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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 June 28, 2020: Keeping Children Safe with More than One Household, COVID-19 Rampant, One More Organ the Virus Attacks, Books for Kids on Racism

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.

 

Spreadability

The Challenge of More than One Household

Since the outbreak of the COVID-19 Pandemic, families with children in more than one household have often struggled to find a path that protects their children while at the same time maintaining pre-Pandemic routines of living with both separated or divorced parents.

A fundamental reality about each of us is our uniqueness.  This is true whether parents remain married or separated.  While married, the differences that exist between any two people still create one household, so the risk of being infected with SARS-CoV-2 virus is not affected by the unavoidable differences between any two people.

But once parents separate and create two different households, then the differences that are inherent between any two people are now expressed in the differing realities of each now distinct home.

When it comes to the risk of being infected with the SARS-CoV-2 viruses, these inevitable differences often are seen in the level of exposure to the virus in the two homes.  When trying to gauge that risk, it is very useful to try to get at least a rough estimate, a sense, of the contact number experienced in each household.

For any home, everyone in that home brings home all the exposures that each member of that household experienced every day.   We can think about the level of exposure we each bring by going in stages from no exposure, to big exposure numbers.

The zero exposure level is achieved whenever a household cuts itself off from all contact with others outside the home for a sustained period of time.  This is very hard, if even possible, to achieve.  Even having your food delivered creates a possible contact with another person outside the home.  And, further, viruses such as SARS-CoV-2, do travel in the air, and so theoretically could pass from person to person without actual contact or exposure.   But it is fair to say that one household, essentially cut off from contact with any other people, has a very low risk of transmitting the new coronavirus within the home.

Now, take one person from this household, and have them leave the home and be in contact with someone else, say one person at a small office.  And now let’s say that one person has been in contact with 25 people outside their own home- at stores, restaurants, and such.  Well, now that one person from our household possibly brings home the viruses that those 25 people are contagious for.  We can say our household’s contact number has gone up from nearly zero to 25.   It can go up much faster, of course.   Say two adults in our household go to work, and in each office there are 50 people they come within 6 feet of during the day.  And each of these 50 co-workers have 25 contacts.  That becomes 50×25 plus 50×25 contacts being brought home, or 2500 contacts!   In case you think such a number is impossible, consider the one 29 year old who went to 3 nightclubs recently.  Since he did so in South Korea, they were able to find everyone he came within 6 feet of that one night, and the total was 7,200, of whom 100 caught COVID from this one person.

Now, back to our home.  How to decide what to do outside your home in terms of risk of catching COVID-19?  Again, I like thinking in terms of contact numbers.  And, I like to think about inside v. outside, since preliminary information suggests that catching this disease is 18 times less likely outdoors than indoors.  And, distance does count, big, viral transmission from more than 6 feet apart is far less likely than within 3 feet.   From this point of view kids playing outdoors, if they keep 6 feet apart, is pretty safe, not much contact occurs, and each of our kids coming home from such time brings little increased risk into our home, but that’s if they stay outside and stay 6 feet or more apart.

What about visiting grandparents?  If the home really has sustained a zero contact experience, there is little risk to anyone from your visits, including grandparents.  And, if the grandparents are a zero contact home, there is little risk they will infect you either.

In fact, two households with zero contacts can visit each other with little risk, if they really have sustained a zero contact level of exposure.

Now we come the instance of two households, each with a separated or divorced parent, what is in the child’s best interest, how to manage differences?

The first observation comes back to what we opened with, take two people, any two people, and guaranteed, you will find differences of opinion, style, approach, feeling when it comes to…   …anything, including how to manage the risk of being infected with the SARS-CoV-2 virus.  So the first point is that both parents should accept the reality that they will differ on what to do, it is a given.  So we do not recommend that an expectation that both households must agree in their thinking in order to agree on a plan.

So let us say one household with a child’s parent has chosen to enforce a zero contact approach, but the other’s child’s parent’s home has not, whatever each parent’s reasoning.  Let’s make it more interesting and posit that the second home not only rejects a zero contact policy, but some of the adults not only go to work, but socialize in close proximity with friends and even travel by plane.  What to do?

We would recommend that the more concerned household do the estimates on contact numbers.  Let’s say the more open household has one parent working, coming into contact with say 500 possible contacts.  Now let’s add up all the friends and their friends that she or he visits, and say that adds another 250 contacts.  And let’s add in just one flight, with 200 people on board, each with 50 contacts, for an additional 1000 more people who might be contagious for various viruses.  And let’s assume the work, the get togethers, and the flight are all indoors.  That totals 1,750 contacts who those adults in that household are bringing potential viruses into their home from.  And, so the children in that home will also be in touch with up to 1,750 people’s viruses, might catch some of them, and bring them back to the zero contact home.  Finally, let’s say that in the zero contact home are living 2 grandparents each 70 years old with diabetes.

The two parents only have a few options, as do all families with split homes for their children:

  1. Complete cessation of visits to the high contact home.  Both parents could agree that during a deadly pandemic, it makes sense to protect the children from exposure to large numbers of contacts, for the child’s health, and the health of adults in the zero contact home who are fairly safe within that home.
  2. Limited visits to the high contact home.  Both parents could agree that the children can visit the high contact home, but only on the condition that everyone keep at least 6 feet apart and outdoors.  This option also clearly reduces the chance the viruses from the 1,750 contacts in the high contact home will be spread to the children in the zero contact home.
  3. Visits to the high contact home will continue without limit.  Both parents could agree, or one parent might insist, that the children have free rein to visit as agreed to before the pandemic hit.  This option will expose the children to all 1,750 of the contacts the adults of that household bring into their home.

Therefore, we recommend that all homes do some calculation, even a very rough estimate, of their contact number, and try to minimize that count.  In the case of children belonging to two households, both households should estimate their contact number, and then come to an agreement on which of the three options they have they will choose to abide by.

COVID-19 Rampant In the United States

It grieves me to share the news we all already know, the SARS-CoV-2 virus is bursting forth across the United States.

We had two chances to avoid this catastrophe.  One was before the first outbreak, when we were amply warned, and widely aware of the danger.  We did not act, and the virus spread, causing over 100,000 deaths.

And so we did act, we embraced a national shutdown, and the outbreak slowed.  This was our American strategy.  As noted many times in Real Answers, other nations adopted a very different strategy, namely- Identify the Infected, then Isolate the Infected.  These nations also slowed the spread of the virus, but far more effectively, and have suffered thousands times fewer deaths, and currently have no serious outbreaks.

The national shutdown slowed the virus, and so we stopped this strategy, without implementing another, meaning we abandoned slowing the spread, and the result, tragically, is that the virus has agreed to our terms and is spreading, wildly.

We are now seeing over 30 states with increasing numbers of cases, with close to 20 states reporting increased numbers hospitalized.  The shift in age of cases is downward, which might reflect that the surge is being driven by young people gathering more than older people.  Makes sense, older people might see the threat of death more clearly.  But the younger age may not mean less harm, as the virus spread is lit, it will flow to everyone, including older people.   And the reports from the hardest hit states, AZ, FL, and TX, is that young adults are getting very, very sick, too.  ER’s are bulging with huge numbers of very sick people right now.

And the surge of COVID-19 is clearly not sparing Ohio this time.  Ohio was largely spared in Jan-May, but not June.  Our case numbers are climbing.  And remember again the lull and the roar of exponential rise.  It always starts with one, and then doubles.  But going from one case to 2, to 4, to 8 is not very dramatic, in fact, it is invisible.  But doubling is doubling, and once you go from 8 to 16 to 32, and then after 10 rounds reach 1,024, just go to 15 more rounds of doubling and you are at 32,768 cases, and at 20 rounds of doubling your are at 1,048,576 cases, over one million, and from just one case.

That’s the unavoidable power of doubling events, aka exponential rise.   That trend is happening, right now, right here in Ohio.  As of yesterday, we had over 1000 cases in one day, which puts us at about 10 rounds of doubling, 10 more unimpeded and we will be over 1 million, just in Ohio.

Severity

A New System that SARS-CoV-2 May be Attacking During Infection

A recent report suggests that in addition to our lungs, kidneys, blood vessels, brain, nerves, and liver, this deadly SARS-CoV-2 virus may also destroy important elements of our immune system, in particular our B and T cells.

The immune system is a highly complex web of cells all devoted to one purpose- destroy dangerous viruses and cells, while not attacking ourselves.   The immune system goes to great effort to really know details of each dangerous virus and cell in the body, and one set of cells that organizes this effort, and the attacks on these dangers that keep us alive are called T-cells.

T-cells get their name from an organ many of us have never heard of, the thymus.  The thymus sits just behind our sternum or breast-bone.  It’s big at birth, and shrinks after puberty.  It’s main duty is to create these special cells, the T-cells, that really are the brains of the whole immune system.  Every T-Cell is devoted to watching for the arrival of one molecule that belongs to an enemy virus or cell.  Say you are the T-cell devoted to watching out for the protein on the chickenpox virus, you will sit out your days doing nothing, until….     …..the day arrives and a chickenpox virus strays into your body.  Now you, the T-cell devoted to this one protein will see this protein, and then go into action.   An activated T-cell can sound a general alarm and choose which warrior cells to send into the fight to destroy anything with that protein on its surface.  The result?  Every chickenpox virus is destroyed.

The body’s DNA is able to shuffle its genes to make T-cells in our thymus to such an extent that literally trillions and trillions of distinct, unique T-cells are created, each devoted to only one molecule to be on guard for.

For reasons not known, when we hit puberty, our estrogen and testosterone hormones push the thymus into shrinking, T-cell creation slows to nearly none.  By the time you hit age 50 or 60, you might not be able to see or find your thymus even with a microscope!

One more cell to explain, the B-cell.  The B-cell is made in lymph nodes, and this cell is the cell of the immune system that makes antibodies.  Antibodies are molecules, each of which can only attach to one molecule on a virus or cell, and work with T-cells to signal where that enemy is so it can be more easily destroyed.

Now comes new evidence, reported recently in the Times, https://nyti.ms/3dwbRzG,   raising the concern that the SARS-CoV-2 virus might kill our T and B-cells.   This would be an alarming development.  Even just hurting the integrity of our T and B-cell networks could cause devastating health consequences.   This finding also raises a possible reason why kids seem protected from harm from this deadly virus, to a large degree.  Maybe, just maybe, people with big thymuses, making tons of new T-cells, can handle their T-cells being destroyed by COVID-19.  If so, that would be kids.

Current Trends Confirm this Virus is NOT Getting Weaker Yet

One could hope as our nation succumbs to yet another huge surge in cases that the cases would be milder.  That would be proven by seeing the number hospitalized dropping, right?  Well then, the reality is that hospital rates are rising in over 16 states, and in some, dramatically, signalling that this virus has not shifted to a mild form, it remains very deadly.

On Racism

Racism is not a new deadly disease like COVID-19 caused by an alien virus, it’s a 400+ year old, deadly disease caused by just us humans.   It intersects with COVID-19 because the virus hits people who gather closely together and who have pre-existing health problems more than others.  And guess who is forced to go to work in cramped quarters, live in cramped quarters, and suffer more pre-existing health problems (like diabetes and high blood pressure) more than others?  Those we think less of, which in the US is mainly native Americans, people of color, and people with less wealth.

And sure enough, these populations, exactly, are dying of COVID-19 in rates far higher than others.

This is of course, also a moment of crisis in which our nation is considering thinking about the decision to create races, to deem one group of humanity as set apart and lesser than another.

At such a moment, we welcome a list of books the Times has identified that will help parents talk to their kids about race.  The books are written to invite the interest of a wide range of ages from toddlerhood through young adulthood.

Here is that list, we thank our friend for bringing this to our attention, and hope you find these books helpful:

https://www.nytimes.com/2020/06/02/parenting/kids-books-racism-protest.html?referringSource=articleShare

BOTTOM LINES

  1. When venturing out of your household, consider estimating contact numbers to judge how much risk you are undertaking in each setting.  This approach can be very helpful for parents who have separated or divorced and must agree across two households on how much risk to accept.
  2. When it comes to two households it might be helpful to keep in mind no two people really ever agree entirely on most things.  Accept there will be differences of opinion and approach on managing the very real risks of exposure to COVID-19.  Know that one household will almost always be more cautious and one less so.  The contact number estimate is one path to both sides agreeing, at least on the level of contact exposure generated by the practices of each household.  Then the parents can discuss how to manage those differences.
  3. The COVID-19 Pandemic is once again raging across America.  Some states are seeing the epidemic reaching to terrifying levels, such as AZ, TX, CA, and FL.  Sadly, Ohio is moving in that direction.
  4. The severity of the disease COVID-19 remains intense, it is not getting milder.  This is an infection very much worth avoiding, as much as you possibly can.  We now have to add real damage to central pillars of our immune system to the list of harm it causes.
  5. This posting offers a powerful list of books parents can use to talk about race with their children.  The catastrophe of race long-predated COVID-19, and sadly will persist long after it is gone.  But right now they intersect, and so these books can be very helpful and meaningful to help families talk about race to their children, of all ages.

As noted in a post in May, this is not the time to relax our guard.  The virus remains very deadly and dangerous, it is right now spreading widely across the US and Ohio.  Be careful, be safe, be well,
Dr. Arthur Lavin

 

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