Yesterday we celebrated change, now we need to get back to work. 240,000 deaths in the US. 10 million cases.

 The United States could soon report more than 200,000 coronavirus cases per day as infections continue to surge across the country, according to CNN.

The US reported 100,000 new cases 7 days in a row last week, and that total will likely continue to increase.

"We are watching cases increase substantially in this country — far beyond, I think, what most people ever thought could happen," Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told CNN.

Osterholm and his team have created accurate forecasts for COVID-19 cases throughout the pandemic. He was named to President-elect Joe Biden's Transition COVID-19 Advisory Board on Monday.

"It will not surprise me if, in the next weeks, we see over 200,000 new cases a day," he said.

On Monday, the national 7-day average of new cases was nearly 120,000, which is triple the average from mid-September.

The number of hospitalizations in the United States are up as well, according to The COVID Tracking Project. On Monday, 59,275 people were in hospitals for COVID-19, marking the country's highest total since July and slightly lower than the April 15 peak of 59,940.

Deaths are on the rise, too, CNN reported. Last week, more than 1000 COVID-19 deaths were reported for 5 days in a row, which hasn't happened since August.

"We're going to see, by far, the darkest days of this pandemic between now and next spring when the vaccine becomes available," Osterholm told CBS This Morning on Tuesday.

"We have a perfect storm coming together," he said. "We have pandemic fatigue...we have pandemic anger...we just are not taking this virus seriously."

WebMD Health News © 2020 

Cite this: Carolyn Crist. US Could Hit 200,000 Daily COVID-19 Cases Soon - Medscape - Nov 10, 2020.

This article should cause you to sit up and take notice. The number of cases are rising throughout the country again, including Maryland.

Current hospitalized cases in Maryland 761, in total we have had 156,709 cases. Our positivity rate is back up to 5.24% total death count 4084.

One of my biggest worries is that this is happening BEFORE Thanksgiving and the onset of the flu season. In a few weeks it could be way worse. Please do not allow “Covid fatigue” to let your guard down. It is not in your best interest and all it takes is being careless.

Maybe things will start to improve now but only if everyone plays their part. We haven’t even begun to turn the corner yet but maybe we can in January now that all the crazy rallies are over.

2 positive things: A new presidential task force (which includes people from my alma mater, yay!) and the imminent release of a vaccine.

Pfizer released their report yesterday that their new recombinant vaccine is 90% effective. Unfortunately there hasn’t been the usual time for ‘peer review’ because they said they would not have been able to keep it secret for the usual month it takes for that process. None-the-less the numbers still have to be examined and then cleared by the FDA. I worry that the media attention will pressurize the FDA to allow emergency clearance which will lead to distrust on the part of the public.

Anyway, as I have said many times, this is not when you need to be focusing on the vaccine. Focus on your life style choices which is something you have control over.

So “Happy Thanksgiving!” is in words only. I really don’t mean it literally.

If it makes you feel better, they plan on using the vaccine on us (medical workers) first. Whoopee!

Yesterday's shocking display. Sets us back on road to pandemic recovery

  Just for the record!

What happened yesterday was outrageous and disgraceful and I hold the doctors completely responsible. Being quarantined and in isolation does not mean going for a joy ride as a photo op!

The doctors are trained to manage patients with infectious diseases with a responsibility to both the patient and the community. They failed miserably. I question their principles and medical ethics.

Any patient can sign out of hospital AMA (against medical advice) that is their right. If this occurs with someone who is harmful to others the doctors should then notify the health department and seek  legal recourse with law enforcement up to and including a legal injunction.

Please understand, this is NOT “Ha Ha, look what just happened!”

It is nonsensical and should be condemned but the entire medical and public health community.

For the record that is how I would handle any of my patients who are ridiculous enough to behave in that manner.

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!

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.

Do-It-Yourself Covid Testing!

 I want to highlight an article I read today in the Harvard Gazette about a new approach that has not been suggested before. This idea is from Michael Mina a Harvard epidemiologist and expert in disease testing. He is calling for a shift in strategy toward a cheap, daily, do-it-yourself test that he says can be as effective as a vaccine at interrupting coronavirus transmission. He believes it is currently the only viable option for a quick return to a normal life.

Dr. Mina, is an assistant professor of epidemiology at my alma mater the Harvard T.S.Chan School of Public Health. He suggests that this would be a better strategy than closing down the economy and keeping schools closed which is really the only other viable option.

These paper-strip tests (similar to the popular pregnancy tests) have already been developed and their shotgun approach to testing cheap and widespread provides a way back to the workplace, classroom, and other venues.

The strategy, “could put hundreds of millions of tests in the hands of consumers within weeks, at a cost far less than repeated rounds of economic stimulus” Mina said. Several companies have produced these tests which can be produced for less than a dollar. With tests like these, ordinary people can perform their own tests each day or every other day. They are not as accurate as the current diagnostic tests but they are effective at detecting virus when a person is most infectious. If everyone who tests positive stays home, the thought is that the widespread effect would be similar to that of a vaccine because people would stop the transmission chains across the country. If people are concerned about false positives they could then follow up with a formal test with their doctor and stay quarantined meanwhile.

So whats the catch ?

First of all unless the tests are FDA approved and federal government sanctioned, companies are not going to invest and produce these tests in the numbers that would be required to be effective.

The currently available tests take time and are expensive. Which makes them impractical for daily in- home testing. These tests may not be perfect but the nation’s current testing strategy catches less than 3 percent of cases early enough for a person to proactively prevent transmitting the virus. Now if those testing positive stay home, “a cheap, at-home testing regimen has the potential to provide a kind of artificial herd immunity, interrupting enough transmission nationwide to cause the pandemic to stall”

Another catch is one that relates to all fields of prevention: it still requires people to take some level of responsibility and motivation to actually do the test and then follow through if the results are positive.

According to Dr. Mina what’s needed, is the federal government’s financial and organizational clout to both provide resources and get companies working together. Though even a $1 per day test gets expensive, if the federal government provides them free to all Americans, the cost would be far less than recent stimulus efforts. We could get these tests up and running right now unlike the vaccines.

“It will stop the vast majority of transmission and it will cause these outbreaks to disappear in a matter of weeks,” Mina said. “This is something we can actually do at warp speed.”

If you would like to read the full article you can read it here:

https://news.harvard.edu/gazette/story/2020/08/cheap-daily-covid-tests-could-be-akin-to-vaccine/

Its not over yet! The 'state' of the state.

There have been 3600 deaths in Maryland so far with huge differences between the counties. For example: deaths in Howard county 106, PG county 741 and Montgomery county 767.

Presently there are 488 people hospitalized in the state, 117 in ICU.

We were doing so well until the July 4th holiday when people became very lax.

I know you are tired of the restrictions but please don’t quit while we are ahead!

We now have to look forward and figure out how to keep our children safe as people press for a return to the classroom.

Even though things are ‘opening up’ please be cautious and don’t go overboard. Just because you can sit inside in restaurants now doesn’t mean you need to.

Your nails can wait another two weeks, two months if they have to!

Covid misinformation and actions that you need to take to stop the pande...

Political Rallies, Beach Parties and other Nonsensical behavior

GOOD NEWS....................sort of! Following up on the good news from last week our numbers in Maryland continue to decline. On June 11th we had 902 people in the hospital and 358 in the ICU. On June 21st we had 608 in the hospital and 230 in the ICU, and today, less than a week later, there are 511 patients in hospital and 209 in ICU. Why in the world would we quit now? Come on Maryland, we cannot do anything about what other states are up to but let’s not quit while we are ahead! Beach parties and indoor dining right now is madness, same thing with indoor cinema. Please don’t shoot me I am only the messenger who brings the truth. Don’t relax, I know its hard but you have to stick with it. Many more are going to die but it doesn’t have to be here because we have followed the rules and science will prevail. I want to make special mention of young adults. Yes, those ‘invincibles’ between the age of 23 and 39 who are the fastest growing segment of corona infected persons. In many places they make up a third of the infected population now. I believe one of the reasons for this is the initial misinformation that it is little more than a flu in young people and they hardly get sick. These young people have clearly not had good public health education. If they did, they would know that they are the key vessels for spreading the virus. People that aren't sick spread the virus the most. When they pass it on to a buddy who takes it home to their grand mother they now become responsible for the death of another human being. If you have a young person in your family or social circle please spell it out for them. It’s not just about how they feel or selfish behavior. For the rest of you avoid these folks like the plague! Just kidding, but you get what I mean. They are not as harmless or healthy as they may look. Especially if they won't wear a mask. I keep hearing slogans like “we are all in this together” but what does that mean if half the people “in it” don’t get it? I personally would love to see the Governors put a tri-state embargo on travel so that all these other non-compliant states couldn't send us more Covid-19 and send us into a second wave and lockdown. (Avoid out-of-towners too!). Anyway, have a plan for yourself and your family. I think it is finally safe to move into phase one. Continue to take your Vitamin C and D and Zinc. Keep washing your hands and wearing your masks. Using ‘common sense’ saves lives! Please stay well.

Racism is a Public health Crisis

I want to talk about racism.

Many of you know that in addition to a Medical degree I also have a Masters in Public Health (plus a bachelor’s degree in Human Biology) and so I am particularly interested in the social causes of morbidity and mortality especially those that can be prevented.

Public health is “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” This is the most quoted definition of Public Health by CEA Winslow a bacteriologist and seminal figure in public health circles in America and throughout the world.

It is clear that the context of peoples lives determines their health and we, as a society, must have an interest in ensuring people can be healthy.

There is a lot of research that supports the idea that 80 to 90% of a person’s overall health is determined by factors outside of clinical medical care. Some of the social things that affect it are: the quality of air and water, the type of work they do, where they live and access to resources and education.

My sense is that this is a watershed moment in America for a variety of reasons, one of which is the pandemic. It feels like finally something has shifted in the American psyche and hopefully the genie cannot go back into the bottle. I am referring to the sudden acute awareness of racism and as the headline in the Harvard School of Public Health magazine last week stated “Racism is a public health crisis”. Apparently sometimes it takes a visual demonstration of man’s inhumanity to his fellow man for things to become undeniably obvious. Facts and figures that have long been long known can no longer be denied.

Racism affects every aspect of the lives of African Americans today resulting in many lives being cut short. Racism affects both the morbidity and mortality of minorities in this country but because it seems too hard a problem to tackle its easier to ignore it.

 “The racial caste system of slavery that operated until the 1960s (known as Jim Crow) and 401 years of systemic racism and structural societal inequality still live on in every aspect of our daily lives. Nowhere is this more apparent than in health outcomes. It has taken a global pandemic—coupled with the visceral, horrifying deaths of George Floyd, Breonna Taylor and Ahmaud Arbery—for many Americans to acknowledge the truth: racism is deadly. This fact is inescapable in the midst of a pandemic which is killing black Americans at nearly three times the rate of white Americans. This disparity is not because of innate susceptibility to the disease; it is because of a wide range of inequalities that have plagued the black community since long before this health crisis began.” Michelle Williams PhD, Dean of the Harvard Chan School of Public Health. 

Montgomery county has the highest Covid -19 infection death rate in Maryland and latino patients are 5 times more likely to be admitted for Covid-19 with a much worse prognosis.

Here are some current stats for Maryland:

Hispanics 32.9% of the cases even though they represent 9% of the population.

African Americans 35% of the cases they make up 30 % of the population. A total of 68% of the cases are therefore minorities, yet whites make up 59% of the population and only 24% of the cases.

The minorities have the ‘triple threat’ to contend with: 1. More exposure, doing essential functions (only 13% of Latinos do jobs that can be done from home). 2.They have more underlying health conditions from poverty and lack of opportunity. 3. Less access to health care and uninsured.

Some one forwarded this video to me and I found it very helpful in understanding the history of racism in this country. It answers one of the questions of why ‘they’ are so angry and suggests we should all care.

It is a little long (15 minutes) but relatively concise considering how much he is trying to cover. I think it is worth watching.

https://youtu.be/AGUwcs9qJXY

 Rather than lecturing people on how to express their anger maybe we could all try to remove the cause. It won’t be fast or easy, it was after all 400 years in the making but every journey starts with the first step.