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September 21 , 2020

 Latest numbers show that we are in a plateau phase. The previously untouched midwest is seeing some increased case volume. Cases are moving to the suburban and more rural areas that have seen little to no exposure. North Carolina peaked on July 23rd. No change in the knowledge that more than 80% of deaths are skewed toward the over 55 age group and 94% of all deaths occurred in a person with a co-morbid chronic health disease. The big question that remains is:

what will happen this winter when we sequester indoors with reduced ventilation and more disease exposure potential? This is a very legitimate question that will be answered in time. Europe is now seeing a second wave of increased cases. We are likely to also see such an event. As with the first newsletter on this topic, keep solace with the fact that there is a 99+% chance of survival for all of us.
NC death cases

We do not know if a major second wave of COVID19 is coming this fall or winter, but we better plan like it is regardless of the leadership position in government. Every single one of us should assume that the virus will have a resurgence some time in the foreseeable future. Plan accordingly. Control what you can control.

The new news:


1) Increased death numbers have not followed the increased case volume over the summer. I.e. we had many more cases but much less death per case tested which is the true bell weather of risk and worry. Remember that the infection fatality rate is the number of infected people versus the number of deaths and not just those tested. Case fatality rate is confirmed cases versus deaths. The CDC data shows clearly that with increasing case positive tests, the volume of ED/hospital admissions and deaths continues to decline. This may be for many reasons including: a) many many more tests being completed now in relatively healthy individuals when we were only testing the significantly ill back in the spring. Think about a corollary experience now - if we tested all children and adults with mild upper respiratory and lower respiratory symptoms for the influenza virus (which we do not do), then the case positive rate would be much much higher and the infection fatality rate would be much much lower for the flu. If we tested the asymptomatic individuals for influenza as is currently happening with SARS2, we would find many more positive flu cases. This is exactly what is going on now. Massive testing equals massive case identification regardless of illness severity or whether it is really a case b) a portion of the fragile and unhealthy have already expired c) treatments have improved with steroid use and improved ICU care d) decreased viral load as people are wearing masks causing decreased severity if one gets ill e) people are exercising better health based lifestyle choices. f) the testing is picking up dead viral protein fragments and the person is not actually contagious. It is likely that (a) is driving most of the changes, but all are likely contributing to the overall mess.
CDC Data

2) Are increased case numbers a cause for worry? The simple answer is yes and no. If they are not tied to increased deaths, increased hospitalizations or an overwhelmed healthcare system, which they are not currently, then we can feel somewhat reassured that we are balancing economic and pandemic forces reasonably well. However, if the case load is increasing because of poor behavior among the populace, then we could have another massive problem this winter as we move more indoors. Currently, the increased case number really only reflects that we are testing a lot more and finding more asymptomatic and mild disease than earlier in the pandemic. In our clinic, there has been a massive uptick in testing as children have returned to school and parents need their child tested in order to return to school. Thus, we are finding more mild to asymptomatic positive cases driving a wedge between testing and death. If we start to see significant uptick in hospitalizations and death, then we have a big problem.


3) It is highly unlikely that we can ever stop this pandemic without a vaccine, therefore, we must maintain a strong prevention based approach to COVID19 to reduce risk and spread. This effectively means that we should wear masks all the time in places where people are congregated, especially indoors. Masks of effective quality appear to be the best method to reduce transmission and also reduce viral load if transmission occurs. We should all continue to wash our hands and socially distance where possible. These are simple and thoughtful practices that reduce spread and will help get the country back on track, get kids back in school learning and reduce the need for governmental intervention which rarely turns out well. Practice prevention first - sleep, eat, exercise and relax mentally every day.


4) Peak hospitalizations occurred April 18th and peak death volume was May 6th. We are long past the worst and moving along. As stated above, this is not to say that a resurgence could not occur and will not occur as no one knows the truth of this, however, the medical community is getting much better at treatment and reducing deaths. Yet, we must all do our part in preventing the virus from hurting us individually.


5) Should you get a flu shot this year? This is a question that comes up every year, however, this year is very special because of COVID. The year after a bad flu season is always a banner year for flu vaccine adoption. The memories of illness push many to adopt a vaccine need approach. Other years the vaccine is poorly effective or we have a mild flu season leading to a poor vaccine adherence the following year. This year has a whole new spin. Getting sick gives everyone the fear that they have corona and fear drives behavior. The simple answer is as follows. We can never be sure that the flu vaccine will be effective at preventing one from getting sick but data on the reductions in flu related deaths after vaccination is solid. Some years they get it right and the vaccine prevents most flu disease. Some years not so much. I would absolutely err on the side of caution by getting the shot this year. More importantly, take care of yourself this fall and winter. Do not let your immune system get run down by poor choices and behaviors.


6) Operation Warp Speed is an ambitious project to develop a SARS2/COVID19 vaccine in rapid time. There are multiple companies around the world working on a vaccine. Will it be effective and more importantly safe? These questions usually take years to answer. Astra Zeneca is the first company to pause their vaccine trial because of a possible case of transverse myelitis, TM, in a vaccine recipient. TM is an autoimmune inflammatory attack on a segment of the spinal column. The myelin sheath is inflamed reducing signal transduction downstream causing numbness, tingling, pain, weakness, bowel and bladder dysfunction. These are the issues that vaccine trials need to look for and time is of utmost importance to find them. We need to be patient and follow the data closely as a side effect from a vaccine is no small thing since 99+% of us will see no major negative outcome from COVID19 statistically. Every American will need to carefully weigh and measure this choice in the ensuing years. If and when we have excellent safety data, then the vaccine will be the answer to problem.

7) Poor air quality is driving more COVID disease. Dr. Petroni and colleagues data follows up on Harvard's research from this spring noting that areas of higher pollution density have higher COVID mortality. Urban and toxic rural areas like Louisiana's Cancer Alley of petrochemical companies along the Mississippi river are notorious for driving cancer and other diseases through toxic air. (Petroni et. al. 2020)


8) Nature Communications has released a bayesian analysis of testing and the likely true case volume. "We estimate 6,454,951 cumulative infections compared to 721,245 confirmed cases (1.9% vs. 0.2% of the population) in the United States as of April 18, 2020." (Wu et. al. 2020)

While this is a scientific guesstimate, the more data that we analyze over time the more we see that significantly more people have been sick with COVID than is known currently.

9) "Long haulers". This is the new name given to individuals who contracted COVID but only partially recovered and are suffering chronic fatigue. These individuals can suffer prolonged bouts of fatigue, loss of smell and taste, lung and other organ damage and prolonged weakness. Some of these issues can be blamed on the significant organ fibrosis occurring in some of the very sick individuals that survive the intensive care unit experience. CT scans of lungs over 4 weeks after infections has shown lasting tissue damage. Others that were mild to moderately sick are also getting significant long term sequelae that are more difficult to explain. There are no biomarkers to date to explain these fatigue states that are known to follow other infections like measles, Lyme and Epstein Barr virus. There is a boat load of information that needs to be learned about these rare but unfortunate patients who beat the virus only to have lingering symptoms. Stay tuned.

Knowledge is power,

Dr. M

Wu Nature Communications
Petroni Environmental Research Letters
Marshall Nature
Smith Medium
Hofman Clin Reviews Allergy Immunology
Ip Wall Street Journal
Van Der Made JAMA
Ellinghaus NEJM
Selmi Expert Rev Clin Immunology
Wallis Scientific American
CDC Death Statistics
MMWR Rhode Island
Carpagnano J Endo Investigation
Cox Nature Reviews Immunology
Rodda Medrxiv
Broadhurst American Thoracic Society