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.

Update on COVID-19 in Childhood in America

For those interested in this subject, there is an excellent update available weekly from the American Academy of Pediatrics:

https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/

The good news is that the illness COVID-19 is clearly milder the younger you are.  This fact seems durable over the time of the pandemic.

But this good news only goes so far, there are troubling realities about this disease and childhood.  Here are some:

• Children get infected.  Yes, when infected, they tend to experience far milder symptoms, but they do get infected.
• Children can become very seriously ill, tragically even to the point of loss of life.  The condition Multisystem Inflammatory Syndrome in Children is a dangerous condition that inflames much of a child’s body.
• Children spread the virus like adults.  In particular all children ages 10 and up spread it as well as adults.   It may be the case that this is true down through age 6.

With these basic facts in mind the current update brings serious concerns.  The main finding is that the number of children with COVID-19 in the United States is up 90%, and this before most of our schools have opened.   The rise in cases is seen primarily in communities where COVID-19 overall is on the rise, which of course is expected.

As of August 6, 2020, there have been 380,000 of our children infected with the SARS-CoV-2 proven by a positive swab test.   That is about 9% of all positive COVID-19 tests in the U.S.    In the last 4 weeks, the rate of increase of COVID-19 in children across the country is up 90%, but in Ohio the number of children infected has gone up 150%!

Across the nation, the chance a child tested will be positive has been at 3-12%.   In our practice, Advanced Pediatrics, that rate has held steady over the last few weeks at about 10%, which is the same rate reported by the entire UH system.

In terms of death, there have been 49 children who have died again as of August 6.   In our state of Ohio 2 children have lost their life.

These trends confirm that children do indeed catch and transmit the SARS-CoV-2 virus.   Think about the rates of infection going up 90%.  And consider that the percentage of children tested turning out to have COVID-19 is about the same as in the adult community.  The illness is here, it is spreading, and children are as much a part of its spreading as anyone.

Thankfully, the update also confirms that although many children get infected with COVID-19, not that many become seriously ill.  Still nearly 50 children have died from this disease.  This number of course included all the children who have died of MIS-C.

The Pill, COVID, Clots, and Time for the IUD.

For older adolescents, an ominous update concerns the risk of developing clots if one is infected with COVID-19.

It is already well-known that the SARS-CoV-2 virus attaches to the cells that line and create our blood vessels, called endothelial cells.  We tend to think of our arteries and veins and capillaries as little pipes, and I suppose they are, but they are living pipes, tubes made out of cells that flatten and attach to each other in a round, hollow shape.  Tragically, these cells in our body make the protein that this virus can attach to, to cause infection, the same protein the virus attaches to in the lung.   But whereas in the lung the virus cause swelling and trouble breathing, on our vessels the virus causes clots.  If the clots are in the blood vessels of the limbs that is DVT, in in the lung that is pulmonary embolus, and in the brain that is stroke.

It is also well-known that oral contraceptives, “the pill,” increase the risk of strokes.

And so it is with concern that we share published insights from endocrinologists that there may be an increased risk of clots if you put these two known risks together:  COVID-19 and taking the pill.  No such increase has been reported, but the possibility is of real concern.

For some time, the American College of Obstetricians and Gynecologists has put forward the policy that adolescents and young adults seeking contraception should consider use of an intra-uterine device, or IUD, rather than the pill.  We at Advanced Pediatrics have supported this policy.   And in particular, in a  time when any of us, any of our children, are at risk of catching COVID-19, anyone on the pill for contraception shift their contraception to use of the IUD and stop using the pill.   For those using the pill for acne or management of periods, we recommend you consult with us to discuss if other alternatives can be used to reduce the risk of stroke with the background of COVID-19 looming.

Immunity

A huge question on SARS-CoV-2 is whether once you have been infected, can you be infected again?

Some infections provoke immunity and such infections only rarely can be experienced twice.  Examples are familiar and include chickenpox and measles.   But some infections provoke no immunity and such infections can be experienced over and over again without end.  Examples of such infections are also familiar and include strep throat and RSV respiratory infections.

So it is a very big question, if SARS-CoV-2 provokes no immunity, like strep, that would mean there would be no end in sight for this pandemic, for many years.  Because the 5 (documented)- 50 (suspected) cases could recur, and many times.  The epidemic would go on until something changed.  But, if SARS-CoV-2 provokes immunity, then those 5-50 million of our fellow Americans who have had COVID-19 will not have it again, and if that number rises to 200-240 million of us, it is estimated that the virus will run out of people to jump into and stop spreading.

We do not have complete proof in hand, but the evidence gathering from experience and a number of new studies is pointing towards good news, that people who have had COVID-19 make antibody and sustain its production for at least 72 days.  One study followed over 250 people who had positive COVID-19 tests for over 70 days.  Antibody to the SARS-CoV-2 virus appeared rapidly within days of first symptoms, and protective levels were detected as far out as 72 days after first symptom (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386524/).  Other studies confirm these data.

And experience confirms this sense as well.  As of now, about 9 months into the pandemic, there have been no reports of established patterns of people once infected with COVID-19 being infected again.

Should these observations continue to be confirmed and the point proven, this opens the door to the pandemic running its course once 60-75% (200-240 million) of Americans are infected, OR, once a vaccine is put into place.  This last point is so important.  Consider RSV, since the infection does not immunize, neither will a vaccine, the major reason there is no RSV immunization.  So, if COVID-19 provokes long-term immunity, a COVID-19 immunization could work, that is incredibly good news, because only then can an immunization truly stop the pandemic.

BOTTOM LINES

1. The update on children confirms
   1. If children get COVID-19 they are very likely to not get very ill.
   2. The number of children infected with SARS-CoV-2 virus is growing rapidly, up 90% in the last 4 weeks
   3. Children catch and spread COVID-19 at the same rate as adults, certainly down to age 10, perhaps 6
2. An important point for children is not an update, but a worry.  We simply do not know the long-term impact of having COVID-19, even if young, even if not having any symptoms.  Evidence in older people suggests there can be organ damage with long-term harm even with mild illness.
3. Putting it all together, children deserve protection from getting infected and having COVID-19, a risk that is very, very real in today’s America where the virus spreads with few limits.
4. The risk of clots goes up with COVID-19 in adults and maybe adolescents, oral contraceptives increase the risk of clots, together they may perhaps greatly increase the risk of clots (DVT, pulmonary embolus, and/or strokes), and so young adults using the pill should consider other choices.  For contraception the top choice for adolescents and young adults is the IUD.
5. Early indicators suggest that infection with COVID-19 provokes immunity at last through the first 72 days after symptoms appear.  This could allow the pandemic to end one day, either by enough people having had it, or via immunization.
6. As we approach the question of opening schools, this update on children should give us all pause, gathering children into an indoor space is a recipe for viral spread, and as indicated, this virus spreads.

To your health,
Dr. Arthur Lavin