Monday, September 28, 2020
Saturday, September 26, 2020
Should you get a covid test right now?
I get asked this question quite a lot and I invariably say: unless you have had a proven Covid exposure or you are sick the answer is No. Here’s why:
Scenario One.
Let’s say you could get every single member of a church congregation to get a Covid test at exactly the same time you could then quarantine the positives and all the other members could hug and kiss and wouldn’t have to wear masks. 2 issues with this scenario: They would all have to stay in a bubble like the NBA players and two, they could not associate with anyone outside of the bubble. Not even family members and housemates who didn’t get tested on the same day as everyone in the church.
Hopefully you can start to see why it’s a complicated issue and logistically difficult.
If you get randomly tested today it tells you nothing about last month and nothing about what may happen next week. So until we have access to daily home tests for everyone random tests are not helpful.
Scenario Two: another option would be to quarantine every single person in the country for two weeks and then we would all be free. Why not? Well, for one thing essential workers still need to do their essential work. You get the picture I am sure, its not so easy to shut down a country. Babies will still be born!
Theoretically as a country we could use the mightiest military in the world to coordinate testing of 90% of the people on one day and manage them accordingly.
This apparently is too heavy handed for the US. I should point out that heavy handed tactics did work in China.
Anyway, I digress. Random tests in terms of time and location are not helpful. Your best bet: don’t get Covid-19 in the first place.
Remember to get your flu shot. If you get a fever or are sick from anything else you will still need to quarantine for 10 to 14 days while you ARE being tested for Covid! Quest lab has a 7 to 10 business day turn around at the moment.
For those who are interested here is my latest video: (You can subscribe for more tales from the trenches)
https://youtu.be/4FGGOF0MBGg
And here is a prior video about Kids and Covid-19 as a reminder (from April!).
https://youtu.be/DRGGwygPHnA
Thursday, September 24, 2020
The Glorious Ruth Bader GInsburg (RBG)
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Monday, September 21, 2020
Thursday, September 17, 2020
COVID-19 Vaccine
OK listen up: there will NOT be a vaccine this year. I said this in the spring and many other times and I am reiterating it again now.
So why am I writing about it? Because people keep asking me about it. Please understand that discussions about vaccines are diversionary tactics and you need to keep your eye on the ball.
We have heard we would have a vaccine by the end of summer, now its October. We even have a military style term for producing the vaccine: "Operation Warped Speed". Come on people, does that really sound like a scientifically sound project or just a good media sound bite? I have to admit it’s a little catchy but catchy doesn’t cut it when you are dealing with people’s lives.
Having a master’s degree in public health (from Harvard) and having studied preventive medicine (at Johns Hopkins) I think I understand a little something about vaccine trials and how they work.
Here’s some information about what “some vaccines are now in phase three testing” really means and why we cannot bank on “herd immunity” anytime soon.
In the US we are long way from herd immunity, this is what happens when enough of a population has developed immunity that spread of a disease in a community becomes unlikely. Herd immunity can happen in two ways: through infection and through vaccination. The herd-immunity threshold is thought to be somewhere around 43% to 66% of the population for corona viruses.
Which would require that we further infect about six times more people than those who have already contracted COVID-19 in this country. If this happened tens of thousands more people would die and the health care system would be pushed to its limits and beyond.
So what’s the deal with a vaccine?.
Think of a vaccine as forcing a practice session on the immune system. Vaccines give the body a sneak peek at one or more key features of a virus before the actual virus invades. The immune system creates a “memory” of the virus and is better able to fight it off.
Operation Warped Speed is being funded by the American tax payer which is one of the reasons the vaccine trials are faster than is normal for a regular vaccine. Why? Well first of all the companies that develop vaccines have to evaluate all along the way whether it is cost effective to continue with the process since they don’t want to end up in the red with a vaccine that doesn’t work. In the case of Covid-19 they don’t have this restraint because the federal government is footing the bill. Nothing like money to make people move at warped speed !
There are multiple different kinds of vaccines that are being tested. For example, one might take a portion of the virus such as the spike (the projections from the virus that give it a crown look, hence the name corona) to see if it can generate a protective response without actually giving you the disease or make you sick in other ways. One may take the antibodies formed by someone who has had the disease and synthetically copy them many times over and see if that helps. One is to take the actual virus and divide it so many times that it becomes so weak it can still generate a response but not cause disease. And so on. They are all different and the race is on to figure out which ones work.
Clinical trials test drugs or medical devices on human beings. To get that far, a vaccine has already shown promise in the laboratory and in animal studies. Once a vaccine is ready for testing in human volunteers, the U.S Food and Drug Administration (FDA) requires success through three trial phases before approval for widespread use.
A phase 1 trial tests the vaccine’s safety with tens of patients. A phase 2 trial tests the vaccine’s safety as well as its effectiveness at different doses with hundreds of patients. A Phase 3 trial tests the vaccine’s safety and effectiveness with thousands of patients. The first vaccines being tested in the U.S. will include 30,000 participants each, and the trials will follow them for two years. One of the challenges is that there is a federal requirement that there should be all races included in the vaccine trials.
Most of the vaccine developers had hoped for at least 50% of black, indigenous and latinx participation in the trials to comply with the mandate to include minorities. So far none of the trials have managed to get more than 27% of minorities. According to the FDA, the least willing to participate are African Americans. So now the vaccine production companies have started recruiting at historically black colleges and universities (which are more trusted institutions for many Black Americans).
But everything from supplying syringes to managing storage facilities will add to the challenge of the greatest mass-inoculation campaign the world has ever seen.
These trials are randomized, double-blind, placebo-controlled trials. That means that some of the participants get the vaccine and others get a placebo injection of salt water. Who gets the drug or the placebo is random and neither the participant nor the health care workers doing the injections will know who gets what. Even the researchers leading the trials will not know who got the vaccine or the saline injection. That’s why the trial is known as “double blind”.
More than half of those receiving early COVID-19 vaccines reported mild, short-term side effects such as fever, headaches, muscle aches, and injection-site reactions.
The first vaccines to be tested in the U.S. have required a booster about a month after the first injection. So the vaccine or vaccines will probably require a booster shot. But there should be a gradual buildup of immunity during the post-vaccination window.
After the phase 3 trials have been successful then the FDA has to approve the vaccine before it can be released to the general public and not everyone will get it at the same time.
The bottom line is that even at warped speed somethings can be speeded up, but nature cannot. For sure a vaccine cannot accommodate an election agenda no matter how many times we say it can.
Every coronavirus death is an avoidable tragedy which has been the case from the beginning of the pandemic. The way forward is to socially distance, clear the air, wash hands, and mask up until a vaccine opens up a controlled, safe road to herd immunity. In the meantime don’t hold your breath. There will NOT be a vaccine for you this year!
I am totally open to feedback. Be safe!
Tuesday, September 1, 2020
Why getting your shots at the pharmacy may not be the best idea
The disadvantages of getting your 'Flu shot' in the pharmacy if you have a primary care physician. (Ideally everyone should have one)
Ok, let’s start at the beginning.
When I have an initial visit with a newborn patient one of the first things I do is track down and document the first Hepatitis B vaccine information. This vaccine is usually given a couple of days after birth, right before discharge from the hospital and I know it will be important for that child when he or she goes to kindergarten.
Right now, it is time to get your Flu shot and I strongly recommend that everyone get one. For one thing some people are anticipating a double-barreled whammy this fall between the pandemic and a flu epidemic so this is an important year to protect yourself as much as possible.
My office will start giving flu shots by the end of next week. The larger buyers get their flu shots earlier than small practices and so the big pharmacies already have theirs.
The price for the vaccine is the same wherever you get it including the doctor’s office. If the pharmacy says you can get it for ‘free’ it is because your insurance covers it and it does not require a copay. Most insurances pay for flu shots, it’s not really ‘free’ even if you have Medicare but there is no copay. (The one exception used to be free vaccines in schools, those are funded by the board of education and I think kids should only do these as a last resort).
Have you ever wondered why your friendly pharmacist has suddenly started pushing certain vaccines really hard? They have quotas to meet!
But getting a shot at the pharmacy is not as easy as it sounds.
Why is it better to be patient and get your vaccinations in your doctor’s office? Well, here are a few reasons:
First, your doctor knows you and any special situation you may have like allergy to mercury or eggs.
She also knows what immunizations might be appropriate for individual patients and when the timing of the shot would be best.
Many patients get vaccinated when they are in the hospital but then they are not sure what they were given and the details are hard to find.
Similarly, when you get vaccinated at the pharmacy the shot does not get put in your medical chart with all the required documentation including batch numbers and expiration dates as well as the brand of vaccine. Once this is entered into your chart this information is all in one place and you can always retrieve it for years to come. Sometimes this information is required years later for college or employment. Or a hospital may call to verify you have received a certain shot.
If there is a problem with a particular batch of vaccine your doctor can contact you.
Sometimes patients say they got a ‘pneumonia shot’ at the pharmacy but they have no idea whether they got a Prevnar or a Pneumovax which is a problem.
Which one you get depends on your age and your medical conditions. If you need both you should get the Prevnar first followed by the Pneumovax 9 to 12 months later. The sequence is important. Especially if you are at high risk and due for a pneumonia shot please get it now, for obvious reasons. This vaccine is given year round.
Last but not least, pharmacists have only just begun to give vaccines, their jobs generally do not involve ‘touching’ people so many are just starting to get used to it.
In addition their shops are not necessarily equipped to handle acute reactions. For example a few years ago when the HPV vaccine was new it got halted in the UK after a 16 year old girl fainted after the shot and died. It was later determined that she fainted as a result of the shot but the cause of death was the head injury that resulted. Then use of the vaccine resumed with special precautions.
I am happy to say that a lot of changes have been made to this particular vaccine since then and it is now much safer and more effective.
What about delayed reactions, do you go back to the pharmacy and ask for the same guy? I am yet to see a patient who knows the name of the pharmacist who gave them a shot and there is no guarantee the same person will be there in 2 months. Fortunately, you do know me!
There are a couple of ‘optional ‘ shots that we don’t stock in the office but even so I like to counsel my patients about them so they can make an informed decision as to whether it is best for them or not. I’m not sure how much counseling goes on in the pharmacy. Generally they look at a chart, tell you what you should do and hand you some standard written information about the shot which you may or may not understand.
However, if you do get one of these shots in the pharmacy please bring in all the relevant information brand, batch number, expiration date to the office as soon as possible for it to be documented in your electronic medical record.
Once again I really hope everyone will get their flu shots this year even those who tell me annually “I don’t do flu shots”. Please make this year an exception, it could save your life.
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