Since my last update there have definitely been some changes to what we know about coronavirus, how it is transmitted and how we can better treat the serious cases. So below, some of the frequently asked questions I have been getting about coronavirus.
Why did the President, and so many others, catch coronavirus at the White House when they were testing everybody?
The testing for coronavirus, and frankly any disease, is imperfect. Specifically,, the test they were using at the White House is not sensitive enough to trust to really rule out people who are contagious. The second issue, and the more serious one, is that they were doing exactly what none of us should be doing during this pandemic. They were holding an event with more than 10 people in attendance, sitting close together, most without masks, and, ultimately, they moved indoors. This was a situation which was ripe for a super spreader event. Nobody should be surprised that it turned into one.
Why do we have so many more deaths than other countries, like Germany, Australia and now even Italy?
There are several issues in this country that make it very different from other countries. First, because of position as central to world trade and academia, we likely had several – what you might call inoculations – simultaneously all over the country. In large cities, such as New York, Los Angeles and Chicago, people come from all over the world. Because of that, it is likely that multiple people at one time came into this country carrying the coronavirus. It could even have been thousands of people. While not all of these people caused a super spreader event, several did. This meant that, from the beginning, we had a challenging course ahead of us. The second problem is that we were not unified, nor aggressive, in our response to this pandemic from the Federal government and throughout the states. The American tendency towards emphasizing individual freedoms makes this a great place to live most of the time, but it is very counterproductive in the middle of a pandemic. You can’t change a country’s entire nature overnight, even in the middle of a pandemic. Finally, the countries that have had some of the best outcomes like New Zealand and Australia do not share land borders with any other countries and so can more easily control their ports of entry, and that is certainly an advantage. However, it should also be noted that those countries also followed standard, well known, practices in containing the virus the US did not.
Why aren’t we doing more contact tracing and testing?
I wish I knew. Although, in some places there are too many cases to actually contact trace effectively, we now know that the majority of the spread is through super spreader events. While individuals typically only spread it to one or two people one individual in a large crowd of people could actually spread it to hundreds or even thousands downstream. For this reason, it would really benefit us to back-trace cases to where they originate and figure out how super spreader events started so that we could then stop future events. Countries that have done this, like Japan and South Korea, have severely limited their cases without overly impacting their citizen’s daily lives.
Are the treatments that the president got widely available to regular citizens?
Many of the treatments the president received are available to everyone. Dexamethasone, a steroid, has proven to be effective in patients with a more severe form of the illness. The president also received oxygen, which is universally available. That, combined with other things we are learning about how to treat the disease, have allowed us to reduce the death-rate of those who end up in the ICU. One medication that he received is an antibody cocktail, and is still in clinical trials. We do not yet know if it is actually effective, or may be more harmful than helpful. Typically, such medications would only be used, outside of the trial, in a person who was expected to die unless something significantly changes their course. I suspect, but do not know, that the preliminary results of the trial have been positive or the drug would not have been used on the president.
Can we really expect a vaccine before the election?
Probably not. There are currently six vaccines in stage III trials (excluding Chinese and Russian companies, who are not following internationally agreed-upon safety protocols). The best estimates of those who follow these trials are that one or more may become available in late November. When those do become available, the first people to get those vaccines will likely be the military, healthcare workers and public safety personnel. The next most likely to get the vaccination will be people at high risk, like people living in institutions such as prisons or skilled nursing facilities. Probably teachers and other educators will follow, followed by the general public. You should know there are several issues with the vaccines which are being produced. One of those, expected to be available the soonest, actually requires storage at very low temperatures. Few hospitals have the capacity to store vaccines at that temperature, community clinics never do. So, an entire distribution chain as well as new and expensive refrigeration devices will be required to distribute that vaccine. It may turn out the vaccine is stable at higher temperatures, but we will not know that until further testing has been done. If you are interested in following the status of ongoing vaccine development, click here for the New York Times’ vaccine tracker.
When can we expect to get a vaccine for everybody?
Probably sometime mid next year. While some vaccines are already in production, even before we know whether or not they are effective, the sheer number of doses required for a country of 300+ million people, requires a complete reworking of logistical chains. Also, the early vaccines require two doses separated by 4 to 8 weeks, and the patient has to be given the second vaccination from the same manufacturer. This is an enormous task, which will require coordination and tracking.
Will a vaccine eliminate COVID 19 like smallpox?
Alas, this is unlikely. For us to consider a vaccine as effective it needs to prevent at least 50% of infections in the vaccinated population. While that doesn’t seem like a high number, a high level of vaccination in the population, in combination with natural infections, can essentially form a block to further significant spread of the coronavirus—somewhat like a fire-break operates in a fire.. Furthermore, anyone who is vaccinated, and develops even a mild antibody response, likely will have some protection against a more severe case of coronavirus. None of this is guaranteed. These are things we won’t know until the vaccines have been in use for a couple of years. However, if the vaccine is at least 50% effective, it will slow transmission down. This will then allow public health measures like contact tracing to severely limit the spread of Covid 19. I think that like many infectious diseases, Covid 19 will probably always be with us. One of the issues with Covid 19, like other viruses similar the flu, is that it mutates quickly. So, someone who is immune to it this year may not be immune to it next year or the year after.
How long will we have to wear masks?
When we lived in Japan, 10 years ago, many people regularly wore masks in public and certainly in crowded areas like the subway. I suspect that many Americans will respond similarly, at least when they are ill with a cough or other potentially contagious disease. The masks are going to be with us for a long time. Mandatory mask wearing will probably be present until the spread drops dramatically or the mortality drops significantly. I think this will likely be some time near the end of 2021 or the beginning of 2022, but that is only a prediction based on past pandemic events typically lasting 1 ½ to 2 years.
How bad is COVID 19, really?
It’s not the Black-Death, but it may actually be worse in terms of virulence and mortality potential than the influenza pandemic of 1918 to 1919. It’s difficult to compare the death rate then, which was a 2.5% case-rate fatality (estimated), to today. The case-fatality rate of known cases of COVID 19 is 2.8% in the US. But, that is thought to be a significant over-estimate. Estimates of actual COVID infections range from 3 to 10 times the actual diagnosed cases. Another estimate is that about half of all those infected are actually asymptomatic carriers.
It’s important to remember that we have come a long way since 1919. One of the huge differences today, is that we are actually publicizing that the pandemic exists. Due to World War I, then President Woodrow Wilson did not want to make news of the pandemic public to keep it from being used as propaganda against American troops overseas. Thus, many people were caught by surprise when their city got hit with influenza. People unknowingly, or simply unwisely, held large events in public without masks. Further, many more people might have been sick than were counted, simply because that’s how influenza works. The numbers are estimates.
Further, while our case-fatality rate is high, we have the benefit of technology—like ventilators, readily available oxygen and medications—that simply was not widely available in 1919. We are roughly 6 months into this pandemic, and we have had about 1/9th of the per-capita deaths as were estimated for the 1918-1919 pandemic. Had COVID 19 arisen then, the death toll would likely be much worse. So, long story short, it’s difficult to compare the two diseases over a century apart. However, it is fair to say that COVID 19 has killed too many Americans. At present, there are 215,000 dead being grieved in America. These deaths have occurred over 6 months. For comparison, the Civil War, long considered the greatest and most tragic loss-of-life in the United States, killed 620,000 people over 4 years. Unless something drastic changes, we will exceed that in a matter of months.
What about going for herd immunity from natural infection, wouldn’t that work?
No, that’s not a good idea. There’s a lot of death between now and a 70% natural immunity rate. Right now, the national percentage of known infections is 2.3%. Even if you presume a 7 times greater infection rate, at 14.2%, that would require approximately 1 million more people to die to achieve herd immunity of 70%. Many of those dying would be young, healthy, people and even children. There is just no scenario where that works for us as a country. The widespread grief and depression alone would be crippling, not to mention the cost in the lives of highly-trained and irreplaceable health-care workers. The second problem is that any immunity to the virus is probably limited to 2-3 years. That likely means still more death as the virus mutates and once again spreads out of control. Our best course of action is to limit infectious spread while we rapidly develop vaccines that can help prevent further spread and mortality—and, incidentally, slow mutation as the virus doesn’t go through as many hosts where mutation can occur.
Is a neck-gaiter a good mask?
Sadly, no. Your options are paper surgical masks, cloth masks shaped like surgical masks or form-fitted around face and N95’s. If your N95 has a valve on the front, you need to cover that with a cloth or paper mask to protect others.
Conclusion
In summary, vaccines are coming but probably not as soon as recently advertised, parties are bad, you should continue to wear your mask and we need to do a better job at contact tracing. I don’t mean to be a Debbie-Downer; most people actually do quite well from COVID 19. But, substantial numbers of people, possibly 10% or more of those infected, are being impaired for a long time, perhaps permanently. So, don’t relax your guard. Keep wearing your mask, wash your hands, and please, NO PARTIES!
Finally, if you are a citizen, please make a plan and vote! While everyone is focused on the national races, there are so many local races and propositions that strongly affect our lives and our communities. Being a voter means being engaged, so VOTE!
As always if you have any questions, even about voting and how to register, please email me at DrEdwards@wowhealingcare.com, or call me at 760-425-4466.
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