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Original Articles By Dr. Lavin Featuring Expert Advice & Information about Pediatric Health Issues that you Care the Most About

COVID-19 Update February 16, 2021: How to Go Back to School- the CDC Guidelines in a Nutshell, Update on the Race – Mutation v. Vaccine, Keeping Safe in the Middle, When Others Want to Gather, Beating the Scares on the Vaccine, & the Direct Contact Family Quandary

By Dr. Arthur Lavin

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.
  • Vaccine Terms
    • Vaccine or Immunization– a dose of a substance that activates your immune system, as if you have the actual infection you are hoping to prevent, leaving you in fact protected from having that infection.
    • Efficacy– the percentage of people immunized with a particular vaccine who will not get infected if exposed to the target infection.  For example, a COVID-19 vaccine will be said to be 95% effective if 95% of people immunized with that particular COVID-19 vaccine will not get COVID-19 if exposed to COVID-19
    • mRNA– DNA works by dictating exactly which proteins your cell will make.  The message on how to construct each protein is delivered to the cell machinery that makes proteins by a piece of genetic material called messenger RNA, or mRNA
    • mRNA vaccine– an mRNA vaccine places a small bit of mRNA code that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected
    • Viral vector vaccine– a viral vector vaccine takes a harmless virus that is known to infect people reliably and places that weakened virus in a person where that virus will in fact infect the person.  The virus is not only weakened, but also attached to a set of genes  that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected.

How to Go Back to School- the CDC Guidelines in a Nutshell

Just a few days ago, the United States issued a comprehensive guide on how to go back to K-12 school.

Here is the Guide, issued by our CDC- https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/operation-strategy.html

The Guide is outstanding.  It covers a lot of ground, it sets forth an approach that allows our children to go to school safely.

It also does something very important- it makes clear there will be situations in which it is not safe to go to school in person, full-time safely.

Given the recent decline in cases, and the specific guidance now available to every school teaching children grades K-12 in America, we can finally endorse the step of returning your children to full-time in-person schooling, if your school actually follows the details of this Guide.  If they do not, the pandemic is still very, very hot, and spread will happen.

Here are the Key Elements Necessary for A School to Follow to Even Consider Full-Time In-Person Teaching Safe

  1. The community must be experiencing a mild level of SARS-CoV-2 virus transmission.  This is measured specifically in two measures:  how many people, per 100,000, in your community are infected AND of all those tested in your community, what percentage are positive.  For Cuyahoga County, these two numbers are currently at 136 per 100k cases, and 11% positivity.  The CDC states that spread of this deadly virus in a classroom is much lower if a community can drop its transmission levels to low or moderate levels.  Moderate levels are defined as 10-49 per 100k cases, and 5-8% positivity rate.  Cuyahoga County right now is well above moderate, per the CDC yardstick our numbers are in the high transmission zone, the CDC’s very highest level of threat from transmission.  So we do not pass the first CDC test for feeling safe about in-person schooling, yet.   These numbers are dropping, we may reach this threshold hopefully soon, but we are not there yet.
  2. Variants or mutations can overturn all plans. The CDC is explicit on this point.  This would be reflected in community transmission, and also level of severity of illness rates.  We now have learned that the UK variant is not only more catchy, but more deadly.  Our community has not felt the brunt of this mutation, it is here, it is spreading, we expect the full bloom in March.  So if this should cause a major surge, plans to learn in-person in classroom would need to be adjusted.
  3. IF community spread is low enough, classrooms can be very safe places, where COVID-19 does not spread.  But only if some very, very specific steps are taken to make them safe.
    • Mask wearing- For K-12, universal, constant.
    • Distancing– the CDC urges all to stay at least 6 feet apart, always.  In classrooms and schools, key aspects of distancing are to also include
      • Cohorting, aka podding- create subgroups and keep subgroups from contacting each other
      • Stagger schedules to keep each cohort from contacting each other
      • Limit visitors to the school
    • Hand Washing and Keeping Coughs and Sneezes Covered
    • Cleaning
    • Contact tracing- Schools need to know who has COVID in their building, which requires adequate testing.  And when a case is discovered, tracking all contacts to see who else is contagious.  This illness causes no symptoms in 50% of cases, and so testing and tracking is the only way to know who has COVID and who is contagious.
    • Effective Isolation and Quarantine- Everyone who is infected or possibly exposed and could become infected needs to be kept from spreading COVID in the school
      • The Infected- All those known to be infected need to be isolated, for the right number of days.  If symptomatic and not hospitalized that remains 10 days with Day 1 being the first day of symptoms.  If there are no symptoms, then isolation is 14 days with Day 1 being the day of the positive test.
      • Direct Contacts-  Direct contacts are all students, teachers, staff, family members, friends, anyone, who has been within 6 feet of a known infected person for as little as 15 minutes.   A direct contact needs to be in quarantine for a period following the last day of contact with a person known to be contagious.  This last day could be Day 10 of a symptomatic known infected person, so the direct contact could be in quarantine for 10 days of someone’s symptoms, plus the direct contact’s further 10 days following last day of contact while contagious.
  1. First things first!  Classroom takes priority over sports.  The CDC is explicit on this point.  And it makes sense to us.  Of the several hundred cases of COVID we have diagnosed over the last year, the majority have been caught at a sport.  There is no reason to sacrifice the chance to return to live teaching by playing basketball, soccer, or any sport.
  2. It is considered optimal to have as close to all immunized as possible.  Starting with older teachers and staff and everyone 16 and older who have medical conditions, but extending to all teachers and staff and all those 16 years of age and older where the Pfizer vaccine is available, or 18 and older for all other vaccines.

The CDC Guidelines for opening schools are very, very clearly written- https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/operation-strategy.html.   It makes sense for anyone working at a school or with a child in grades K-12 to read them.  It also is urgent that schools not re-open for full-time live teaching until these guidelines can be put into place and practices fully.

Update on the Race:  Mutations v. Vaccines

As noted in Real Answers recently, the question of whether we end this Pandemic in America rests on two opposing forces: the emergence of mutations that could cause a whole new Pandemic to rage and the quenching power of vaccines.  It turns out that this BOTH ends of this race will be determined by OUR actions.  Mutations can only form during someone’s infection.  If we all take steps to stop the spread, stop transmission, there will be dramatically fewer cases, and therefore, fewer mutations.  If we all take steps to get immunized, there will be dramatically fewer cases, and therefore, fewer mutations.

There are two mutation events I fear the most.  The first has been talked about widely, the possibility a new SARS-CoV-2 variant will emerge that our current vaccines do not stop.  The second is hard to even mention, but is possible.  The possibility exists that a mutation of the current coronavirus could possibly cause children to become very ill from infections.  We have seen that the South African variant makes young adults far sicker, far more likely to die than our current version.  Both of these, and of course, other potentially deadly changes to the virus are possible, only very close attention to stopping the spread by our actions and by our getting immunized, can reliable keep these from happening.

On the vaccine front of the race, the news is very good.  The United States now holds confirmed orders for 600 million doses of vaccine.  That is enough to immunize 93% of every American, easily enough to end the Pandemic.  The delivery is also set.  At the very latest we will have enough doses in hand to fully immunize 200 million Americans, 83% of all adults in the nation, easily enough to dramatically slow the spread amongst adults, by the end of May.   That puts a dramatic slow down of adult spread in our hands, at the latest, in 100 days.  The goal of having enough material to immunize a full 300 million Americans is assured to be in hand by the end of July.

Now, we will have the shots in hand, but when will they be given?   The good news here is that we have an absolutely focused, huge energy, extremely competent effort in place, right now, to make sure once a vaccine vial is delivered, the vaccines in it are given.  Even so, we will likely not have those 200 million Americans immunized by May 31.   But my expectation is that every week we will learn of new approaches that will help us near this ultimate goal.  As of today, the United States has immunized 46 million, about a quarter of the way to that 200 million mark we hope to hit as close to May 31 as possible.

The bad news is that to go from 200 to 300 million Americans immunized, we will need to be able to immunize children.  There are about 75 million children in the US, leaving about 245 million as adults.  We will almost certainly never hit 100% of adults immunized, so to get to 300 million you can see the essential nature of children being immunized.  We are closing in on concluding studies on children ages 12-18 for Moderna and 12-16 for Pfizer.  If they demonstrate it is safe and effective, we will open the door to both vaccines being given to all children 12-18 years old.  We hope the studies demonstrate this can be done.  And AstraZeneca, in the UK, announced it has opened studies looking at giving their vaccine to children 6 years old and up.

Even so, there will be a period of time in which far more adults will be immunized than children under 16 years of age.  We are in that reality right now, with 46 million adults immunized and 0 children less than 16.

A huge unanswered question will be what will the actual face of the pandemic be during this phase when adults are largely immunized but no children are?  My surmise is that once we hit 70-85% adult immunization rates we will see hospitals empty of cases of COVID, and deaths will dramatically drop.  That will create nearly infinite pressure as the nation will roar a move back to normal, in work, play, and school.   When that almost certainly happens, we will have set the stage for the virus to transmit rather ferociously, mainly in children, and so quite invisibly, as long as children remain so highly unlikely to get ill.  This scenario will allow mutations to breed, and will expose all of us to the virus on a daily basis, allowing it ample opportunities to find paths to infect the immunized.

With all this in mind, it becomes imperative to keep in mind this is no time to relax our guard.  Elements are gathering to end the Pandemic, but until it is ended, letting loose only helps defeat those elements, and keep the nightmare roaring.

Keeping Safe in the Middle

Readers of Real Answers will recall that last posting we developed the notion that we are no longer in the Beginning of the Pandemic, and we are certainly not at the End.  We are in this phase we call the Middle.  The Middle started when tools to end the Pandemic came into our hands.  But the Middle is the phase in which the virus continues to roar, to kill, to hurt, because the tools to End the Pandemic are not yet in full force.

In many ways, the Middle is a particularly tragic time.  We see the End in sight, but if we act as though the End is here, the virus will surge, thousands will die, all within sight of the End.   We will be tested in the Middle, particularly those of us who have been fully immunized.  Fully immunized does not mean fully protected.  If you are fully immunized and you walk into a gathering where the virus is thick, you can still get infected.  Your chance of that happening is down 95%, but not 100%.  Worse, we have no idea how less likely you will be to have the virus infect you and cause no symptoms, but allow you to spread it to someone who could die from the infection.

When Others Want to Gather

Perhaps the most palpable feeling of this tragic twist to the Middle is the feeling I suspect we all feel, right now.  A palpable urge to gather again.  To go out, to see friends, to see grandchildren, to see family.  To shop, to be with people.  We all ache to do so.  Why not if the disease is in retreat?  Why not if we are immunized?  This is THE question for the Middle.  And the answer is as just stated.  By definition, the Middle is a reality in which this very deadly virus is still all over us.  Across all our neighborhoods, in the air, spreading.  Think again of the fire analogy.  If the virus is a fire, the Middle is a state in which a raging wildfire still rages.  It may be 20% contained, but 80% is still red hot.   Now, think about it.  If your house is on fire, would have dinner in it, even in a state-of-the-art fire suit?  No!  How about if the fire was 20% extinguished, but 80% of the rage was still red-hot?  No!

And so it is right now, and will be until the transmission of this virus is actually snuffed out.

So now what to do when someone you love implores you to gather?  Or even someone you just like?  What about the grandparent, the very person you fear could be killed by this virus, says, I’ve been immunized, I am the one at risk, I deem my risk is low enough I want to take it?  What do you say?  Or to the friend who has not seen your baby yet, and has been immunized, and wants to come over?

We would urge everyone to say to everyone, not yet.  Not yet here in our neighborhood where the CDC documents transmission remains in its highest category.  Not yet when over 4,000 Americans still die every day from this virus.  Not yet when the reality is very, very real, that gathering now can cause many to die.

For those wondering, really, isn’t most of the danger over, isn’t it bit crazy to still be this careful, let us all take another look at the land that is almost 70% immunized, Israel.   The death and mayhem for those over 60, those immunized, is dropping, but not the nation’s suffering.  How can that be?  Cases across the nation have not yet substantially dropped, even with over 2/3 of the nation immunized.  Why not?  Because they did take the crisis of the Middle seriously, they exulted in the End nearing, and everyone has let go- shopping, gathering, traveling, and so even in the face of rising immunization, the virus is roaring, the cases not dropping, and people are dying.  This concern is for real.

We cannot relax, even a bit, until we win.  We are winning, but we have not won, we must remain apart until it truly is safe, it is not safe, yet.

Beating the Scares on the Vaccine

The Moderna, Pfizer, AstraZeneca, and other COVID vaccines have now been given to over 160 million people!

And now we know.  These vaccines are safe.  No lasting, serious side effects have been proven to be caused by these vaccines, across 160 million people.  No one has died because of the vaccine.

And now we know.  These vaccines work.  In nations with the highest rate of coverage, Israel has immunized 68% of their nation, the number of people getting sick and the number of people dying in the target population, over 60 years old, has dropped dramatically.

Therefore, it is urgent to know the baloney, and firmly reject it, here is the baloney, let us reject it:

  1. Reject the rumor that these vaccines affect fertility, it is a rumor without fact.
  2. Reject the rumor that if you had COVID you don’t need the vaccine, you do.  I had COVID, I got immunized, had to if I wanted to stop this dying.
  3. Reject the rumor that this is a rushed to market product.  Readers of Real Answers know this already, this vaccine took 30 years to develop, and was tested thoroughly before release, and 160 million people are proof it is safe.
  4. Reject the inane idea that this vaccine can give you COVID.  All COVID vaccines are dead, there is nothing living in them, they cannot, will not, will never ever give anyone COVID.
  5. Reject the rumor that the genetic material in this vaccine will change our DNA.  The vaccine contains a form of genetic information called messenger RNA, or m-RNA.  m-RNA takes info from our DNA to our cells machinery to make proteins.  So when we introduce m-RNA it talks to our cells’ protein factories, it cannot even enter the part of our cell where our DNA sits.  It has been studied, and this m-RNA does nothing to our DNA.

The Direct Contact Family Quandary

The last point we will discuss in this COVID Update is a recognition of the difficulty all direct contacts face.

Again, a direct contact is anyone who has spent more than a few minutes within 6 feet of someone known to have COVID-19.

A direct contact can be anyone, can be a sibling, a parent, a teacher, a friend, a neighbor, a sports teammate, anyone.

For many direct contacts, the contact lasts a moment, their risk of catching it is limited to that moment, and the time they need to be in quarantine is timed from that single moment.  Consider a friend finding out that on March 1 they spent 30 minutes with a friend who turned out to be contagious that moment, and that they were not in contact with that friend either before or after March 1.  That person in contact is of course a direct contact, and could get infected.  About 30 million Americans have been infected this way, so why not this person?

There will be two indicators of whether this direct contact will get infected, and whether this direct contact will spread the disease to others, some of whom might actually lose their lives.  Those two indicators are:  the test and the calendar.

The PCR test takes 5 days to turn positive if you get infected.  In this example, the direct contact could have only been infected by their contact on March 1, their test if infected on March 1 will not turn positive until March 5, and so they must be in quarantine for sure through March 5.   If the test is positive, then they must remain in quarantine for 14 days from contact, or through March 14.   And, if the test is positive, they must let everyone who they have been in contact with since March 3 (you begin being contagious 2 days before turning positive on tests) that they are now direct contacts.

But what about this person if their test is negative?  The problem is that tests can be falsely negative, so to really stop the spread of the virus, the CDC, and all agree, requires that any direct contact, if free of all symptoms, and even with a negative test, stay in quarantine for 10 days after the last direct contact.  In this case, that would be March 10, even with a negative test.

So to summarize, this direct contact, with only one day of contact, can count days from that one day of contact and come up with these possibilities for required quarantine:

The test is positive and they have no symptoms- quarantine for 14 days from contact, or in this case March 1-14

The test is negative and they have no symptoms- quarantine for 10 days from contact, or in this case March 1-10

The test is negative but they have symptoms- quarantine is extended to 14 days, or in this case March 1-14

Here is the Family Quandary

The family quandary is a quandary for any situation in which the direct contact continues to be in contact for more than one day.

Let us take as our example of the quandary a family of two parents and three children, and one of the children is tested as a direct contact on their hockey team, has no symptoms, and is found to be positive on March 5, and we also know their only known contact was on March 1.    If this child has no symptoms, we must assume they could be contagious from March 3-14, and so of course, as noted already, this child is to be quarantined from March 1-14.

Here is the rub.  This child will be contagious, possibly, and likely, on March 3, and March 4, and March 5, and March 6, and March 7, and March 8, and March 9, and March 10, and March 11, and March 12, and March 13, and even March 14.  That means anyone in contact with this person can get COVID from them on any of those days.

For the two siblings and two parents living with this child the whole time, they could catch COVID on any of those listed days, including the last day, March 14.

That means each family member becomes a direct contact all over again, each of those days, and as we know even with a negative COVID test, you might be infected AND contagious, so each family member has 11 days of direct contact, and therefore, eleven calendars of quarantine.  To be specific, the father in the house is in contact with his infected child on March 3, so even with a negative COVID test, he could have caught it from him on March 3 and could be contagious through March 12 if he has no symptoms, and March 16 if he has symptoms.  That is his calendar of quarantine for the day of contact March 3.

But this father could also catch COVID from his child on March 10, meaning even with a negative COVID test he could spread the virus from March 10-20 with no symptoms, or March 10-24 with symptoms.   That is his calendar of quarantine for direct contact on March 10.

But even worse, the time the child could transmit the virus extends all the way to March 14.  And so this father could catch COVID and spread it to others, some of whom might die, even on March 14.  And his quarantine calendar for March 14 puts him in quarantine March 14-24 if he develops no symptoms, and March 14-28, with symptoms, even with a negative COVID test.

Think for a moment what that means.  Everyone in the household could of course catch COVID from the one child, but since they are in direct contact every day of his contagion, these direct contacts must remain in quarantine for 10 days (with no symptoms) or 14 days (with symptoms) even with a negative COVID test, from the last day of direct contact.  For these two parents and two siblings, their quarantine from living with the infected child, will extend from March 1 through March 28!

But it gets worse.  Say either of the parents or other two children test positive for COVID on March 10.  That could easily happen.  Now the other 3 members of the family must face the fact that their time of being a direct contact starts all over with the new case.  Those remaining 3 direct contacts in the family must know they could catch COVID from the infected parent anytime from March 10-20, and so their quarantine calendar now extends at least 10 days out from March 20, or March 30.

You can see why the reality is that once the COVID virus enters a home where everyone is a direct contact every day of contagion, the days of quarantine necessary to assure everyone they are not spreading the virus to someone it may very well kill pile up quickly.

We go through this level of detail, because only by seriously trying to stop the spread of the virus will it be stopped.  Again, immunization will NOT get us off the hook.  We only get off the hook when no one spreads this virus to someone it could hurt or kill.  That end is within reach, but the quandary of the repeated direct contact must be met to succeed.

Bottom Lines

  1. The data are in, if set up properly, in communities with low transmission rates, schools from K-12 can re-open for in person teaching without raising the risk of spreading COVID-19.  The CDC lays out just how to set it up properly, here is the link to a very clear guidance that all can now know and follow:  https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/operation-strategy.html
  2. Key elements of opening without fueling the spread of this deadly disease include, not doing so until your community’s spread is low or moderate; strictly observing masking, distancing, cohorting (pods), staggering; start with opening classrooms before sports; immunize everyone in the system; trace and quarantine and isolate infections.  All these elements must be in place for schools to be a safe place to attend.
  3. A major RACE is on.  Will we extinguish the fires of COVID with careful behaviors AND immunization, or let the fires roar, even as we immunize?  As the virus roars, it changes, it mutates, it develops variations.  We have 7 new ones just discovered here in the US.  It is urgent and critical, that we be as careful as we ever have been right now, and not pretend that because relief is in sight we can ease up.
  4. Immunizations alone are not sufficient to put out this fire.  They will help tremendously, but if we gather before the danger is put out, the danger will explode, we see this in the nation of Israel with nearly 70% immunization, but no national drop in cases because people gathered.
  5. GET IMMUNIZED!  Know the baloney that is being peddled and know that these vaccines have been given to 160 million people.  All of whom are safe, all of whom now can be confident their risk of dying from COVID has been dramatically dropped.
  6. The Direct Contact is a person who has been within 6 feet of someone known to be infected with COVID.  Their risk of catching it, and therefore spreading it to someone who could be killed by the virus, begins the first day of their contact with the contagious, and does not end until 10-14 days after their last day of contact with an infected.  In a household this could lead to nearly a month of quarantine, or more, as outlined above.

My Takeaway – In One Sentence:

We are approaching the End of COVID, but many will die unless we are as careful in this Middle of the Pandemic as we were at its Beginning, let us endeavor to save lives by NOT Gathering, Masking, Staying Distant, Avoiding Group Activities like Sports, NOT travelling, until we have truly put out this most deadly fire.

To your health,
Dr. Arthur Lavin

 

 

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