Image by Gerd Altmann from Pixabay

 

 March 23rd, 2020

 

SARS2 Severe adult respiratory syndrome coronavirus is the viral name

COVID 19 is the disease name

Preamble note: 99% of us are not at risk for a bad outcome. Take solace in that notion. Please do not use that as a license to be cavalier with other people's health.

CDC statement: Since February 12, 4,226 COVID-19 cases were reported in the United States; 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths occurred among adults aged ≥65 years with the highest percentage of severe outcomes among persons aged ≥85 years.

We are now officially in lockdown here in North Carolina and throughout most of the country. While many may debate the validity of this decision, that debate is tabled for another day when we can Monday morning quarterback the why, how and where of it all. The decision to close Primary and secondary schools, in my mind, was probably the best decision as children are the asymptomatic carriers that can rapidly worsen this crisis. I am saddened for the seniors of High School and colleges around the country and I also thank them for social distancing and keeping many a grand parent alive to see another grand child walk, cry, smile and hug.

Remember why we are trying to flatten the curve of new cases in the first place? The slower these cases develop, the more capable we as a medical system are of handling the acute respiratory distress that requires an intensive care unit and mechanical ventilators. We are not at all expecting to stop this virus in its tracks. We are just trying to control the narrative a little more and also avoid the Western European experience of triage based death. We are still at the front end of the wave of cases here in the US. We have yet no idea how bad this is going to get. Preliminary data says that we are doing ok but not great.

This may be a factor of our younger average age than Europe or just too early to know.

Further data has emerged:

1) The sensitivity of the nasal swab rt-PCR test (real time polymerase chain reaction) is ok but not great. This is the test that we are rarely using to date but basing all of our quarantine decisions on. In a study in the Journal Radiology by Dr. Fang and colleagues, we see a sensitivity of 71%. This means that if we test a hundred true infected individuals, we will find 71 of them and miss 29. That is not ideal but better than no test. The chest CT is much more sensitive but is reserved for the significantly infected. If we had and will initiate rapid and nationwide testing with rt PCR at least we would find the 71% and could quarantine them.

2) In a letter from Dr. Lu, "As of March 10, 2020, the 2019 novel coronavirus (SARS-CoV-2) has been responsible for more than 110,000 infections and 4000 deaths worldwide, but data regarding the epidemiologic characteristics and clinical features of infected children are limited." "In order to determine the spectrum of disease in children, we evaluated children infected with SARS-CoV-2 and treated at the Wuhan Children's Hospital, the only center assigned by the central government for treating infected children under 16 years of age in Wuhan. Both symptomatic and asymptomatic children with known contact with persons having confirmed or suspected SARS-CoV-2 infection were evaluated." "Of the 1391 children assessed and tested from January 28 through February 26, 2020, a total of 171 (12.3%) were confirmed to have SARS-CoV-2 infection. The median age of the infected children was 6.7 years. Fever was present in 41.5% of the children at any time during the illness. Other common signs and symptoms included cough and pharyngeal erythema. A total of 27 patients (15.8%) did not have any symptoms of infection or radiologic features of pneumonia. A total of 12 patients had radiologic features of pneumonia but did not have any symptoms of infection." (NEJM letter Dr. Lu) Yet again the data points to the difficulty that arises from the mildly infected children being able to transmit with no obvious warning signs. We need to broadly test in order to know who is spreading. That is still not happening on the front lines of pediatric medicine.

3) A new CDC report notes these statistics: "This first preliminary description of outcomes among patients with COVID-19 in the United States indicates that fatality was highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65-84 years, 1% to 3% among persons aged 55-64 years, <1% among persons aged 20-54 years, and no fatalities among persons aged ≤19 years.

As of March 16, a total of 4,226 COVID-19 cases had been reported in the United States, with reports increasing to 500 or more cases per day beginning March 14. Among 2,449 patients with known age, 6% were aged ≥85, 25% were aged 65-84 years, 18% each were aged 55-64 years and 45-54 years, and 29% were aged 20-44 years. Only 5% of cases occurred in persons aged 0-19 years.

Among 508 (12%) patients known to have been hospitalized, 9% were aged ≥85 years, 26% were aged 65-84 years, 17% were aged 55-64 years, 18% were 45-54 years, and 20% were aged 20-44 years. Less than 1% of hospitalizations were among persons aged ≤19 years. The percentage of persons hospitalized increased with age, from 2%-3% among persons aged ≤9 years, to ≥31% among adults aged ≥85 years.

Among 121 patients known to have been admitted to an ICU, 7% of cases were reported among adults ≥85 years, 46% among adults aged 65-84 years, 36% among adults aged 45-64 years, and 12% among adults aged 20-44 years. No ICU admissions were reported among persons aged ≤19 years. Percentages of ICU admissions were lowest among adults aged 20-44 years (2%-4%) and highest among adults aged 75-84 years (11%-31%).
Among 44 cases with known outcome, 15 (34%) deaths were reported among adults aged ≥85 years, 20 (46%) among adults aged 65-84 years, and nine (20%) among adults aged 20-64 years. Case-fatality percentages increased with increasing age, from no deaths reported among persons aged ≤19 years to highest percentages (10%-27%) among adults aged ≥85 years." (CDC report)

What can we glean from these fresh data sets and papers. First, the age negativity predilection for the elderly to have bad outcomes persists very strongly. Second, some 20 to 30 year olds are getting sick enough to land in the intensive care unit but they are not dying. Third, teens and younger children continue to be spared serious disease despite infection and transmissibility. Fourth, the rt PCR is adequate but not great as a screening tool for disease. Having a negative test DOES NOT MEAN that you did not or do not have COVID. It means that we are unsure and are going to have to guess. A positive test means that you almost definitely have it regardless of how you feel. To my knowledge, the CDC has not released their test sensitivity and specificity data.

 

The bottom line continues to be: practice social distancing and help educate the children, teens and millennials that their exposure and spread is likely fueling a large part of this disease nightmare.

This site continues to have the best information about the presentation of the virus

The to do to keep your immune system strong and prevent disease spread:

1) Practice social distancing no matter how old you are
2) Eat super healthy - no processed food
3) Get 8 plus hours of sleep per night - KEY
4) Think positively
5) Mildly exercise daily
6) Meditate/pray
7) Eat asian mushrooms, cruciferous vegetables, red/orange/yellow peppers and small oily fish daily
8) Drink lots and lots of water

A final reiterated note: 99% of us are not at risk for a bad outcome. Take solace in that notion. Please do not use that as a license to be cavalier with other people's health. Avoid the elderly and family members that are over 60 years old where possible especially if you have disease carrying younglings. Children that are mildly symptomatic or completely asymptomatic can and will spread disease in some if not many cases. Grandma and granddad need to live to see the next great grandchild event and that will not happen in some cases if we keep business as usual with grandmothers and grandfathers seeing their grandkids often like nothing has changed.

Stay tuned,

 

Dr. M

NEJM Coronavirus History Article
NEJM Child Analysis
AAP Video for Parents
Biggerstaff BMC ID Article
Zhi Pubmed Article
Heyman Lancet Article
CDC Clinical Presentation Page
Peter Attia Show Notes Page
Van Doremalen Transmissability Article
Fang Radiology Article
NEJM Letter Dr. Lu
Ai Radiology Article

AAP Resources:
• Information from the CDC for health care professionals,
• Information from the AAP Red Book,
• AAP policy Infection Prevention and Control in Pediatric Ambulatory Settings,
• Information for parents from HealthyChildren.org on coronavirus, and talking to children about disasters, http://bit.ly/3arJbXj