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.

COVID-19- A Personal Journey

[Important NOTE:  Please know that I was made aware of being COVID-19 test positive on Thanksgiving.  Every family in the practice who was in contact with me when I became infectious until I entered quarantine on Thanksgiving, has been notified by me on Thanksgiving.  Given my position I am considering my COVID status public information.]

Many may not be aware, but every week, all of us who work at Advanced Pediatrics screen with a swab to see if we have been infected with the SARS-CoV-2 virus.  At this time, as outlined below, the virus has spread so dramatically, we feel compelled to test, even though everyone tested weekly is asymptomatic.  (Anyone who develops symptoms of viral infection is tested right away and sent home).

Thankfully, we have had, until the week of Thanksgiving, only 2 positive swabs.  Both in our staff, one a long time ago in March, and the other instance this fall without any patient contact.

But this Thanksgiving week, with no warning of any symptoms, it turned out to be my turn to experience COVID-19 in person.   I personally contacted all the families I was in contact with this week, and this gave me the opportunity to give serious thought to the experience of this virus and infection.  The experience of having it, of worrying about exposing others, about how it spreads.

As to my own experience, so far I am one of the lucky ones who have not had serious illness.  I estimate that I became infected around Friday, November 20th and contagious on the next Monday.  I was swabbed in our routine screening on Tuesday the 24th, and had my first symptom on Wednesday, the 25th.   So as I write this essay, I am about 11 days into being infected, and about 6 days into my days of symptoms.   This puts me squarely into what I think of as the 2nd of 3 possible phases of having COVID-19 and very likely no longer contagious.

The first phase is when the virus lands in my body, almost certainly my eye, nose, or mouth.  No one can sense this event, it only takes 300 microscopic viruses to land to start the infection, you just can’t feel that happening.   Once landed, the virus gets into my cells and makes zillions of copies.  You can’t feel or sense that either.  But at some point the body notices the invasion, and builds up enough of a counter-attack that you might start to feel something.  About 50% of people infected never sense anything happening and go on to stay free of symptoms, or the asymptomatic.

For me, when my body started trying to wipe out the invaders, the second phase was felt.  The indications were all-in-all very mild.  A slight runny nose (almost none), scratchy or sore throat, chills without fever, occasional cough and shortness of breath, stomach ache, and lots of fatigue.  These feelings, or symptoms came and went in waves that might last a few hours, alternating with stretches of feeling almost fully fine.  This second phase is the period when the virus and my immune system are duking it out.  I certainly expect, and hope, my immune system will win, but not by too wide a margin.

My second phase is happening right now, so what happens next remains unknown.  If I am very lucky, this is all I will experience, and in about a week or so, my symptoms may go away all the way, and my SARS-CoV-2 virus will be eradicated.  And, although I hope to make a lot of strong antibodies, I am also strongly hoping my immune system will find a way to calm down.

If my immune system decides not to calm down, I may develop a third phase in which all sorts of possible inflammatory situations might develop.  I won’t go into detail about the possibilities, but they tend to show up after my contagion ends, somewhere in the neighborhood of 2-4 weeks after infection.

Speaking personally, it is a bit daunting to sit here and ponder, I wonder what symptoms and phases I will or will not experience.   Surprisingly it feels little different than I have felt the last 10 months, when like all of us, I woke every day wondering, I wonder if I, or anyone I care for, will ever come down with this scary disease?  At a certain level it is the uncertainty that is upsetting and scary.  Who will get sick?  What will happen to anyone who gets sick?  What could go wrong?  How can I avoid getting infected?  At a certain level, we have no very good answers to these urgent questions, and so we all share a certain and very real sense of dread and worry.

One fact that seems very well-known and highly reliable over many months of observation, a person cannot spread COVID-19 after 10 days from the first day of symptoms, unless their illness is particularly severe.   To be safe, most policies call for someone with COVID-19 with symptoms, like me, to stay isolated for 10 days starting with the first day of symptoms and until symptoms improve. For me, that means, barring something getting worse, I will no longer be contagious after December 6.  And so I will be out of the office until December 7 and a good recovery.

The Danger is Here – The Spread has Ushered in a New Reality

Very briefly, the danger from COVID-19 continues to grow ominously.

The numbers across the US, every state, show an epidemic galloping ahead in shocking scale.

In Ohio, the number of daily cases spiked well over 10,000 this week, now back around 9,000, a level that is frankly dangerous, and showing no signs of slowing.   In Cuyahoga County, the numbers are rising rapidly too.

Hospitals are filling and deaths are rising.

From January until October, the spread of COVID-19 was described by very discrete spots.  One group here, another there.  This city and not that city.  In such a reality, it made sense to know these spots and shut down the spread from them.

Now as November comes to a close, it is ever more apparent that we have entered a new reality, the reality of a confluent epidemic.  Rather than the illness appearing here and there, so that a case could reliably be traced to one known source, the COVID-19 Pandemic here is now coming at us from many, many directions all at once.

This is not a novel experience.  Every winter, common colds and the influenza virus carpet the world.  And so every year, we all see colds and flus appearing everywhere and all at once, over and over.  In such a situation, it is impossible to know just where “your” case came from.  Worse, there is so much virus in the air, it is not clear one can fully avoid being infected.

We know of a case of someone who has kept very strictly isolated, never went out, accepted no visitors, who still got COVID-19.

More of these cases will be seen as new cases become far more frequent, causing a near carpeting of our communities with COVID-19.  In fact, it may time to ask this question, could it happen that so many Americans have COVID-19, and are about to get secondary to Thanksgiving travel and gatherings, that one might start seeing people infected simply through the air and not actual contact with people within 6 feet of distance?

How painful it is to observe that on the very brink of the end of the Pandemic, we are clearly in our most dangerous time, and the frenzy of travel and gathering that millions are pursuing right now for Thanksgiving are essentially certain to make the danger remarkably worse, far more palpable.

Now is the time to be as careful as possible:

• Do Not Gather
• Do Not Travel
• If Together Stay at Least 6 feet Apart
• Wear a Mask

Large Groups Still Dominate the Spread

While it remains urgent to take the steps we can, the steps listed just above; on a national level, the country must pay attention to the major sources of the exploding spread as listed in this article: https://www.nytimes.com/2020/11/23/health/coronavirus-holiday-gatherings.html

It is reported there that “in Colorado, only 81 active cases are attributed to social gatherings, compared with more than 4,000 from correctional centers and jails, 3,300 from colleges and universities, nearly 2,400 from assisted living facilities, and 450 from restaurants, bars, casinos and bowling alleys.”

Note that spread of the virus does occur when we gather, but far more happen in formal settings of large groups of people.

Thinking about Getting the COVID-19 Vaccine

We have been talking about the possibility that an immunization for COVID-19 might be developed and in use.

The United States and the world are rapidly moving from talking about it to doing it.  The time when a COVID-19 immunization will be available to you is coming rapidly enough it is now time to start talking about deciding to get it and how it should roll out.

Here are some preliminary observations and thoughts.

First- Can we Really Believe a COVID-19 Immunization will Work.

Yes.  We are ready to say very clearly that vaccines released to prevent death from COVID-19 will do this very well.

Trials of many different types of COVID-19 vaccines each have demonstrated very high levels of working well, high enough that if enough people get a COVID-19 vaccine, we are confident the pandemic will end.

Of course one cannot be sure of this until the pandemic is actually seen to end, but the level of success is very, very high, so it really should work.

Second- Is it Safe?

What we know is that the COVID-19 vaccines appear free of any major, that is, permanent or serious side effects based on several months of observing about 30-40,000 people getting the shot for each brand.

This is a very good level of safety.   But the numbers observed are too small to observe side effects that may only occur one in every million or so people, so we will be watching carefully for serious side effects as millions do get protected.

Does it Make Sense to Get the COVID-19 Vaccine?

Yes.

Keep in mind, this is the first and only vaccine I will be giving, to help make sure someone I care for does not face an imminent threat of death from the disease I am preventing.

There is no such equation to weigh with Hepatitis B vaccine, or the polio vaccine, or many others.  There could be if we stopped giving them, but the diseases we immunize against are largely vanquished, because of immunizations.

It should be obvious this is not the case with COVID-19.   Can anyone doubt that this illness is challenging everyone with death or permanent harm?  The danger is less for children, but not zero.  The danger for those 18 years old and up is palpable and close, and getting closer as the numbers go up every day.

So deciding not to get this immunization, will certainly increase the chance the person choosing to not be immunized may not live, or will pass it along to someone who in turn will not live, or suffer years of disability.

And Therefore, taking into account just how amazingly well these COVID-19 immunizations will work, how excellent their safety profile is to date, the critical urgency of the danger this infection poses, if given the opportunity to receive a COVID-19 immunization, I will take it with profound gratitude, and really urge everyone I care for to do the same, for all the same reasons.

Who Should Get it First?

I deeply appreciate the national consensus that doctors, nurses, and front-line health care workers should get this protection first.   I appreciate the interest and care of our nation in hoping we come through safely.  And I know what I am about to recommend will likely not be followed, but it needs to be said.

In any emergency, I say, let those in the greatest danger get protected first.

For COVID-19 that is one population in particular- it is the elderly and at risk communities of color and poverty.  Period.  In the US the risk of dying from COVID-19 is far higher if you are poor or if you have color.  So this should be where the first doses go.

I am fine having the medical world come in second, but with us should come everyone who is required to be in contact with people- grocery workers, delivery workers, agricultural and meat producers.   I cannot accept valuing the life of a doctor over anyone else’s.

What is the Current Plan from the US and Ohio?

In 17 Days Pfizer will be shipping the first ever publicly used, licensed COVID-19 vaccine in America.  Others will follow.  But the current plan is for about 3,000 doses to be sent to Metro, St. Vincent’s, and the Cleveland Clinic.  Those doses will go fast, but the numbers made available will grow dramatically following December 15.

Since far from enough for everyone will be available at first, who decides who will get the first shipments?   At this time that decision is made mostly by each state, in consultation with the US government and the manufacturer(s).

And so here it will be the State of Ohio who decides who will go first and then who next.

All would agree the first doses should go to those in the greatest danger, or to those whose loss could cause the greatest harm.

The evidence is clear who is in the greatest danger, namely 3 groups:

1. The elderly
2. Those with the most risky risk factors
3. Those in the riskiest settings- assisted living facilities, and prisons

The people whose loss would be most keenly felt are not so easy to list.  There appears to be some consensus that health care workers are on that list, but so are all essential workers.

My own preference is for the vaccine to be made available first to those in the greatest imminent danger of harm from this virus, then those whose loss would affect everyone else.

Keep in mind that in anyone’s priority list of COVID-19 vaccine recipients, children will be last.  They are the least likely to get very ill from COVID-19, and all trials to date have been in adults.  As the vaccines are proven safe in huge numbers of adults, embarking on trials in children will be seen as safe, opening the door to kids getting COVID-19 vaccine, but not for many months from now, I suspect.

General Distribution

Because so many excellent vaccines for COVID-19 are likely to be made, we will move at some point by the Spring of 2021, it is thought, from discussions of who should get the vaccine first, to a discussion of how do we get these vaccines delivered to as close to everyone as possible.

The question of universal use is the question that will determine if the Pandemic will truly be ended, or whether the danger will continue to lurk.

We see this with every type of immunization.  If enough of a nation’s population gets immunized, the virus will cease to spread, at all.  But leave enough unimmunized, and COVID-19, though subdued, will continue to spread, threatening lives, even of those immunized.

This is a very important point.  Imagine that you are immunized against COVID-19 by a vaccine proven to be 95% effective.  And now imagine that you are attending an event with 200 people, once the Pandemic is thought to be over.  You are in a group of 100 people at an event who are immunized, but another 100 present have COVID-19 and don’t know it.   If the vaccine is 95% effective, 5 of the 100 immunized will still get COVID-19, and you could be one of the 5.

This scenario cannot happen if enough people in a nation, or world, get the COVID-19 vaccine.  We don’t know what that number is, so the only way to be confident the Pandemic will truly end, is to have as many people here in Ohio, across the US, and around the world, get the COVID-19 vaccine.

BOTTOM LINES

1. We are in a new phase of the COVID-19 Pandemic here at home.  The numbers are so high that exposure is coming at all of us from many, many directions.
2. This Thanksgiving week, I came down with COVID-19, still in my second phase, which is so far quite mild.  I hope it remains mild and ends with phase two.   Many, many thanks to so many good wishes, which I share with everyone, for staying healthy!
3. Now that the Pandemic is everywhere, it becomes urgent to get very strict about staying away from others, if together make it outdoors with mask and 6 feet apart.
4. A COVID-19 vaccine is due to arrive in Cleveland on December 15, and so we must start thinking now, should I get one of these COVID-19 vaccines?  I am urging everyone to do so.  The trials show that they work remarkably well, and no serious side effects in groups of 30-40,000 have been reported.  Keep in mind, the question of concern about getting a COVID-19 vaccine must be weighed with the very real danger of not getting the vaccine and catching COVID-19.

My Takeaway – In One Sentence:

I am now an infected with COVID-19, grateful to not be harmed so far, and hoping that we all know how easy it is to get infected, and adopt the most safe practices until we can all get vaccinated.

To your health,
Dr. Arthur Lavin