.S. Things are progressing so quickly that it behooves me to provide a few additional mid-August updates:
The Russians are already marketing a vaccine (dubbed “Sputnik-V”), but they have skipped the important phase 3 or their clinical trials in the interest of being first in the world with a marketable vaccine.
The U.S. continues to lose in excess of 1,000 lives a day from COVID-19 infections.
Five companies now have vaccines in phase 3 trials.
The U.S. has been developing a standardized preparation of Sars-CoV-2 for use in challenge trials if such trials were to be conducted.
The number of American COVID-19 tests being done each day has been falling despite the rising need and stubbornly high national positivity rate.
Oleander has just recently been suggested by our administration as a possibly viable COVID-19 treatment despite zero scientific or medical evidence of any potential benefit. – WAC