CV🦠News, Week of July 20, 2020 – The Village Doctor

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CV🦠News, Week of July 20, 2020

 

Greetings, TVD friends,

Interesting. Oregon? Really? And please also note that coronavirus is booming in California, so we continue with our overarching message below- Help us keep San Mateo County OFF the State COVID watchlist!

  • Wear a mask when out in public

  • Use “physical distancing” when going out

  • Shelter in Place as much as possible

Your #BLM tidbit for the week. Did you know that Orgeon (home of Portland and the recent and highly visible protests) has a surprisingly (at least to me) racist history? Oregon’s territorial constitution, adopted in November 1857 – less than two years before it became a state – barred people of color from coming within its borders. It wasn’t until 1926 that the provision was repealed. Oregon imposed a tax on people of color in 1862, and racial exclusion laws and bans on interracial marriages were on the books for decades, the latter until 1951. “That kind of set the template for what, many decades to come afterward, forms the racial exclusion, anti-Black hostility, housing covenants in Portland, Eugene and other cities that make it difficult for Black people to move in and work in Oregon,” Joe Lowndes (a professor of political science at the University of Oregon) said. “It’s a white state by design.” Yikes. Read more here.

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ARE THERE “HOME TESTS” FOR CORONAVIRUS?
As of July 22, 2020, there continues to be wider availability of at-home testing for COVID-19, however with the current surge, the tests turn around times have generally been longer than expected. Each of these tests looks for ACTIVE disease by testing for viral RNA. As with any COVID-19 testing, it is crucial to remember that a negative test only means the virus was not detected at the time you collected the sample, but that you could have been exposed and were still in the early stages of infection when you took the test.

Each of these tests is authorized by the FDA under the Emergency Use Authorization (EUA), but they are NOT officially FDA-approved. The EUA only allows unapproved products to be used during the public health crisis. The FDA does provide recommendations for the test validation in its EUA policy, emphasizing  that “false results can have broad public health impact,” but the exact accuracy of these tests is not known.

Pixel by Labcorp is a self-collected nasal swab. You will complete a short eligibility survey and then, if eligible, you can decide if you want to pay out of pocket ($119) or have it billed to your insurance. Patients must be over 18 years old and are typically eligible if they are mildly symptomatic or have had potential exposure. The kit will be shipped to you overnight. You will follow the instructions to register the kit and prepare a self-collected nasal swab, and then return the kit with the included shipping label. Results are currently taking 3-5 days from the time your sample is received at the lab. After receiving your results, you have the opportunity to speak to a licensed physician who can answer questions and help guide your next steps.

Everlywell also offers a self-collected nasal swab. You can be asymptomatic or have mild symptoms, and must be over 18 years old. After an online screening, if eligible, you can choose overnight or within 3-day shipping to receive your kit. The test costs $109. You will then register your kit, collect your sample, and drop it off for overnight shipping to the lab. Samples cannot be returned over the weekend. Results are typically available within 72 hours after the lab receives the sample. If your results are positive, you will have an included telehealth consult to guide you through next steps.

Vault has a saliva test available for people over and under 18 years old. You will need a unique email address for each person taking the test and can order the test easily for $150 (out of pocket, but HSA and FSA funds accepted). When you are ready to use the test (it is shelf-stable for 2 years), you have to log in through their website to have a Zoom session with a test supervisor. The test supervisor has to guide you in collecting your specimen for it to be valid. There’s no appointment needed, but a test supervisor has to be available. The availability of the test supervisors is Sun – Thurs between 11 am – 9 pm PST, and Fri – Sat between 11 AM – 7 pm PST. The kit must then be dropped off for overnight shipping. There is currently no known sensitivity or specificity for this test. Test results are available within 48-72 hours after it arrives at the lab.

hims&hers also offers a saliva test, but only for symptomatic individuals after a medical consultation to determine if you are eligible. If you are eligible, the cost is $150. It is a self-collected saliva sample that can be collected at any time, but must be sent back within 24 hours of collection. They report that the time to results is 3-5 days from the time the sample is shipped to the lab.

CAN A MEASLES VACCINE (OR MMR) BOOSTER REDUCE THE RISK OF COVID-19?
The simple answer is: we don’t know, but many scientists are calling for further research.

Typically a childhood vaccine series, the measles-mumps-rubella (MMR) vaccine is also recommended as a one-time adult booster for high-risk patients such as healthcare workers. Recently some scientists have proposed studying whether an adult booster of this live virus vaccine might generally ramp up immunity, preventing some of the most severe effects of COVID-19. The thinking is that because the MMR vaccine uses highly weakened, or attenuated, versions of the measles, mumps and rubella viruses to produce immune protection without making people sick, the use of these “live” viruses might stimulate an immune response that is broad and goes beyond the production of antibodies. “There is mounting evidence that live attenuated vaccines provide nonspecific protection against lethal infections unrelated to the target pathogen of the vaccine by inducing ‘trained’ nonspecific innate immune cells for improved host responses against subsequent infections,” Paul Fidel of Louisiana State University and Mairi Noverr of Tulane University wrote in a letter to the journal mBio.

Supporting this concept for COVID-19 risk reduction, it was recently postulated that the milder symptoms (and only one hospitalization) in the 955 sailors on the USS Roosevelt who tested positive for COVID-19 could be due to the fact that all US Navy recruits receive adult MMR booster vaccines. Additionally, epidemiological data suggests a correlation between geographical locations where MMR vaccine is commonly available and reduced COVID-19 death rates.

While this has not yet been studied for its effect on COVID-19, there are only a few contraindications for administering a live attenuated vaccine like MMR to adults, including if the patient is immunocompromised, pregnant, or has shown previous allergic responses to the vaccination.

DOES WEARING A MASK REALLY MAKE A DIFFERENCE? DOES IT MATTER WHICH KIND?
A case report published July 17, 2020 in the CDC’s Morbidity and Mortality Report showed the power of wearing face masks to stop the spread of the SARS-CoV-2 virus.  The report suggested wearing a face mask wasn’t just protective of others, but that it also protects the wearer.

On May 12th, a hair stylist in Springfield, Missouri developed respiratory symptoms, but kept working for 8 days until a COVID-19 test came back positive. Another stylist got sick 3 days later and worked for another 7 days before testing positive and staying home. Both stylists wore masks only when customers were present in the salon.

Six close contacts of the first stylist got COVID, but of the 139 clients exposed to either of the two symptomatic hair stylists while both the stylists and clients wore face masks, no symptomatic secondary cases were reported. Among 67 clients tested for COVID-19, all were negative. Adherence to the community’s and company’s face-covering policy likely saved the day. Robert Redfield, director of the CDC, said last week that if the American public embraced wearing face masks, the pandemic could be brought under control in less than two months.

A hypothesis among some Infectious disease researchers is that wearing a mask blocks 65-85% of viral particles. Breathing in a smaller “viral inoculum,” or smaller dose of infectious particles, correlates with having milder or even asymptomatic infection. This is likely because the immune system gets a better chance at mounting a defense. This is seen with many other viruses: it is a race between the virus replicating within the body (increasing viral load) and the immune system’s ability to kill it. Thus, breathing in less virus gives the immune system a better chance.  In areas where a high percentage of people wear masks, the number of cases may rise, but the number of deaths falls. In San Francisco, for example, with a high level of mask-wearing, the cases have risen, but the death rate has remained flat. In fact, there have been no new deaths there since June 27.

But which kind of mask is best? Researchers at Florida Atlantic University experimented with different materials and styles of non-medical masks and found that a well-fitted stitched mask made from two layers of quilting fabric was the most effective in stopping the spread of droplets from experimentally reproduced coughs and sneezes. They found that droplets from a simulated uncovered cough were able to travel more than 8 feet, with a bandana they traveled 3 feet, with a folded cotton handkerchief they traveled 1 foot, 3 inches. With a stitched cotton mask droplets only traveled 2.5 inches.

WHAT DO I NEED TO KNOW ABOUT POSSIBLE “AEROSOL-BASED” COVID TRANSMISSION?
There has been a lot of discussion recently regarding whether COVID-19 is regularly transmitted via aerosols (small particles <5 microns in diameter that can hover in the air for hours) vs. droplets (larger particles that are believed to drop to the ground within 6 feet of being generated, though some more recent studies have shown even these larger particles can travel up to >20 feet in some settings). While we know COVID can be transmitted via aerosols during procedures such as intubation or mechanical ventilation (i.e. in an ICU setting), some anecdotal reports have recently suggested aerosol-based transmission may be occurring in more common indoor settings (examples include several members of a choir becoming infected, as well as a large percentage of workers in a small call center).  

We are still trying to more definitively answer the question of how large a role aerosol-based transmission is playing in COVID-19. Most experts believe it probably plays some role, but not a large part. If aerosol-based transmission played a large role, we would expect a larger number of people to be infected from each infected person (more like measles, which has an R naught of 18, compared to COVID-19’s of around 2-3) and we would expect N95 masks, made to prevent passage of smaller particles, to prevent more infections than surgical masks in the hospital setting (but studies have not convincingly demonstrated this). It would have made it less likely that countries which employed early universal masking policies (using surgical and cloth masks) would have so effectively curbed their infection rates as they did. 

The answer to how large a role aerosol-based transmission plays in COVID-19 transmission will help guide prevention strategies. Aerosolized particles can build up in the air in unventilated, indoor areas and potentially infect someone passing through hours later. Because we do believe this is playing at least a minor role in transmission, it is a good idea, until we know more, to minimize time spent in indoor communal settings without good ventilation.

For more information, an article written by Chanu Rhee, a colleague of Dr. Abrams’ from her Stanford Internal Medicine residency, now an epidemiologist and infectious disease physician at Harvard’s Brigham & Women’s Hospital, wrote this helpful piece published in JAMA.

UPDATE: HOW LONG DO YOU NEED TO ISOLATE IF YOU FEEL SICK AND THINK YOU HAVE COVID BUT COULDN’T GET TESTED?
The CDC’s recommendations for discontinuing home isolation were updated on July 20, 2020. Important changes include that they are no longer recommending a “test-based strategy” under normal circumstances and they changed the “symptoms-based strategy” as well. These changes reflect evidence that people with mild to moderate disease are no longer contagious 10 days after their symptoms began and those that have severe illness (or are severely immunocompromised) are no longer contagious 20 days after their symptoms developed. The new guidance is as follows: 

Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue isolation under the following conditions:

  • At least 10 days* have passed since symptom onset and
  • At least 24 hours have passed since resolution of fever without the use of fever-reducing medications and 
  • Other symptoms have improved.

*A limited number of persons with severe illness may produce replication-competent virus beyond 10 days, that may warrant extending the duration of isolation for up to 20 days after symptom onset. Consider consultation with infection control experts. 

Persons infected with SARS-CoV-2 who never develop COVID-19 symptoms may discontinue isolation and other precautions 10 days after the date of their first positive RT-PCR test for SARS-CoV-2 RNA.

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

Perfect! You may not know of the young Irish singer Allie Sherlock, but this is worth a heart-lifting watch and listen (especially if you are a fan of Ed Sheeran, or if you speak Italian 😇). Enjoy!

Iconic album covers? OK, this is fun. Residents at the Sydmar Lodge Care Home in Edgeware, England, have been in lockdown for four months. As Activities Manager at the home, Robert Speker wanted to keep spirits up while visitors and outside entertainment aren’t permitted. 

Thus, a brilliant project was born: re-creating classic album covers with residents cast as the rock stars. Check the final results out here

Again, 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.

*****

Yours, in health and resilience,

Eric and the TVD MD team…