April 26th, 2021
In my opinion: It is time to stop worrying about masking outdoors when running, walking or generally exercising. The year long analysis of COVID points clearly to indoor, crowded, time intensive experiences as the major source of transmission. Walking by a person on a path is not a source of viral disease transmission. I even struggle to understand the logic of masking during outdoor teenage sporting events like soccer or lacrosse.
To date the preponderance of the transmission of SARS2 has been from 20 to 50 year old individuals in close contact indoor environments. We now have half of America partially or fully vaccinated including the highest risk individuals based on age and employment. Thus, in my mind, the vigilance for pandemic suppression must remain on indoor environments and the young adults.
Follow the data.
I read once that you worry about the shark swimming in your pool not in the ocean. We have spent far too much bandwidth worrying about rare single risk cases like the shark in the ocean as opposed to the shark in our pool.
Many individuals have told me that they have avoided sport and exercise because of the mask mandate which for these sport endeavors is extremely low risk. We know without a doubt the incredible benefits of exercise for immune enhancement and general mental health. Therefore, let us put the logic into context, we are asked to mask in outdoor low risk sport pushing many away from the exact viral fighting activity that they need.
I see individuals masking while walking, running and playing sports only to sit down in a restaurant unmasked. Not very logical. The way that we are risk stratifying makes little sense. The indoor eating location is vastly riskier than the outdoor activity, yet.....
I will leave this thought here. I am questioning the logic behind the mask mandate as it stands. I believe that it is time to go maskless outdoors and remain masked indoors at all times in crowded environments especially if you are unvaccinated until all of those that want to get vaccinated are. Until the laws and rules change, this is just one person's opinion.
Quick hits
1) Airborne Transmission - In a well written piece in the Lancet this month, we find 10 well thought out scientific explanations why SARS2 is predominantly spread through airborne routes. (Greenhalgh et. al. 2021) The reason that this matters is because to understand where the risk of disease transmission lies is to understand where to focus our prevention efforts. Since the airborne route predominates in transmission, we all should keep our focus on avoiding airborne exposure which includes indoor, poorly ventilated, crowded environments without proper protective gear and over a prolonged time course. Even if you are vaccinated, there remains a very small chance that you can contract the virus and get ill from an airborne route.
For more on this topic, read Derek Thompson's piece in The Atlantic Magazine entitled Hygiene Theater: Deep Cleaning isn't a victimless crime. "You can put away the bleach, cancel your recurring Amazon subscription for disinfectant wipes, and stop punishing every square inch of classroom floor, restaurant table, and train seat with high-tech antimicrobial blasts. COVID-19 is airborne: It spreads through tiny aerosolized droplets that linger in the air in unventilated spaces. Touching stuff just doesn’t carry much risk, and more people should say so, very loudly." (Thompson D. 2021)
It is very clear that we need to follow the data and not the politically driven narrative that drives fear and poor decisions around prevention and safety. The data is pretty clear now that we can go back to regular hand washing and general contact safety for each individual. Deep cleaning your home environment makes little sense and may be very unhealthy for your family over the long haul as chemicals are known to be unhealthy at volume and over time. Buildings and structures will always struggle to maintain complete cleanliness for all bacteria and viral diseases, thus it is up to us to wash our hands and avoid touching our faces in general.
2) Covid Vaccines and blood clots - what is going on? Johnson and Johnson's Adenoviral vector COVID vaccines have been rarely associated with clotting or thrombosis in certain individuals. If you remember from previous newsletters that SARS2 infection increases the risk of clotting in severely ill individuals, then we have to discuss risk overall. With significant SARS2 illness, the risk of clotting is very high at 20% of hospitalized patients. (Malas et. al. 2021) Not knowing which individuals will develop severe COVID disease makes the risk of COVID related thrombosis much higher than a vaccine related event. This in no way minimizes the tragedy of a vaccine related event so much as it puts it into context of risk. The mRNA vaccines seem to not carry this risk which is good news. Remember that even oral contraceptive pills carry some risk of clotting in certain individuals although rarely the brain related type as seen with these vaccines. (Trenor et. al. 2011)
From the CDC: "As of April 12, more than 6.8 million doses of the Johnson & Johnson (Janssen ) vaccine have been administered in the U.S. CDC and FDA are reviewing data involving six reported U.S. cases of a rare and severe type of blood clot in individuals after receiving the J&J vaccine. In these cases, a type of blood clot called cerebral venous sinus thrombosis (CVST) was seen in combination with low levels of blood platelets (thrombocytopenia). All six cases occurred among women between the ages of 18 and 48, and symptoms occurred 6 to 13 days after vaccination." (CDC site)
According to another study from England, the incidence of thrombosis was 39 per million for the Johnson and Johnson vaccine versus 4 per million for mRNA vaccines and 5 per million for Astra Zenecas'. (Taquet et. al. 2021)
When the Johnson and Johnson vaccine comes back on line, it is prudent to realize that if you cannot get one of the two mRNA vaccines, this vaccine is less risky than natural disease. For those that are going to look at this data to further the anti vaccine narrative, please be mindful of the reality of statistical risk versus emotional risk. There is no judgement here just data.
3) In 2017, the United States had excess deaths roughly 3X to COVID in 2020 depending how you look at the death numbers as compared to our European counterparts! This is a sobering stat. A group from the University of Pennsylvania published in the Journal PNAS an analysis of the death data. "In 2017, the United States suffered an estimated 401,000 total excess deaths, those beyond the "normal" number of deaths expected to have occurred. The Centers for Disease Control and Prevention reports 376,504 deaths related to COVID-19 in 2020.""In 2020, 4.41 million years of life were lost to COVID-19, yet that's only about one-third of the 13.02 million life years lost to excess mortality in the United States in 2017." (MedicalXpress 2021)
What this means in laymen terms is that compared to Europe, the United States population is much less healthy than our friends in developed nations. We have major systemic health issues running rampant through our society that predate COVID and will postdate it as well. COVID was and is a spotlight on our unhealthy collective societal behaviors. We die far more often and early than we should based on simple truths.
As a society of individuals, we have control over certain behaviors that affect us. We have many systemic societal problems that are out of our control and would be the focus of advocacy. Yet, we must clean up our house and body first and foremost.
On balance as a society:
We eat too much
We eat the wrong foods too often as the wrong foods are subsidized by the government making them cheap while the food companies have maximized taste over health
We are too sedentary
We are exposed to too many chemicals too often
We are too stressed mentally without good coping mechanisms
We don't sleep and rejuvenate ourselves well
We take too many medicines that are toxic
We are too socially isolated while we watch and interact with too many screens
And on and on...
4) Rates of Covid 19 hospitalization for 0 to 17 year olds remains the same, very low, with the new variants taking a larger share of the case volume. (CDC Webpage) Interestingly, if you look at the graph, the only groups to vary significantly over the course of the pandemic are the over 50 and over 65 year old clusters. If hospitalization remains a prerequisite for a bad outcome, then again we see the reality that schools should be in person regardless of vaccination for children if the teachers and at risk individuals are vaccinated.
5) Pregnancy remains low risk with preterm, less than 37 weeks gestation, delivery occurring 2% more commonly in third trimester affected mothers than controls. Infant transmission remains very low. (CDC Tracker)
6) Our clinic experience with Covid and children remains all over the map. Children are presenting in myriad ways and testing remains the only definitive way to know with the exception of loss of smell and taste. Many children are presenting with fever, headache and gastrointestinal distress. Many are presenting with upper respiratory congestion, cough, headache and fever. A large percentage remain without symptoms. Too date, we have been fortunate to have fleetingly few severe cases and no deaths.
AAP/government numbers are showing a slight uptick in COVID cases in children. Currently, 1.9 cases per 1000 children. Death is very rare with 15 states having none to date. Hospitalization remains infrequent at 1.5 per 100 known cases. And case positivity rate of those tested vacillates between 8 and 12%. (AAP Stats)
7) A good read on why we may and likely won't need yearly boosters can be found at this link. We still have a long way to go, but things are looking really good for all of those individuals vaccinated with one of the mRNA vaccines.
8) From the American College of Cardiology: "Quick Takes:
• COVID+ patients with STEMI represent a high-risk group of patients, with one in three patients succumbing to the disease even among patients selected for invasive angiography (28% mortality).
• It disproportionately affects ethnic minorities with diabetes mellitus.
• COVID+ patients with STEMI are less likely to undergo PCI, and the reported door-to-balloon times are longer in this group." (Dehghani et. al. 2021)
STEMI stands for ST segment myocardial infarction or an electrocardiogram specific ST elevation finding in heart attack victims. This study notes that patients with COVID who undergo a heart attack and have diabetes have a very high mortality risk. This finding was not unexpected as diabetes and atherosclerosis are both inflammatory diseases of lifestyle risk coupled to host genetics that were shown early in the pandemic to be a risk of death. Diabetes mellitus is the end result of years of dysfunctional dietary choices that lead to insulin resistance and inflammation of the fat cell and liver cell. Diabetes is one of the greatest risk factors for atherosclerotic heart disease which in turn is a leading cause of death annually. Over 600,000 Americans die annually from heart disease.
9) Israel remains at the forefront of COVID vaccination efficacy and thus study related outcomes. In this months issue of Nature Medicine, we see the following: "Our analysis revealed that a little over 2 months after the initiation of the vaccination campaign, with 85% of individuals older than 60 years already vaccinated with two doses (24 February 2021), there was an approximately 77% drop in cases, a 45% drop in positive test percentage, a 68% drop in hospitalizations and a 67% drop in severe hospitalizations compared to peak values." (Rossman et. al. 2021)
These analysis are very useful for prognosticating our pandemic resolution.
10) "Twenty-two possible breakthrough SARS-CoV-2 infections occurred among fully vaccinated persons ≥14 days after their second dose of COVID-19 vaccine. Two thirds of persons were asymptomatic. A minority of persons with breakthrough infection experienced mild to moderate COVID-19–like symptoms; two COVID-19–related hospitalizations and one death occurred. No facility-associated secondary transmission was identified." (Teran et. al. 2021)
This study from multiple skilled nursing facilities provides us with great insight. There will be post vaccination breakthroughs of infection. They will be very rare and mild to asymptomatic in most cases. The cases posed no secondary viral pandemic like spread which is so incredible. Viral loads were very low in the infected.
The vaccines are so effective even among the very ill.
11) Asymptomatic SARS2 infection does produce quality antibody responses albeit less than a symptomatic individual. (Dufloo et. al. 2021)
12) 6 foot distance indoors is not adequate for aerosol viral spread prevention depending on the activity according to a group from MIT. (Bazant et. al. 2021) For example, singing indoors without a mask can cause transmission to occur over large distances. Indoor air exchange rates can change risk as is noted in buildings with adequate ventilation and airplanes. This data set is primarily for the over 15 year old crowd as transmission at the younger ages is minimal. This article has a lot of modeling information to parse through. Bottom line is that poorly ventilated, crowded indoor environments are not a good place to spend time with or without a mask unless you are vaccinated.
Dr. M
Greenhalgh Lancet
Thompson Atlantic
Malas EClinical Medicine
Trenor Pediatrics
Oxford News
Taquet Oxford Press
University of Pennsylvania Medical Xpress
Preston PNAS
Woodworth CDC
Dehghani ACC
Rossman Nature Medicine
Teran MMWR
Dufloo Cell Reports Medicine
Bazant PNAS
