I wanted to give you an update as we head into the holiday weekend. First, some data: There are now ~1,701,000 confirmed cases of COVID-19 in the world. The total number of deceased people is ~102,800. In the U.S., our total confirmed positive cases have soared to 502,049. New York is still bearing the brunt of this outbreak with 172,358 cases and a death rate of 7,844. We know the death rate is higher as there are many who are dying in their homes, in the hospital hallways waiting for a bed and on the streets.
There is still chaos in some of the larger metropolitan cities of the Northeast such as Detroit, MI, Chicago, IL, and Boston, MA. We can only hope that their peaks of infection have been reached or will be reached soon. North Carolina’s peak is still estimated to be in 5 days. To see the models of expected surges and the resources available, check out www.covid19.healthdate.org. The models are changing as the variables such as degree of social distancing and allocation of supplies change.
Shortages of supplies for our hospitals and healthcare providers continue to hinder our response to the novel coronavirus. There has been a development this week of FEMA (Federal Emergency Management Agency) confiscating supplies from some hospitals and redistributing them to other areas. These supplies include much needed PPE, face masks, ventilators and gloves. Certainly, they may have more information as to where the allocation of supplies is most needed, but the lack of transparency in the redistribution has been a bit unsettling for the healthcare industry.
In North Carolina, we did receive some shipments from the Strategic National Stockpile of surgical masks, but we only received about 50% of the N95 masks that we requested. We are very short on gowns and face shields, but we are doing pretty well on the amount of gloves we need. (Info from the NCDHHS.gov dashboard).
We have known that our lack of testing will need to reverse course to be able to manage the COVID-19 outbreak for the next few months. Currently, there are plans to have pharmacists run tests from places like Walmart, Walgreens, and CVS. Unfortunately, the government has made it more difficult for physicians to obtain and run tests. The FDA changed the designation of the antibody test that tests for IgM and IgG antibodies and involves a finger prick, to “high complexity”. Earlier in March the FDA allowed the purchase of the rapid tests under The Emergency Use Authorization (EUA). This emergency use authorization allows for supplies like the rapid COVID test and medications to be used without having to wait on the long process that it usually takes for FDA approval. They explained that they are only allowing very few suppliers to sell the tests because of an increase in fraudulent testing supplies. By changing the designation to “high complexity”, this further limits the availability of physicians not affiliated with a big lab set up to use these tests. Makers of these rapid tests are still hoping to get the EUA letter and have the ability to sell tests in the near future. It remains to be seen when this will happen.
Some background on how these serology (finger prick) tests work: The test lets us know if a patient has been recently exposed to COVID-19 and thus has IgM antibodies. As the person recovers, they produce IgG antibodies which shows likely immunity to COVID-19. The number of IgM antibodies decreases, and the IgG antibodies increase as the disease progresses. Since there are multiple strains of coronavirus, there is the possibility of cross-reactivity in this testing method. In other words, if you had a different strain of coronavirus in the past, you would possibly have IgG antibodies on the test which would give the false sense of protection.
Dr. Fauci, one of the respected leaders on our national coronavirus response team, in an interview to JAMA explained the importance these rapid serology tests would have in the coming months as we continue to battle COVID-19 and want to prevent a resurgence. He said that 15-30% of colds that we get now are due to 5-6 different coronavirus strains. So, there is a valid concern for cross-reactivity. However, in watching COVID-19, while there has been some mutation, there haven’t been any significant functional mutations (any mutations that would have an effect on how the virus works, etc). He also said that serology tests will play an important role in our phases of getting back to normalcy. We need to be able to recognize those workers who have been exposed, recovered, and therefore are protected. He thinks since the virus has been relatively stable, that if a patient was infected/exposed in Feb-March, then they should have some immunity in Sept-Oct. It will be helpful especially in those patients that have high exposures with the public to know those that are protected. He also cautioned that we need to do some validation of the current tests available to make sure that we are giving accurate information. DPC docs are in a unique position because of our autonomy to try to “validate” some of this testing on our own. We were in the process of comparing the rapid serology tests to known positives (by the PCR nasopharyngeal swab test done at hospitals) and seeing if the results matched. The test kits that we purchased were showing promise in that most results were matching up. It was definitely not perfect, and there is certainly a bit of a risk that needs to be communicated to patients, but to use Dr. Fauci’s words again, “Don’t let perfect be the enemy of good.” We will resume testing when able and keep an eye on this evolving situation.
This brings me to a question that has been on many of your minds. When we have reached the peak number of positive cases and the “surge” is over, how long will it take to get back to normal? In the next week or so we will likely be seeing a plateauing out of the number of cases and deaths. While this is good news, we still have to be very vigilante to “test, track, trace, and quarantine” any new cases so that we aren’t in the situation of exponential growth that we saw by not being prepared early this year. We still do not know the pathogenic mechanism (or the way this virus is so destructive to our bodies) and although there are a lot of clinical trials and vaccination studies; those are months away from being useful. We will probably get an EUA (Emergency Use Authorization) for promising medicines and in the vaccine earlier than the projected 18 months, but this will not be all that is needed to contain this virus for the long term. Currently, we need to make a plan on how we will test on a massive scale (likely via the rapid serology testing discussed). There are prototypes in the works for how we will track – different apps on phones similar to the one that China is using to track the movement of its citizens. There is also a need for tracing. So, when a person is positive and contagious- we need to trace their contacts and isolate all persons with exposure. This was attempted by our local health departments when a positive case was identified in March and we were still working on containment. They would call all known contacts that the positive person had been near and ask them to quarantine themselves. We need to make sure that the 14 days of quarantine is an adequate amount of time for resolution as well.
So, in order to “test, track, trace, and quarantine” going forward, we will probably see a lifting of restrictions in phases. Retail shops and restaurants might be able to open, but with a reduction in the capacity that they once had. In NC, Gov Cooper put into effect a new executive order starting Monday for essential stores to only allow limited capacity and marking 6 feet in areas where there might be congregation such as at registers. As we open up the “non-essential” businesses, there will probably be similar recommendations at first and ease up over the next several months. Our ability to do widespread testing (see South Korea’s model) will mean that we can get businesses open much faster, and our economy back on track quicker but in a responsible manner. Mass gatherings may not be allowed even going into the fall. Whether that will just restrict concerts, sporting events, or mega-churches remains to be seen. Again, we will need the ability to be able to identify new cases as they develop and isolate those cases to get back to normalcy. As a small business owner (and rather new one at that) myself, I am very concerned about our economy and understand that while the stimulus bills such as the CARES Act is helpful, ultimately what we will need is to be able to open our businesses and restore a good number of those jobs that have been affected. As a physician that is also concerned with loss of life and the well-being of our citizens, I also want to be sure we lift the restrictions in a manner that doesn’t allow the COVID-19 to cause mass destruction as we’ve already seen. If we are able to secure supplies and testing such that we can “test, track, trace, and quarantine”, then we can get back to normal much faster in a responsible way.
There are some permanent changes that we will need to make as a society regardless of what our government is able to accomplish. We will need to implement:
- Constant effective handwashing that is 20 seconds and often
- No sick child should be sent to school (and we need to make provisions and think about safety nets for parents who work on how to help them with childcare should their child get sick)
- No sick worker should be made to work (we need to make sure that businesses allow for adequate PTO days and in some cases such as healthcare, culture changes such that a healthcare worker isn’t made to feel weak or guilty if they need to stay home due to illness)
- Change the way we greet each other. Hand shaking spreads germs easily and quickly.
- If someone has a fever, they need to stay home from all activities, work and otherwise
Finally, a thought exercise that one of my fellow physician colleagues, Dr. Wilson, thought would be beneficial for us. “Say to yourself, ‘Self, think about the top ten people you love most in life. Now, Self, how many of those people are either older than 65, have heart disease, diabetes, asthma, emphysema, rheumatologic issues, pregnancy, or cancer?’” When your “self” answers, you will find that upwards of 50, 60, 70% of your loved ones in life will fall into that category. Then it’s easier to understand why we social distance and make personal sacrifices so that others don’t get sick. I am not taking a chance with my top ten and your social distancing shows that you aren’t either. Your (our) worth is not tied to an age, a condition or a diagnosis.
We love you all, even with your pre-existing, comorbidities, and underlying health problems! Stay safe, stay home.”