News

CV🦠News – Week of May 25, 2020

Healthy greetings, TVD friends!

Here is the eighth issue of CV🦠News to hit your email inbox. Two months of weekly newsletters during these interesting “pandemic times”. Again, thank you to all five of our physicians, and also the various contributors to our Hope and Grace page, a collection of works and perspectives gathered from around the world. 

NOTE: CV🦠News is a labor of love. If you enjoy reading this, please share widely! Was this forwarded to you by a friend? Please subscribe here.

 

VACCINE UPDATE?
Recall that there is not yet a vaccine against COVID, or the coronavirus, but there are plenty of scientists and organizations working on developing a vaccine. The first Coronavirus vaccine trial started March 16, 2020 in Seattle. But more recently…

A preprint study (not yet peer reviewed) of the vaccine being developed by Oxford University and AstraZeneca released May 13th showed that vaccinated macaques were protected from COVID pneumonia.    

Moderna (Cambridge, MA) last week announced completion of Phase 1 of its human coronavirus vaccine trial. It had only 8 subjects but demonstrated acceptable safety data to move on to Phase 2 trials. They added that all 8 subjects developed neutralizing antibodies which should protect against severe COVID disease.

China’s vaccine candidate, which uses an adenovirus vector to deliver the vaccine’s genetic material, has also completed Phase 1, with safety data published in The Lancet May 22nd. Subjects all had rapid binding antibody and neutralizing antibody responses following vaccination. However, they observed that subjects with preexisting antibodies to the adenovirus used in the vaccine had lower immune responses.

Novavax this week announced it had begun clinical trials in Australia. Novavax was an early frontrunner among smaller biotechs, receiving $388M from Coalition for Epidemic Preparedness Innovations (CEPI), which is backed by the Bill & Melinda Gates Foundation. It too has an aggressive timeline, but is also leveraging global manufacturing partners in China and India, scientific partnerships with the Serum Institute and Oxford University to be able to produce any one of dozens of vaccine candidates in the works worldwide, including in their new plant in the Czech Republic which they say will be capable of 100 million vaccine doses per month by January 2021.

ABSENT A VACCINE, AND AS WE SLOWLY “REOPEN”, HOW SHOULD I THINK ABOUT, AND PERSONALLY LIMIT, “RISK”?
With many states in the US “reopening” to some extent, how should each of us think about our risk and minimize it as much as is reasonable? Any increase in social interaction increases risk of contracting COVID-19 to some extent. There will be some things we must all do to protect the most vulnerable in our communities (e.g. wearing masks in public, indoor spaces or when coming within 6 feet of others). Your personal risk tolerance for increasing social interaction with those outside your home may be closer to ‘zero’ if you are at high risk for severe infection or live with someone who is (i.e. immunocompromised people or those who have significant chronic health issues). With these considerations as our foundation, we might begin to analyze and limit the risks we each take personally in venturing more outside of our homes by using two frameworks – the first in relation to our own activities and the second in relation to the activities of others. 

In terms of our own activities, think about the level of proximity, the kind of activity, and the amount of time. For example, the highest risk scenario is if you are in close proximity, indoors, for a long period of time with someone who is infected. This is why most COVID cases are contracted from someone at home. Short-term interactions outdoors are safest (e.g. passing a stranger on a trail). Longer interactions, indoors, are higher risk (e.g. visiting your hair stylist). If both people coming together are wearing masks, this greatly decreases risk. Certain activities expel more droplets, such as singing. In one case, 52 people in a choir became infected from one infected person. Other activities, such as some family get-togethers, involve a lot of people hugging one another, also leading to higher rates of infection. Conversely, there have been no documented cases of someone acquiring COVID-19 from passing a stranger while walking outdoors.

To minimize risk in our own activities:

– Wear a mask whenever you are indoors in public spaces or within six feet of others
– Avoid crowded spaces (bars, sporting events, movie theatres)
– Host get-togethers in a park or your backyard
– Sit at least six feet away from others who aren’t part of your household
– Use your own utensils and bring your own food and drinks
– Skip the hugs, kisses and handshakes
– Choose take-out instead of eating out. If eating out, choose outdoor tables at least six feet apart
– At work, consider rotating staff in staggered shifts or every other week, spacing work stations and conference room seating by at least six feet
– Skip a crowded elevator and wait for the next. Try to stand on opposite sides from other riders and face away from them
– Minimize cumulative risk: your risk increases with every additional person you come in close contact with. If you have to return to work, you can decrease your risk by minimizing social gatherings outside of work. If you choose to eat at a restaurant, perhaps you can avoid that trip to the hair salon.  

In terms of considering the activities of others, before coming together, consider how friends and family are thinking about their own risk and activities. Also, consider risk in relation to the current state of local infection rates.

When considering decreased social distance with others, begin with other families who are carefully socially distancing. You can think of this as ‘pooled risk.’ It’s a bit like how you might consider safe sex practices – those in monogamous relationships are lowest risk and those with mulitple high-risk partners are highest risk. If you’re planning to come together with others, it is safest to do so with those who have been socially distancing as carefully as you have, particularly during the 2 weeks before the get-together. If planning to travel with another family, for example, it might be helpful to discuss how socially distanced each family plans to be for the two weeks prior to the trip. If you are a grandparent who misses your grandchildren, if both families have been sheltering at home carefully for two weeks it should be very low risk for both families to join together. However, if someone goes back to work or continues to visit the grocery store frequently, this can increase the risk for both families. 

When local rates of infection decrease, the individual risks we take out in the community are also lower. For example, beginning to think about hosting a socially-distanced gathering in your backyard probably makes more sense soon in the Bay Area but likely would not feel as safe in an area with higher rates of infection such as New York City.

We encourage you to explore the concepts of proximity, activity and time when considering your activities as the US begins to reopen. Don’t be afraid to bring up these topics with others as you consider decreasing social distance with them. Taking precautions such as wearing a mask in public and holding smaller events outdoors, socially distanced, without food sharing will help protect everyone, including our most vulnerable, who face the most risk from potential infection and, as a result, the most challenge from the impact of continued stricter social distancing. We can greatly ease the burden on these community members if we carefully consider the risks we take to minimize local community transmission rates.

ANYTHING NEW ON THIS WHOLE “HYDROXYCHLOROQUINE” THING?
Without wading into politics (don’t get us started), I would simply note that data published in The Lancet, on May 22, 2020 reporting on a large multinational data analysis with over 90,000 patients found no benefit of hydroxychloroquine. The findings showed increased rates of cardiac toxicity in those patients who received hydroxychloroquine. To date this is the only published article that has studied this drug and its potential efficacy in COVID patients. In addition, on May 24th the WHO paused one arm of its Solidarity trial which was studying hydroxychloroquine in COVID patients. The decision to pause comes after initial data suggested greater harm than benefit from the drug. You will find more information here. I would simply say, #science. 

CAN WE NOW GO TO BAY AREA PARKS AND OPEN PLACES?
From the County of San Mateo Park Department website:
On Monday, May 4, the San Mateo County Parks Department reopened 13 of its 23 parks after being closed since March 27. Visitors are required to hike single file on narrow trails, keep six feet apart from others, not congregate with people who aren’t from their household, and carry face coverings. “We are eager to welcome visitors back to San Mateo County Parks and for them to experience the physical and mental health benefits of being outdoors and on the trails,” said Parks Director Nicholas Calderon. “During this time, it’s critical that park users follow the new rules developed to prevent overcrowding, discourage gatherings and that support social distancing. Let’s work together to ensure that parks are safe environments for everyone.”

Playgrounds, picnic areas, campgrounds, fields, visitor centers, and some restrooms and parking lots remain closed. Visit the County of San Mateo Park Department’s website for more information.

IS IT SAFE TO EAT AT RESTAURANTS AGAIN? HOW CAN I REDUCE MY RISK?
As local and state governments make decisions to allow restaurants to reopen, individuals and families will have to assess their own risk to decide if it is safe to eat at restaurants in their community. In areas where there are still new cases popping up every day, you can assume there continues to be a risk for transmission in public settings. If you or a family member falls into a high-risk category, it is probably best to continue to be extra careful. That said, if no one is personally at high risk, then look to the restaurant to pick the safest options and do a little homework before you go to determine what precautions they are taking to keep their diners safe. Generally speaking, the restaurants that pose the highest risks to diners are those that only offer indoor dining and do not reduce their seating capacity to assure that different parties are spaced out by at least 6 feet. The CDC has offered guidelines for restaurants that plan to open including (but not limited to) modifying seating layouts, requiring face coverings for staff, increasing frequency of staff hand washing, posting signs promoting protective measures, maintaining strict disinfection routines, avoiding use of shared items that are reusable and increasing air circulation.

If you are truly sick of home-cooked meals, your lowest risk option is getting food delivered or picking it up from a restaurant that does not offer a dine-in option (as that slightly increases the risk, especially if there’s indoor seating). If you and your family members are low risk and you opt to dine at a restaurant, here are some tips to stay as safe as possible (you can read more here and here):

– Sit outside at least 6 feet away from other diners when possible and don’t linger after you finish your meal
– Maintain your distance and wear a facemask when you are not drinking or eating
– Wash your hands frequently – bring your own hand sanitizer and consider bringing alcohol wipes if feasible
– Ask for disposables if available (condiments, utensils etc)
– Avoid touching your face, eyes, nose and mouth with your hands

HOPE AND GRACE

If you have made it this far, time for a reward, something to lighten your day, and acknowledge the human spirit. Find some escape, or perhaps even inspiration, in this collection of works and perspectives gathered from around the world. Please contact me directly if you have come across something that has lifted your heart today.  Dr. Eric Weiss

Bring Me Little Water, Silvy” by Huddie Ledbetter (Leadbelly). Arranged for voices with body percussion by Moira Smiley / Body Percussion Sequence by Evie Ladin / Shot by Seamus Egan / Edited by Ben Guzman. Huddie Ledbetter, (1888–1949) wrote “Bring Me Little Water, Silvy”, and recorded it with Anne Graham in 1950 for Folkways Records. Many artists since then have played, arranged and recorded this beloved song. Read more at Ordinary Women Doing Theological Things. Listen to another wonderful rendition here.

Love! Written by my friend, and Stanford Emergency Physician Ben Lundquist, with proceeds going to “Get Us PPE”I Love You When You’re Close and When You’re Far Away is worth a read. This rhyming children’s book highlights the importance of staying safe during a global pandemic and understanding that love transcends all circumstances – even distance. Find it here on Amazon. Congrats, Ben!

Who is your friend? My friend’s name is Litchy” (writes my friend, Danyelle Kelly). “I find that at this place my feet are the same as the dirt on the ground, as if they are linked and intertwined. My spirit soars at a special rock in front of the waterfall where I feel the divine completely present and all linking as one. Here at this friend’s place all is one. I feel loved, scared, nourished and surprised”. 

“This is a response to a stimulus from a group that I am part of where I was asked to provide a photo of a place which is very special to me among special places. One place from where I deeply connect, draw strength and feel deep belonging. I was asked to write two – three sentences about my relationship with this place and introduce this place by name as your friend. If you were asked to do this what place would you write about? What place do you deeply connect, draw strength and feel deep belonging?”

Read more about Litchfield National Park (Northern Territory, Australia) here. 

*****

Yours, in health and resilience,

Eric and the TVD MD team…