Greetings Friends of TVD!
We hope this note finds you all well, staying home these past cozy, rainy days, not spending too much time on social media nor the news, and now that the sun is out, getting outside for a breath of fresh air. As many of you know, we’ve been working hard at keeping our website up to date with coronavirus and COVID-19 information. We have been fortunate to leverage the fact that The Village Doctor has FIVE physicians working together to keep your family safe, healthy, and informed. The physician team “Zooms” daily to share knowledge and experience gained in the past 24 hours so we can serve you, and our community better. In the spirit of keeping YOU up to date, we’ve decided to launch this weekly newsletter devoted to coronavirus topics, including a section we call Hope & Grace. Let us recognize the beauty in the human experience, even in this painful time we are experiencing.
Until then, it is on to “Plan Be”… where we can focus less on “waiting” for things to get better, and more on “being”. Being healthy, being with each other, being supportive, being loving. Being human.
Cautious good news! Or as Dr. Sara Cody said on Monday, “We’re not out of the woods, but there are a few little sparkles of optimism.” Coronavirus cases continue to expand in the Bay Area, but the sheltering in place is reducing the rate of expansion. The volume of hospitalized people in Northern California is gradually increasing (approximately doubling every week, see graphs below), however the volumes are currently manageable. It is expected that the number of people will increase and peak hospital utilization will occur in late April or early May. We may be sheltering in place until June. Overall, our local hospital, Stanford, appears to be well prepared. Note this does NOT mean we can let down our guard… please continue to stay home!
The Santa Clara County Dashboard has been updated and also provides helpful data about current hospital and lab testing statistics.
On April 9th, the NIH announced a clinical trial to evaluate the safety and effectiveness of hydroxychloroquine for the treatment of adults hospitalized with coronavirus disease 2019 (COVID-19) starting at Vanderbilt University Medical Center, Nashville. Participants will be randomly assigned to receive hydroxychloroquine 400 mg twice daily for two doses (day one), then 200 mg twice daily for the subsequent eight doses (days two to five) or a placebo twice daily for five days. “Hydroxychloroquine has showed promise in a lab setting against SARS-CoV-2, the virus that causes COVID-19 and preliminary reports suggest potential efficacy in small studies with patients. However, we really need clinical trial data to determine whether hydroxychloroquine is effective and safe in treating COVID-19”, said James P. Kiley, director, Division of Lung Diseases, NHLBI
PUBLIC HEALTH ADVISORIES
We continue to #stayhomesavelives! As of March 31, Health officers in seven Bay Area jurisdictions are extending a previous stay-at-home order through May 3, 2020 in order to preserve critical hospital capacity across the region. The health officers have determined that more and stricter social distancing is needed to slow the rate of spread, prevent deaths, and stop the health care system from becoming overwhelmed. The new order adds some clarifying language around essential business and activities, as well as some new directives, including:
* Use of playgrounds, dog parks, public picnic areas, and similar recreational areas is prohibited. These areas must be closed to public use.
* Use of shared public recreational facilities such as golf courses, tennis and basketball courts, pools, and rock walls is prohibited. These facilities must be closed for recreational use.
*Sports requiring people to share a ball or other equipment must be limited to people in the same household.
* Requires essential businesses to develop a social distancing protocol before April 3rd.
* Most construction—residential and commercial—is prohibited.
* Funerals limited to no more than 10 people attending.
* Essential businesses expanded to include service providers that enable residential transactions (notaries, title companies, realtors, etc.); funeral homes and cemeteries; moving companies, rental car companies and rideshare services that specifically enable essential activities.
* Essential businesses that continue to operate facilities must scale down operations to their essential component only.
Home delivery of testing kits is temporarily delayed because of concerns by the FDA regarding quality of testing. Hopefully this can be resolved within the next week. Note there are two types of tests: one uses PCR (polymerase chain reaction) to look for actual coronavirus RNA to determine if you have COVID-19 at the time of testing while the other looks at antibodies in blood to determine if you had COVID-19 in the past.
Note also that there were some earlier questions about how accurate the testing was at Stanford (accuracy is measured by a test’s sensitivity and specificity). It appears that some of the early tests’ weakness had to do with how the samples were being collected rather than the test itself. More recently, samples being collected at Stanford have both outstanding sensitivity (96%) and specificity (nearly 100%), which means the test is quite good at determining whether or not you have COVID.
Lastly, here are some updates from the news this past week:
(3/27/20) Abbott launches a new test that can detect COVID-19 in as little as 5 minutes.
(3/26/20) Curative Inc labs racing to deliver 10,000 saliva tests / day to LA County.
(03/22/20) Everlywell offers COVID-19 test kit, but limiting it to frontline medical facilities.
HYDROXYCHLOROQUINE FOR COVID TREATMENT? A small trial published in China revealed that hydroxychloroquine may be helpful for mild or moderate disease. It was a small study of only 60 people and some American scientists question the validity of the study. That said, much of the very early excitement has now been tampered down, but this hasn’t stopped the political pressure. Some claim that even our FDA put politics over science when it issued an emergency use authorization for chloroquine and hydroxychloroquine on March 29, 2020. On March 30 the University of Minnesota started a trial looking at hydroxychloroquine used as prophylaxis against COVID-19. So all to say, there is a lot to learn, a lot of political pressure and a tremendous amount of clinical need. The coming few weeks should be very interesting!
STILL NOT SURE ABOUT THE NEED FOR PHYSICAL DISTANCING? Please read this piece from Jonathan Smith at Yale University.
Hey everybody, as an infectious disease epidemiologist, at this point I feel morally obligated to provide some information about what we are seeing from a transmission dynamic perspective, and how it applies to social distancing measures.
Like any good scientist I have noticed two things that are either not articulated or not present in the “literature” of social media.
Specifically, I want to make two aspects of these measures very clear and unambiguous.
First, we are in the very infancy of this epidemic’s trajectory. That means even with these measures we will see cases and deaths continue to rise globally, nationally, and in our own communities in the coming weeks.
Our hospitals will be overwhelmed; people will die that didn’t have to. This may lead some people to think that the social distancing measures are not working. They are.
They may feel futile. They aren’t.
You will feel discouraged. You should. This is normal in chaos. But this is also the nature of a normal epidemic trajectory.
The enemy we are facing is very good at what it does; yet we are not failing. We need everyone to hold the line as the epidemic inevitably gets worse.
This is not my opinion; this is the unforgiving math of epidemics for which I and my colleagues have dedicated our lives to understanding with great nuance, and this disease is no exception.
We know what will happen; I want to help the community brace for this impact.
Stay strong, and with solidarity know with absolute certainty that what you are doing is saving lives, even as many people get sick and others die.
You may feel like giving in. Don’t.
Second, although social distancing measures have been (at least temporarily) well-received, there is an obvious-but-overlooked phenomenon when considering groups (e.g., families) in transmission dynamics.
While social distancing decreases contact with members of society, it of course increases your contact with group (family) members. This small and obvious fact has surprisingly profound implications on disease transmission dynamics.
Study after study demonstrates that even if there is only a little bit of connection between groups (e.g., social dinners, playdates, playgrounds, etc.), the epidemic trajectory isn’t much different than if there was no measure in place.
The same underlying fundamentals of disease transmission apply, and the result is that the community is left with all of the social and economic disruption but very little public health benefit.
You should perceive your entire family to function as a single individual unit; if one person puts themselves at risk, everyone in the unit is at risk.
Seemingly small social chains get large and complex with alarming speed.
If your son visits his girlfriend, and you later sneak over for coffee with a neighbor, your neighbor is now connected to the infected office worker that your son’s girlfriend’s mother shook hands with.
This sounds silly, it’s not.
This is not a joke or a hypothesis. We as epidemiologists see it borne out
in the data time and time again and no one listens.
Conversely, any break in that chain breaks disease transmission along that chain.
In contrast to hand-washing and other personal measures, social distancing measures are not about individuals, they are about societies working in unison.
The results from these measures also take a long time to develop.
It is hard (even for me) to conceptualize how ‘one quick little get- together’ can undermine the entire framework of a public health intervention, but it does.
I promise you, it does. I promise. I promise. I promise.
You can’t cheat it. People are already itching to cheat on the social distancing precautions just a “little” – a playdate, a haircut, picking up a needless item at the store, etc.
From a transmission dynamics standpoint, this very quickly recreates a highly connected social network that nullifies all the work the community has done to that point.
Until we get a viable vaccine, this unprecedented outbreak will not be overcome in a grand, sweeping gesture. Rather, only by the collection of individual choices our community makes in the coming months.
This virus is unforgiving to unwise choices.
My goal in writing this is to prevent communities from getting ‘sucker- punched’ by what the epidemiological community knows will happen in the coming weeks.
It will be easy to be drawn to the idea that what we are doing isn’t working and become paralyzed by fear, or to ‘cheat’ a little bit in the coming weeks.
By knowing what to expect, and knowing the importance of maintaining these measures, my hope is to encourage continued community spirit, strategizing, and action to persevere in this time of great danger and uncertainty.
Link to this publication in the press can be found here.
CAN OUR KIDS GO ON PLAYDATES WITH OTHER CHILDREN? No, not now. While social distancing by staying home is hard, it is very important – for both adults and children, since both can act as carriers for the disease as well as experience the illness directly. Note that as parents, if we don’t take this seriously and curb face-to-face interaction, we also defeat the purpose of closing schools and workplaces.
Note there are some terrific resources out there for you parents challenged with a “shelter in place” order, and kids home from school. Thank you to TVD Pediatrics for putting this list together!
FAQs and Answers: COVID-19 & Children — CDC
COVID-19: What Parents Need To Know — Stanford Children’s
How to Talk to your Kids About Coronavirus — NY Times
Talking to Teens and Tweens About Coronavirus — NY Times
9 Questions Parents May Have About Coronavirus — NY Times
UC Davis Kids Considered Podcast for Parents
How do you manage fighting kids during a lockdown? | CNN
HOPE AND GRACE
If you have made it this far, time for a reward, something to lighten your day, and acknowledge the human spirit. Let us recognize the beauty in the human experience, even in this painful time we are experiencing. Find some escape, or perhaps even inspiration, in this collection of works and perspectives gathered from around the world. Maybe even joy. Please contact me directly at firstname.lastname@example.org if you have come across something that has lifted your heart today.
NOTE for this week’s Good Friday services, there are multiple Bay Area churches offering online services.
Please enjoy David Mathews’ new song, “Singing From The Window”. Turn up the volume.
And before we go… Please take a contemplative few minutes to both read, and reflect on, this thoughtful piece by Lynn Ungar:
Pandemic, by Lynn Ungar (with permission)
What if you thought of it
as the Jews consider the Sabbath—
the most sacred of times?
Cease from travel.
Cease from buying and selling.
Give up, just for now,
on trying to make the world
different than it is.
Sing. Pray. Touch only those
to whom you commit your life.
And when your body has become still,
reach out with your heart.
Know that we are connected
in ways that are terrifying and beautiful.
(You could hardly deny it now.)
Know that our lives
are in one another’s hands.
(Surely, that has come clear.)
Do not reach out your hands.
Reach out your heart.
Reach out your words.
Reach out all the tendrils
of compassion that move, invisibly,
where we cannot touch.
Promise this world your love–
for better or for worse,
in sickness and in health,
so long as we all shall live.
Yours, in health and resilience,
Eric, Jenn, Prerana, Sky and Jackie