Glossary

• Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
• Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
• SARS-CoV-2– the specific name of the new coronavirus
• COVID-19-the name of the illness that the new coronavirus is causing
• Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic– a sudden burst of an illness that comes and goes over a limited time
• Pandemic– an epidemic that bursts across the world not just one region
• Spreadability– how contagious is the disease, how many people will end up infected
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
  • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
  • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
• Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
• Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
• Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
• Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.
• Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
• Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.

Spreadability

Tragically, the key update is that the SARS-CoV-2 virus ranges across our nation and our local neighborhoods without much to slow it down.

Across the nation, we approach 170,000 dying from COVID-19, with nothing in sight to keep that number from going to 300,000.  For frame of reference, the loss of life in the most deadly 1918 flu pandemic in the US was about 550,000, prior to modern medicine.

In Ohio, our cases continue to pile up, at the 1,000-1,500 cases each day, since July 1.  This is a higher rate than at any time.  The only good news is that this number has not exploded upwards.  Perhaps our work using masks and distancing has helped.

In our community, we have a sense of the activity of this virus.  Just in our small office, we have diagnosed over a dozen children/adolescents with COVID-19.  That number is greater than the total number of cases of COVID-19 in many nations!  And we are only sampling a tiny fraction of the whole practice.  There is no doubt.  The SARS-CoV-2 virus is spreading easily and quite widely right here, in our neighborhoods.  It is here, it is spreading.

This is a fact confirmed by our region’s top public health official, the Commissioner of the Cuyahoga County Board of Health, Terry Allan, whose public health expertise is highly regarded around the United States.  On the last day of July, Mr. Allan let our community know that this virus is indeed spreading across our County, and doing so at a rate that leads the Board of Health to officially recommend that no school in Cuyahoga County open now, and that no sports be begun.  Acknowledging that some schools will choose to open and some sports will choose to begin, he observed that it is very likely that these schools will experience outbreaks of COVID-19.. https://www.ideastream.org/news/cuyahoga-county-health-board-recommends-schools-begin-remotely-no-sports

As of August 15, across Cuyahoga County, not including the city of Cleveland, 419 of us have died, ages 36 and up.

On the Brink – Schools and Colleges Open – Preparing for the Flood of Normal Viruses in a time of COVID

For better or for worse, some portion of 50 million school children, and most of 15 million college students will return to school and college in the next few days.

We will soon see, will the viruses that have always exploded on the scene every year schools get together.   What do I mean?  Every year, every family, and certainly this office, sees a true explosion of viral illnesses within days of the start of school- fevers, runny noses, coughs, vomiting and diarrhea, rashes.  Prior years there has been no COVID, but this year there will be.

Even now, before schools convene, in the last week or so, we have seen a very real, not dramatic, but real uptick in the number of calls and visits for such mild viral illnesses.

Should the precautions set by those schools and colleges opening work, we will not see much increase in the flow of any viruses, the usual fevers and coughs, including those from the illness, COVID-19.

Lots of signals suggest this may not be the case, the main signal being the conclusion cited above by the agency whose very job it is to track all the numbers and alert us to dangers and how to avoid them.  As noted, the top public health official in our Cuyahoga County has gone on record, he expects schools that open to in-person class and/or sports, will have outbreaks of COVID-19.

Second, schools are perhaps the finest vehicle we normally experience for whipping up viral waves of infection.  Perhaps army barracks do better, but not many others.

And so starting next week, we will be on the alert at Advanced Pediatrics, for the emergence of signs that viral illnesses are really flaring, becoming far more common.  And, if that happens, we will be looking for big jumps in the occurrence of COVID-19.

To prepare for this dangerous and threatening situation, it makes sense to share some basics as we help you find out if your child’s fever, cough, runny nose (now seen in COVID-19), or diarrhea is COVID-19,or not.

The Germs that Cause Fever and Illness

The vast majority of fevers in children are caused be a long list of viruses, to which we must now add COVID-19.  Three illnesses are not caused by viruses, but by bacteria, as noted.

THE THREE MOST COMMON BACTERIAL CAUSES OF FEVER

• Strep Throat.  Strep throat is caused by a bacteria called, Streptococcus pyogenes, or Group A strep, or most commonly, Strep.   It can cause no symptoms, or mild cold symptoms, or the full experience of sore throat and fever.  If you found 1000 kids with Strep throat, you would find 333 had no symptoms, 333 a mild cold, and only 333 sore throat and fever.   If you have Strep throat and are not sick, it typically does no harm, so we do not test people who feel well.   Testing is done by a throat swab with rapid results ready in a day, and back-up results in 2 days.
• Ear infections.  Middle ear infections, or ear infections are the result of pus building up behind the ear drum because mucus from a cold begins to grow.   Testing is done by looking at the eardrum, if it is normal, there is no pus, no ear infection. If it looks infected like a red pimple there is pus and an ear infection.
• Urinary Tract Infections (UTIs).  UTIs usually cause pain on peeing, but sometimes just fever.  But they do not cause runny nose, cough, earache, sore throat.  Testing is done by peeing in a cup and seeing if the urine is infected.  We don’t collect urine if the fever has cold symptoms as listed,but may if only fever is present, and will if there is pain on peeing.

All three of these infections are easily cured, with a short course of oral antibiotics.

THE MOST COMMON VIRAL CAUSES OF FEVER AND COLD SYMPTOMS THAT ARE NOT COVID-19 or INFLUENZA

There are a host of viruses that love to land in our noses, throats, and eyes, and then infect all those parts and then our lungs.  Makes sense, because being a virus in the air is a great way to spread around.   All these viruses cause the same possible problems:  fever, aches, sore throat, runny nose, pink eye, cough.

All these viruses can cause mild illnesses, an ache, or fever for one day.  AND, can cause really bad colds and flus with many days of misery, high fever, severe discomfort and/or weeks of cough.   But for most healthy kids, these illnesses are not dangerous.  We all have them.

• Rhinovirus- by far the most common of them all, the cause of most common colds
• RSV- tends to cause worse colds and flus, very, common, second only to rhinovirus
• Adenovirus- another respiratory virus, same sort of symptoms as rhinovirus and RSV, a common cause of viral pink eye.
• Old Coronavirus- believe it or not, there are 4 types of coronavirus that have been causing our common colds for about 8,000 years, and they cause about 25% of these colds and flus to this day.

THE INFLUENZA VIRUS

The influenza virus causes these colds and flus too, but only at a certain time of year:  mid-December- April.

This means until mid-December, if you have a fever, ache, sore throat, runny nose, pink eye, or cough, you don’t have an infection with the influenza virus.

But after mid-December, until the end of April, and mainly in late December, January, February, and March, you might.

There are two types of influenza virus- Type A and B.  Tests for the influenza virus test for A or B.

THE SARS-CoV-2 VIRUS

This virus causes COVID-19.  It is NOT seasonal, and it IS here.  If you have a fever, sore throat, runny nose, cough, you might have COVID-19 and should be tested.   If you have been within 6 feet of anyone tested positive with a swab for COVID-19, you should be tested.

Although COVID-19 can cause the same symptoms of all the above germs (except UTIs), it is VERY different in once critical way:  it can kill people.

This is a point that has been amply discussed all along in Real Answers.  But the point needs to be emphasized.

For the first time, we approach a fall and winter season in which even the most innocent viral problem, the mild fever, the little cough, that we have learned together over time presents no harm, now might.  

COVID-19 is a disease with two faces.  At least half the time it causes no signs or troubles.  But then it can also cause organs to fail, including lungs, heart, kidneys, liver, our blood vessels, and even our brain.

The test to see if you have COVID-19 the day of the test is a swab of your nose or throat.

This fall and winter, should the non-COVID viruses do their usual flare, we will be do all in our power to be able to see if the virus your child has is SARS-CoV-2.

Testing at Advanced Pediatrics Once the Schools Begin to Cause Widespread Viral Illness

Starting after Labor Day, we will be organizing all regularly scheduled health supervision and evaluation visits, “check-ups,” will take place from 9-Noon and 1-2.

Then all visits to assess illnesses will be scheduled for 2PM onward, unless urgency requires earlier evaluation, to limit exposure of possible COVID-19 infections to those who are well.

If the surge of viral illnesses from school openings comes to pass, we will begin sending tests as follows

• From the Surge to mid-December- a swab will be sent to evaluate for presence of the 3 most common viruses listed above- rhino-, RSV, adeno- -virus, and strep AND for COVID-19.  Results will be in hand within 2-3 days
• From mid-December through April– a swab will be sent to evaluate for all these and Influenza A and Influenza B.  Results will be in hand within 2-3 days.
• For the evaluation of strep symptoms, we will do two swabs, one for our usual rapid strep with results within 10 minutes.  And the other swab will be sent as noted above, depending on the time of year.

Treatment for Viruses

The short answer to this question is that there are no known, reliable medications available to treat any of the viral infections listed above.

If we find out your child does not have strep, ear infection, or even a UTI, but DOES have a viral infection, be it rhinovirus, RSV, adenovirus, influenza Type A, influenza Type B, or even SARS-CoV-2, as of now, and for the foreseeable future, there is not medication we would recommend for use unless the illness requires hospitalization.

A word on Tamiflu going into this unusual season.  Tamiflu over the years has been impressive for its failure to help substantially.  In direct contrast to antibiotics for strep or ear infections, Tamiflu has a nearly negligible impact, and carries with it serious risks, including causing seizures in children.  Many, many studies have found that Tamiflu shortens the course of a typically 8 day illness by about 0.7 days, and then only if started within 48 hours of the first sniffle.  Therefore, Advanced Pediatrics has joined with most infectious disease authorities in NOT recommending its use in children, even if their viral swab is positive for Influenza Type A or B.   This season, a new question comes up, will COVID-19 make influenza worse, if so will Tamiflu help?

You can have more than one virus

In past seasons, if you had RSV you knew all you had.  Not this year.  Already we know a child can have COVID-19 AND rhinovirus, or adenovirus, or RSV.

We do not know if the surge of all the common respiratory viruses listed above will block or worsen the course of COVID-19.  We hope the usual viruses block COVID-19’s spread, but only time will tell.

Recommendations as We Approach School-Induced Waves of Viral Illness

First, we hope enough families stay home that this does not happen.  Let’s follow the warnings that surround us, the official warnings from Cuyahoga County’s top public health officials, stay home.

Second, if enough families flock back to school and in Eastern Cuyahoga County, this is a problem faced primarily by families who attend private schools, we hope these schools’ plans to limit viral spread work.

Third, we will know if they work.  We get calls when kids get sick.  Should we see the nearly universal surges of fevers and colds that follow school openings, we stand ready.  And we recommend your child be tested for all the common viruses, for strep, and of course, for COVID-19.

Fourth, should COVID-19 surge, we  hope the County and/or State stop it by closing the schools should they be seen as the source.

Lastly and most importantly, we implore our nation to do the simple steps dozens of other nations have adopted to stop the spread of COVID-19, by Identifying the Infected and Isolating the Infected.  Then we can go to school have our colds, and not be worried that a deadly infection is spreading.

Treatment

A working, safe immunization against the SARS-CoV-2 virus is the surest path to ending the pandemic.   Not all immunizations, even very promising ones work, not all are safe.  So we must investigate any candidate immunization before releasing it to billions of humanity.   To do this right takes time, time we are taking now to test candidate immunizations.  Maybe we will have access to a safe, working immunization in 2021, maybe not, time will tell, but there are candidates that just might deliver.

Work on medications that can treat COVID-19 also is progressing, but progress is slower than hoped.

Certainly for today, tomorrow, and the rest of the year, we will need to continue to turn to ourselves to end the dying from COVID-19.  We can, we should.  It will take individual, family, neighborhood, workplace, school, and, ultimately, national efforts to do so.

We will know when we succeed, for when we do, the dying will decrease dramatically, at times cease all together.

BOTTOM LINES

1. The COVID-19 American epidemic rages on. Tragedies rise as we reach towards 200,000 dead with no end in sight but for the distant hope for a vaccine.  All this despite the solution being within reach at any moment our nation agrees to do it.
2. In the setting of active and quite widespread COVID-19 spreading, opening schools is likely to cause outbreaks.  We live in such a setting.
3. If the opening of enough schools ignites the universal surge of thousands of fevers, sore throats, coughs, aches, Advanced Pediatrics stands ready to test those with these symptoms to see just what virus is present, including SARS-CoV-2, or if it is strep.
4. All respiratory viruses have no known reliable, very helpful medication available, none of them.  The main reason to see just what your child has if they have cold or flu symptoms, is to identify a non-COVID or COVID cause of the illness, so you know if you have to isolate.
5. JUST TO BE CLEAR, the influenza virus does not appear in the US until mid-December.  All the colds and flus that are likely to start with schools opening are NOT influenza.  But after mid-December many such colds and flus will be caused by the influenza virus.
6. WE DO NOT KNOW if a surge of typical fall and winter viral infections, including influenza after mid-December, will block COVID (good) or make COVID worse (bad).

And so, once again, while the virus rages, and until our nation stops it from raging, we strongly urge all families to take steps to protect yourself from COVID-19, a clear and present danger.  Wear masks, stay 6 feet away from everyone, avoid crowds, wash hands.  These steps help, not enough, but they help.

To your health,
Dr. Arthur Lavin