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
• 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

In this update, we take a look at the emergence and spread of new viruses and bacteria to humanity.  Spoiler alert: COVID-19 was not the first and will not be the last new health threat to humanity.

Before diving in, here is an interesting map of where contacts with others occur: https://nyti.ms/2WtKAY4

This article looks at gyms, malls, offices, etc. and asks, where is one really most likely to catch a virus?

A Striking Approach to Managing Re-Opening from South Korea- The Numbers are Highly Instructive:  1, 3.8, 10, 40, 95, 7200

Today, it is reported that one man in South Korea tested positive for COVID-19.  His story, the nation’s response, should teach us all across the world, including here in the US.  https://nyti.ms/2LfXgMY

The first number to share is 95.  In S Korea, they can trace the source of one case of COVID-19, 95% of the time!

The second number to think deeply about is 10.  The nation of S Korea did not begin to re-open its country to full business activity until the average number of new cases appearing in S Korea dropped below 10 new cases in the nation a day!

Before we go further, it is important to spend a moment to consider what this nation of 54 million, a democracy like ours, has achieved.  Imagine if we achieved the same level of understanding and care.  We would not open businesses until our nation had dropped to 60 new cases a day, and we have achieved 95% effective contact tracing.  Instead, we actually have no idea who is infected, let alone achieved effective contact tracing.  Just citing who has tested positive, which we know is missing at least 50% of our cases, the nation had over 20,000 new cases yesterday, nowhere close to 60.  The notion that this, our democracy, could know with confidence where each of those of us who have tested positive caught the virus, 95% of the time, seems impossible.  But that is what the democracy of S Korea has achieved.

This difference in performance meant that S Korea never had to shut down, because instead of asking everyone to isolate, they achieved the ability to isolate mainly those infected and exposed, keeping business open.  What is the result of effective, democratic functioning?  The virus still has raised unemployment in S  Korea, but the increase in South Korea was from 3.3% before the pandemic, to 3.8% by the end of March https://tradingeconomics.com/south-korea/unemployment-rate

Now we return to the one man diagnosed with COVID-19 on Saturday in S Korea.  What was the nation’s response?  It was what so many are talking about, contact tracing.  Here is what that means.   That Saturday, this one man had gone to 3 nightclubs.  In S Korea, people going to busy places of business sign in, so they could trace all his contacts from all 3 nightclubs, as well as all the places he had been while possibly contagious.   The number this one man had contact with was, 7,200 people.  South Korea found all 7,200 contacts, and tested them all.

Now guess how many of the 7,200 contacts tested positive?  According to the government, 40.  All 41 cases, the one man and 40 contacts who are positive are in isolation to stop further spread.  And given what the nation learned, they closed all nightclubs and bars.

We promised these numbers would teach us.  Here is what I have learned:

• A serious, well-functioning democracy facing a serious threat to its citizens’ lives will learn how to know where the threat exists, in deta
• The first step in achieving this, which S Korea demonstrates is in fact doable, is to know as close to 100% of who each infected person is.
• The second step is knowing who that person may have spread it to, test each of them (the contacts) and see who else is infecte
• The result is that in a democracy that has achieved good management of this pandemic, a high percentage of cases will have known sources, we would know who is infected, how they got infected, all towards isolating enough of us who are infected to achieve the ultimate aim- slow its spread to reduce the number to be killed by the virus.  In the case of South Korea, this democracy has achieved knowledge of sources of each infection at a level of 95% of the time.
• And finally, here is the benefit.  With this level of knowledgeand management, South Korea’s economy never had to shut down.  It’s unemployment is at 3.8%, its new case rate is under 10 per day, and, since April 16, their daily death count has never exceeded 2 a day!  Here is the result when such knowledge and management is not attempted, our unemployment is catastrophic, our daily new case rate is 20-30,000, and our death rate is about 2,000 deaths a day.

The Reality of New Germs, New Diseases

Three sources of new health dangers are worth noting, credit goes to Fareed Zakaria’s newest Op-Ed for highlighting these three:

The Population Explosion

Take a look at the trends in human population growth over time, here at https://ourworldindata.org/future-population-growth

The good news is that the rate of increase in our population seems to be slowing for the first time ever, starting in about 1980.  But the total numbers appear to be going to go up until about 2100.

One thing is for sure, as human numbers rise, the amount of food we need to survive rises too, and the amount of the land area of the planet we live on and farm rises too.  And so weclear out forests, plant fields, grow our cities, and each of these steps bring us closer to wild animals.

Did you know that most of the viruses that make us ill originally evolved in animals?  About 75% of our infections came from animals.  In fact, much of our disease experience really took off about 10,000 years ago when someone came up with the idea of farming.  Prior to that we only really came close to animals in hunts.  After that we began to live with cows, pigs, horses, which gave us the flu, measles, and many other diseases.  The process continues to this day.

Anytime humanity chops down another barrier and draws closer to animals, new diseases appear.  This can happen from simply getting nearer, but happens faster if we eat the new animal.  AIDS only exists in humanity because we started eating more chimpanzees.  Ebola, SARS, MERS, all came from increased proximity.  As we cover more of the planet and start being driven by hunger to eating more types of animals, we will see new diseases appear.

Factory Farms

One solution to feeding billions of people meat is to raise sources of meat- pigs, cows, chickens- in vast factory-sized farms.   This requires packing zillions of animals together, a recipe for mass death of the livestock as it serves them up for bacterial and viral epidemics.  The bacteria are managed with massive use of antibiotics.

Now, one cannot conjure up a plan more likely to breed super-bacteria that cannot be killed by modern medicine any better than packing countless animals together to breed astronomical numbers of bacteria, expose them all to all known antibiotics, and then let the animals and bacteria breed.  The result?  Guaranteed- deadly bacteria that can kill humanity with no known antibiotic able to cure us.

Climate Change

One of the greatest killers of all time has been malaria.  Over time, it has killed hundreds of millions of humans, more than any but a handful of infections.

Now, did you know that the United States has its very own malaria line?  Since 1763, two surveyors drew a line across what would become the United States.  Below that line, malaria was common in the US until the 1940’s.  Above that line, it was common only when imported, but most of the time we did not see malaria north of that line.

The surveyors?  Charles Mason and Jeremiah Dixon, hired not to delineate malaria risk zones, but to draw the straight line boundary between Maryland and Pennsylvania.   But ever since, the Mason-Dixon line also nicely demarcated the South and the North in America.

Why was there less malaria North of this line?   Winter.

But as climate change warms the planet, the mosquitoes carrying malaria, and yellow fever, chickungunya fever, and dengue fever, will be flying north of lines like the Mason-Dixon line.   Malaria is currently not circulating in the US, and we have a vaccine for yellow fever, but we have no way to protect ourselves from chickungunya fever, and dengue fever.  So as the planet warms, and we are seeing warm, and the mosquitoes carrying disease begin to be able to live around us here in Ohio, and we are seeing their range expand, we will see tropical diseases erupting across the world where once we did not.

Severity

An Update on COVID Vasculitis in Children

Readers of Real Answers are likely familiar with the tragic development that some children with COVID-19 have developed serious inflammation of their blood vessels, a situation medically called vasculitis.

When blood vessels inflame near the skin, it changes the color of the skin, so many people with a vasculitis will have a strangely colored rash.   If the blood vessels get inflamed severely enough, they have trouble delivering good blood flow, and blood pressure can drop, and if that drop is severe enough that is shock.

The children affected by severe COVID-19 vasculitis now number as many as 73, and cases now are appearing in more states, including still New York but now also California, Louisiana, and Mississipi, here is the latest update: https://nyti.ms/2WGMtRl

Tragically, this COVID-19 vasculitis is being seen in toddlers, one of the 3 American children who died of COVID-19 vasculitis was only 5 years old.

This is a new disease within a new disease.  COVID-19 is a new infection, still only 5 months old.  COVID-19 vasculitis in children is a new disease caused by COVID-19.

Doctors who have treated children with COVID-19 vasculitis, and I was privileged to speak to a colleague who has seen children with this just a few days ago in NYC, report that the children look similar to children who have had some already known diseases.   The rashes these children have, the inflammation of their hearts remind them of Kawasaki’s syndrome and their sudden loss of blood pressure, of Toxic Shock Syndrome.

But we should be clear.  COVID-19 vasculitis in childhood is NOT Kawasaki Syndrome or Toxic Shock Syndrome, or a combination of both.   It is its own new problem, and we now have to learn about it.

For parents it is urgent that we keep in mind that not all rashes indicate vasculitis, or COVID-19.  No, babies will still get diaper rashes, kids will still get mild rashes with fevers, eczema still will be common, none of these common rashes even suggest vasculitis.

Here is what to watch out for and call us for worries about COVID-19 Vasculitis in Children:

1. NOT a typical looking rash, but an angry, often purpleappearing rash.  It looks like a deep stain rather than light red dots that make up most innocent rashes.  Here is a link to a picture of “COVID toes” which illustrate how the skin looks when a vasculitis is present:   https://www.ctvnews.ca/mobile/health/coronavirus/pediatricians-warned-about-covid-toes-in-children-infected-with-covid-19-1.4913770?cache=yes?clipId=68597
2. An intensely red tongue, some say looking like a strawberry.
3. Very intense, and sustained fever.  Fevers of 104-5 lasting for many days are of concern, particularly with the other symptoms listed here.
4. Sudden loss of vitality.  This could be a sign of dropping blood pressure.

Should your child develop any of these symptoms call us for help right away.

Very importantly, stay tuned.  Our hope is that this condition, now being dubbed PMIS or Pediatric Multi-System Inflammatory Syndrome stays incredibly rare.  So far only 73 of 100 million children in the US have been identified with it, but it has spread in where it is seen and in numbers, to date.  So stay tuned, if it continues the nature of PMIS will almost certainly change, we will keep you updated.

Treatment

We conclude our overview of the COVID-19 Pandemic with a look at three important developments when it comes to treatment.  One is taking place everywhere right now, including of course at Advanced Pediatrics.  Two are hopes.

Telehealth

Members of Advanced Pediatrics have had access to telehealth services for over a year, but the arrival of the COVID-19 Pandemic and our lock-down has pushed us all to actually use these services.  RIght now an astounding 80% of medical care today across the United States is being delivered by telehealth.

Our brand of telehealth is called AP Televisits, provided in an app we use called Healow, fully embedded in our outstanding electronic medical record and all its privacy protections and connections to your chid(ren)’s medical record.

Even before the pandemic, we have felt that telehealth offers some very important advantages to care, mainly in relation to convenience.   With telehealth, families are spared at least two trips per visit, the trip to the office and the trip home.  In time, we look forward when we all go back to work, to establishing regular access to telehealth with three screens, the child at day care or school, the parent at work, and the doctor, opening up for the first time the option of getting necessary medical attention without having to leave work and pick up your child.

Some years ago, we looked at technologies that will allow parents to place a light in their child’s ear and sending images of their eardrums to us via telehealth by cell phone, even digital apps on your cell phone that allow us to examine lungs and hearts by telehealth.  These applications are still being studied by us, but stay tuned, we are confident this is the near future.

As we move to use of easy-to-use technologies that allow us to get together without any travel, a major shift in practice is underway.  What remains is our close relationship with all the families in the practice, we will still be seeing you even in telehealth!  Also, what remains the same is that what Dr. Hertzer and I do is share information.

That is our value, and remains our value, our ability to understand your situation, share our insights and relevant guidance.   The main difference emerging is how that information flows.  It may not require actual being in the same room for information to flow just as well.   We hope that insurers and the government continue to recognize the flow of information by telehealth (audio with or without video, that is phone and video) is as valuable as in-person care and can continue to be compensated in a similar way.

One more item that will not change, though, will be a broad range of situations, that still will require being together in-person for a long time to come.  This includes giving immunizations, but also some concerns that require hand on evaluation and examination.

Vaccine Update

The next two overviews on treatment do not yet exist, but just might.

On the vaccine front, many companies are moving to clinical trials.   Johnson and Johnson, for example, is set to go this September for these trials.  Right now, they are gearing up to be able, should their vaccine prove that it really works and is really safe, ready to manufacture 1 billion doses!

Vaccines essentially put something into our body that gets our immune system to believe it has had the illness, so when the real thing hits, the germ has no chance.  As noted before, this idea has worked before, think of polio and smallpox, they are gone from our lives.

But first a vaccine that will really eliminate the chance of getting COVID-19 and will not make us sick needs to be proven.

Passive Immunity Update

Another promising idea has to do with passive immunity.  Vaccines are active immunity, something activates your immune system to create the protection.  Passive immunity simply means placing the protection all set to go into the body, so our body receives protection, but does not generate the protection.

One example is the work of Regemeron, which has created a way to manufacture batches of antibody to SARS-CoV-2 virus.  This is a company that used this approach to effectively provide real protection from Ebola.  It is being tested now, and entering clinical trials in the next few weeks.  Again, it has to be proven to work and not make people sick or harmed.   And, even if it works, it only lasts for a bit of time.  Think about getting a dose of this antibody, and it keeps you from getting COVID-19, but the body will metabolize it so it never stays for long, long times.

Even so, we just might have an injection of antibody to SARS-CoV-2 virus, keeping us safe from infection and getting COVID-19 and suffering all that it can cause.  Perhaps as soon as later this year.  The company is right now developing manufacturing ability to make hundreds of thousands of doses available later this summer.

BOTTOM LINES

We take a step back, a broader view of trends this post.  Highlights include:

1. The emergence of this tragedy of a new disease seems so shocking and unexpected, but new diseases showing up are the norm of life.  And by the growth of humanity on the planet, the crowding of livestock into massive dense herds, and the warming of the planet, we are poised to see such new diseases emerging more and more commonly.  We have seen this increase in frequency over the last 40 years, so it will almost certainly continue.
2. Most tragically, the near perfect invulnerability of children to tragedy from COVID-19 has been pierced, not shattered, but pierced.  PMIS, or the vasculitis of COVID-19 in children has emerged in the last few weeks as a real and rarely deadly event in this pandemic.  It remains rare, but seems to be spreading slowly.  This post notes the key signs to watch for, and which fevers and rashes are NOT worrisome.
3. Telehealth.  It has arrived, we hope it stays.  How convenient!   Advanced Pediatrics has been able to provide this service for a long time, now families are finding out how easy and effective it is.  Stay tuned as we explore how to make this a permanent new feature of how we see you to offer care.
4. Vaccines.  Hope is in the air.  But hope is not yet a solution.  But clinical trials are starting by the end of the year.  Factories to make enough for everyone are being built ready to go once a vaccine that works.  The hope is that a vaccine just might be available sometime in 2021.
5. Passive immunity.  Again, more hope. If this path works, doses of antibody to the SARS-CoV-2 virus which could protect us, might be available even this summer.
6. We close with the lessons once more from South Korea.  As we re-open the US, so many times we have heard that identifying, contact tracing, and isolating will be central to success.  Failing that, all agree that the inevitable outbreaks will erupt into raging flares.  South Korea, a thriving democracy of over 50 million people, has achieved the ability to know who is infected, with 95% chance of knowing each cases’ source.  This Saturday they found one person infected, traced all 7200 contacts and tested them all, found 40 contacts infected, and isolated all 41 of the infected.  They are able to knowhow their virus is moving, so they know how to stop it.  That is why their unemployment rate deep into the pandemic remains less than 4% and why they can keep their economy far more open than ours, safely.

To your health,
Dr. Arthur Lavin