Greetings, Friends of TVD!
Here we are, the fifth issue of CV🦠News! 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.
And, one last reminder that our Coronavirus FAQ page has undergone a substantial revision, with new formatting, and improved search functionality to help you find the answers to all your burning COVID-19 questions. Have a look here!
As this pandemic continues on, it is easy to be overwhelmed, and even confused, by the amount of information coming at us every day. Of course, part of the goal of this newsletter is to filter and parse your mental inbox. However, a few days ago The Atlantic published a really excellent review of the Virus, the Disease, the Research, the Experts, the Messaging, the Information, the Numbers, and lastly, the Narrative. I recommend that you read it here.
TESTING, TESTING, and ‘IMMUNITY TESTING’
Immunity tests, also called “immunoassays,” measure coronavirus antibodies (IgM, IgG) that the body makes in response to COVID-19 infection. These antibody tests give us a sense of whether you have been exposed to the virus by testing a blood sample that is either drawn from phlebotomy (ELISA) or obtained from a finger prick (“lateral flow tests”). Both operate on the same principle, detecting the presence of a target substance (IgM or IgG antibody in a patient’s blood) by binding it with reactive molecules that show a visual positive or negative result. While ELISA-based tests need to be read in a lab, lateral flow tests tend to provide simply a positive or negative result in the form of presence or absence of a band (think of a home pregnancy test) and are the basis of many of the home antibody tests you may have read about. Better information on the reliability of these tests is needed before we recommend them. UCSF is studying the sensitivity (ability to detect exposure) and specificity (ability to distinguish people who are infected from those who are not) of these tests and has so far tested 12 of them against blood samples of patients with known infection and blood samples of patients prior to the outbreak (i.e. with known lack of infection). While many have specificities greater than 95%, if infection is rare in a population, a false positive rate of 5% can cloud the picture of the true infection rate. For an individual patient, this means a 5% chance your positive result isn’t real. While we all hope a positive serology test means a person is immune and “safe,” there are still big questions about the reliability of the tests and we do not yet know if, or for how long, immunity may last. Doctors worry that knowing you have a positive IgG response could lead you to feel more comfortable being less careful with social distancing, decreasing protection of at-risk loved ones or yourself, which could be harmful until we know more about how protective an IgG response is.
SPEAKING OF TESTING, CAN WE USE A TEST TO GUIDE BACK TO WORK?
Currently there is not an agreed upon guideline for getting us “back to work” in either the public or private sector. Corporations in the US as well as worldwide are developing plans, but also revising them frequently in this ever changing environment. Some have suggested a negative swab after several days of isolation could be used as clearance to return to work. Unfortunately, this plan has many drawbacks. Any negative test is simply a snapshot in time and does not tell us about a person’s infectivity the next day. In addition, the rate of false negatives is thought to be higher than reported based on the observation that some patients with documented COVID pneumonia are found to have several, repeated, negative PCR tests. Even knowing this, the CDC suggests we would need 30 million tests/day to safely have guidelines for the US. Additionally, Harvard and others have talked about the limitations of using serology as a marker of a positive case since we do not know if the presence of antibodies confers immunity and the timing of development of antibodies. Corporations around the world are using their own criteria. Ferrari company talks about their back to work plans here.
SPEAKING OF BACK TO WORK, WHAT IF THERE IS NO VACCINE?
Yikes! What happens if a coronavirus vaccine is never developed? While countries around the world navigate this new reality of social distancing/ shelter in place, we optimistically await a vaccine that could bring daily life back to normal. Perhaps as soon as 12-18 months according to Dr. Fauci. But other epidemiologists and virologists caution it could be the latter, and even then, it is the best case scenario. But what if one never comes? It has happened before (HIV, malaria, dengue fever, adenoviruses and rhinoviruses that cause the common cold). And although we have several vaccine candidates, some of which have begun human trials, it is the testing phase which is the limiting step, holding up or completely scrapping vaccine candidates when lack of efficacy or safety data knocks out an entire team’s Herculean efforts. The human body is just not as predictable as we might wish it to be and vaccine development can often seem hit or miss.
So for the next two years or, in the worst case, decades until a vaccine is found, what will life look like? Everyone agrees, it will be very different. Lockdowns are not economically (or probably politically) sustainable. As countries try to creep out of their paralyses, experts would push governments to adopt an awkward new way of living and interacting, fundamentally requiring a social contract among citizens to stay home if they feel sick and for employers and coworkers to treat them as heroes rather than pariahs. In the short term, a vast program of testing and contact tracing would need to be implemented to allow societies to function alongside COVID-19. One that dwarfs any such prior program and one which remains some time away for major countries like the US and UK. We will need a robust public health system, contact tracing, testing in the workplace, symptom surveillance, and early communication of the need to re-implement social distancing. With these systems in place, and during periods of minimal transmission, it may be possible to open things up for sporting events and large gatherings, perhaps with fans separated in the stands, and other precautions. But it would not be permanent, and would require continual monitoring by governments and public health bodies. NFL and MLB games might resume for weeks at a time — before quickly shutting down stadiums when the threat rises. And from time to time, there will be outbreaks, movement will be restricted, within counties, states or regional state coalitions. While many debate the timing, the outlook is optimistic that an effective vaccine will come. But if previous outbreaks have proven anything, it’s that hunts for vaccines are unpredictable.
HOME ALONE? AND SICK?
If you suspect that a loved one has coronavirus, it is critical to play it safe while taking care of them to avoid getting the infection yourself and also to avoid spreading it to others while you await testing or results.
Do your best to limit contact with the person, but make sure that you are providing support and helping them to follow their doctor’s instructions while watching for any warning signs. It is recommended that both the sick person and the caregiver wear cloth face coverings when they must interact. If the mask causes breathing difficulties for the patient, then only the caregiver should wear a mask. Both parties should also wash their hands frequently and the caregiver should wear gloves when possible, especially if they will be in contact with bodily fluids.
As with most viruses, you should encourage them to drink a lot of fluids and rest as much as possible. You can offer Tylenol or other recommended over-the-counter medicines or supportive measures to help them feel better. Help them get their prescriptions if needed and also get other groceries and supplies for them so that they can stay in quarantine. When you do see them or talk to them, watch for emergency warning signs which include (but are not limited to): difficulty breathing, shortness of breath, unrelenting chest pain or pressure, confusion, bluish coloration of lips or face. If these occur, call 911 and inform them that the patient has or may have COVID.
In order to limit contact, the sick person should ideally use their own living space (bathroom and bedroom) if possible and avoid any visitors. If spaces do have to be shared, leave windows open and use fans to improve ventilation. The sick individual should eat in their own room and their dishes and utensils should only be handled when wearing gloves. To clean and disinfect, follow the guidelines listed here.
You can read more about the recently updated CDC guidelines on “Caring for Someone Sick at Home” here.
HOME ALONE? AND CONTAMINATED?
What about keeping our homes clean, and virus free? As part of your daily routine, you should try to clean and disinfect frequently touched surfaces and objects (phones, door handles, light switches, countertops etc). You can use soap and water first if the area is obviously dirty and then use a disinfectant*. If someone is sick, it is best for them to use a separate bathroom which they should clean and disinfect if they can, or limit to cleaning only when necessary. Try to use lined trash cans whenever possible, especially if you will be putting disposable gloves or facemasks in the trash. For laundry, it is best to avoid shaking dirty clothes and to use the warmest settings possible for washing and drying. Remember to wash your hands after and also disinfect the hamper if someone is ill. Please see the CDC’s guide here for more tips.
*If you are concerned about running low on your packaged wipes, you can also make a disinfectant spray instead of using wipes: mix 5 tablespoons of bleach into 1 gallon of water or 4 teaspoons of bleach into one quart of water.
HOME ALONE WITH A SICK KID?
Some have heard the news coming out of Britain associating Coronavirus with a rare inflammatory syndrome – Last week, Britain’s Paediatric Intensive Care Society issued a warning that they are seeing an increase in children with symptoms that are similar to those seen in a rare inflammatory condition called Kawasaki disease and they suspect Coronavirus may be a cause. Cases have also been reported in Spain, Italy and the US, but Dr. Brad Segal, a physician who treated a patient at Stanford, believes this will be “exceedingly uncommon.” The WHO is still in the process of gathering information to see if there is truly a link so there is very little information available, but there are now of course studies underway. Kawasaki disease includes fevers for at least 5 days and four of the five following symptoms: rash, red eyes, swollen glands, swollen red tongue, and redness and swelling of the hands. Along with those symptoms, the walls of the blood vessels become inflamed, so special treatment is needed. In these new cases, the symptoms are occuring weeks into recovery from the virus and thus it is thought that the inflammation is caused by a late immune reaction to COVID-19. The condition has been seen in kids who tested positive for COVID-19 and those who have not, which is likely because the child is no longer actively infected. If your child has already had coronavirus, while there is a very small chance that they could develop this complication, remember that there are generally effective treatments. For now, the bottom line is that if your child develops high fevers and a rash, do as you normally would and call your pediatrician for advice!
OK, no more Home Alone references… 😀
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
Shelter in Peace guided meditation from our friends at Stanford: Everyone Sheltering In Place is invited to join the free, weekly, guided meditation practice, Sheltering-In-PEACE, from 12:10-12:50 p.m. on Mondays through the end of May via Zoom and YouTube. This program provides evidence-based contemplative practices known to support health and well-being. The practice is based on the P.E.A.C.E. framework – Pause, Exhale, Attend, Connect, Express – created by Stanford’s Contemplation by Design program. To join via Zoom, click on this link: https://stanford.zoom.us/j/120715842. A livestream of the guided meditation practice will also be available here on YouTube. In response to your requests, video recordings of the weekly program will become available at: https://tinyurl.com/shelter-in-peace
Morning MeditOceans (!)
More beautiful guided meditations from our friends at the Monterey Bay Aquarium. These are terrific, ~10 minute sessions. Enjoy some quiet with the beautiful jellyfish, kelp forests, open seas, or waves crashing upon the rocky shore. Enjoy.
Enjoy US National Park Hikes… from home!
Slowly the country’s national parks will begin to slowly reopen after closing due to the coronavirus pandemic, but if you don’t live near one, here are four parks you can hike virtually from the comfort of your quarantine (NOTE: The Google Chrome browser is required to run Google Earth (but worth it!) 1) On average, 4 million people a year visit Yosemite National Park in California to see its famous granite cliffs and giant sequoia trees—but you can see those virtually from your couch. 2) Perhaps the most famous of America’s national parks, the Grand Canyon in Arizona has many of its hiking trails and best lookout points available virtually. 3) Big Bend National Park is a sprawling protected area along the border of Texas and Mexico that is home to thousands of different species of plants and animals, with a nearly five mile trail online for virtual hiking. 4) Don’t let the name scare you—California’s Death Valley has gorgeous views of the desert, winding canyon trails and even an old gold mining town.
Lastly, enjoy this read by David Byrne (yes, that David Byrne) on how we might imagine what we might be, what our future might hold.
Yours, in health and resilience,
Eric and the TVD MD team…