Reflections and COVID-19 Update

By Dr. Bill Queale

During this holiday season I couldn’t help but reflect on what has been a very challenging year.  Like all of you, Karen and I have been weathering this storm.  We have seen loved ones fall ill to COVID-19 or experience the devastating effects of social isolation and school closings.  Yet, on another level, the pandemic has brought us closer and given us a new perspective on our life.

We are currently in the middle of a resurgence of this disease.  However, as you can see from the recent Maryland COVID-19 Data Dashboard, after a predicted rise during the cold and flu season, there is some flattening of the curve.  National data show a similar trend.  While travel during the holiday season may cause an uptick in cases, these data suggest we are near the midpoint of a 4 or 5-month resurgence, assuming we continue measures to contain the spread of the virus.

With two effective vaccines being distributed, and others in the pipeline, there is reason to believe the situation will improve and the worst of this pandemic will come to an end by this coming summer.  Until then, we need to remain vigilant and continue to focus on minimizing transmission of this virus.  There has been a lot of new information available over the past couple months, including information on prevention, vaccination, testing, treatment, and exposure guidelines.  Here are my thoughts on these issues:

Prevention

The CDC has provided guidance on COVID-19 prevention, which I fully endorse and can be found here.  Ideally, we would be able to avoid exposure to this virus completely; but since the virus is widely circulating and highly contagious, complete prevention of exposure and infection is not possible.  Instead, we should focus on the prevention of severe illness, which is what drives morbidity and mortality from this disease.  

I believe there are 2 key drivers of severe illness.  The first is the “dose” of virus a person is exposed to.  In my opinion, the main benefits of wearing masks, maintaining physical distance, washing hands, and avoiding large crowds in confined spaces are to reduce the dose of virus encountered.  Although we are all tired of the restrictions, I recommend continuing these measures until you receive the vaccine.  The second is the health of the person who gets infected.  Healthier people are less likely to develop a severe illness from this infection.  Therefore, during these upcoming months of winter and spring, I recommend you continuing to get a good night sleep, eat a healthy diet low in sugar and processed foods, get regular low intensity exercise, and minimize stress.  With vaccine distribution already in progress, it would be a shame to develop a serious illness from COVID-19 from this point forward.

Vaccination

Vaccination is what will bring this pandemic to an end.  There are two vaccines currently available under Emergency Use Authorization – Pfizer BioNTech and Moderna.  These vaccines are slightly different than a typical vaccine and warrant a brief explanation.  Generally, vaccines involve manufacturing key viral proteins and injecting them into our muscle tissue.  This prompts our immune system to make neutralizing antibodies.  In contrast, these new vaccines inject an RNA “blueprint” of the viral protein, allowing our own cells to manufacture the protein, prompting our immune system to make neutralizing antibodies.  The data on these 2 vaccines are very compelling with efficacies well over 90%.  Likewise, data regarding safety have been very reassuring.  I personally have no reservation with getting either of these vaccines at this point.  AstraZeneca and Johnson & Johnson have similar vaccines in the pipeline.  These vaccines utilize DNA instead of RNA to produce the vaccine proteins, but the principles are similar.   There are traditional protein vaccines in the pipeline as well.  A good interview regarding vaccines can be found here.  A fun and more technical lecture on the science behind these vaccines can be found here.

The real challenge now is how to administer these vaccines to over 300 million people in a rapid and coordinated fashion.  Vaccine distribution and administration will be overseen by state governments under the guidance of the CDC and the Advisory Committee for Immunization Practice (ACIP).  The most recent ACIP recommendations regarding vaccine prioritization can be found here.  In summary, the vaccine will be distributed in 4 phases:

Phase 1a:   Healthcare personnel and residents of long-term care facilities (currently underway).

Phase 1b:   Persons aged ≥75 years and frontline essential workers (non–health care workers).

Phase 1c:   Persons aged 65–74 years, or persons aged 16–64 years with high-risk medical conditions, and essential workers not recommended for vaccination in Phase 1b.

Phase 2:     All other persons aged ≥16 years not already recommended for vaccination in Phases 1a, 1b, or 1c.

Each state health department will have its own specific vaccine distribution and administration plan based on these guidelines.  Residents of Maryland can review the draft Maryland COVID-19 Vaccination plan here.  The exact timeline and process for vaccine administration after Phase 1a have not been determined.  Due to strict requirements around vaccine transport, storage and administration, most vaccines after Phase 1a will be administered by large retail pharmacies such as Walgreen and CVS, since they have the infrastructure to meet these requirements.  This has been the way other vaccines, including flu shots, have been delivered successfully for many years.  Over time, additional sites will likely be approved.  At this point, it is unclear whether Hopkins will be a site for vaccine administration to non-healthcare workers.  Vaccines will generally not be delivered through private physicians’ offices, including ours, due to the regulatory requirements.  We will, however, keep you updated and assist you with getting the vaccine in any way possible. 

Testing

As many of you have experienced, one of the greatest challenges of the pandemic in this country has been testing. Fortunately, this has gotten somewhat better.  If you are exposed to COVID-19 or if you develop symptoms, please reach out to our office and we will help arrange testing.  We use Hopkins for most of our testing.  They use the preferred RT-PCR test and have a turn-around time of 24-48 hours from scheduling to results. 

There has been a lot of frustration around the lack of access to the rapid antigen test.  Rapid antigen tests are less accurate and generally only available through urgent care facilities if you are symptomatic.  Having said that, Patient First at Green Spring Station does do rapid testing, if indicated.  We are happy to coordinate an evaluation if you are interested.  We have also been keeping an updated list of other rapid testing sites around the state, so please reach out to us if you need assistance with testing.  

There are also home tests which are now entering the market.  The FDA recently approved the Lucira COVID -19 All-In-One test.  However, this test is approved for prescription use only and is not available to individuals over the counter, basically making it impractical.  What we need are simple, less expensive home tests, akin to home pregnancy tests.  There are products like this available, but they have not yet received FDA approval.  A good video on home testing, and rapid testing in general, can be found here. 

Finally, antibody testing is available to determine if you have been infected by the SARS-CoV-2 virus.  However, antibody testing has no utility in diagnosing acute illness.

Treatment

For patients who have symptoms and test positive for COVID-19, the CDC recommends that you isolate for 10 days from the onset of symptoms (a note on terminology: you isolate if you test positive, you quarantine if you are exposed to someone who tests positive).  For people who test positive and have no symptoms, the CDC recommends isolating for 10 days from the date of the positive test.  The official CDC guidelines for a positive test can be found here.  

Fortunately, most people with COVID-19 will have a self-limiting illness akin to a bad cold or a mild flu.  Many people will be completely asymptomatic.  Treatment is similar to other viral illnesses and includes, rest, fluids and over the counter medications to alleviate symptoms.  Vitamin C (1000 mg), Vitamin D (1000 IU) and Zinc (25 mg) may also help.  For patients at high risk for severe illness, two monoclonal antibodies treatments have received Emergency Use Authorization in the outpatient setting, one from Eli Lilly and one from Regeneron.  These have been shown to reduce the need for hospitalization and are available in select circumstances.  If you are sick and test positive for COVID-19, please contact our office so we can help you obtain proper treatment.

As you know, a small subset of people will go on to develop a severe illness requiring hospitalization.  The hallmark of severe illness is shortness of breath.  If you develop shortness of breath for any reason you need to go to your nearest hospital for evaluation.  Inpatient treatment of COVID-19 is complex, but in general we are doing a much better job now than earlier in the pandemic.  Antiviral drugs like remdesivir and anti-cytokine drugs like tocilizumab have not panned out to be the miracle drugs we hoped, although they might have a role in selected situations.  On the other hand, the steroid dexamethasone and new methods for mechanical ventilation in patients with severe illness have had a positive impact.  In the event you require hospitalization for COVID-19, we will work with your inpatient team to ensure the most appropriate treatments are provided.

Exposure

Exposure to someone with COVID-19 has caused a significant amount of confusion and distress.  The CDC guidelines for exposure definition and quarantine have been updated and can be found here.  In summary, the CDC definition for exposure is having spend a total of 15 minutes within 6 feet of a person contagious with COVID-19 within a 24-hour period.  A person is considered contagious from 2 days prior to developing symptoms (or testing positive) until 10 days after developing symptoms (or testing positive).   If you are exposed to someone with COVID-19, the CDC recommends you quarantine for a minimum of 10 days, although more recent guidelines allow for a shortened quarantine of 7 days plus a negative test.  Please note, there is no immediate need for testing if you have been exposed to someone with COVID-19.  The likelihood of a false negative test is extremely high, and it will not change how we handle your situation.  If you think you have been exposed to someone with COVID-19, please contact our office so we can assist with quarantine recommendations and testing if needed.

In summary, this has been a difficult year but there is light at the end of the tunnel.  My only hope, when this is all said and done, is that we will have learned some lessons so we are better prepared for the future.  I hope you all get to enjoy the remainder of this holiday season.  While we might wish to be physically closer to loved ones, I believe our efforts will pay off and we can look forward to a happy and healthy 2021.