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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 May 19, 2020: A Dangerous Time, One hospital’s approach, A Path to Stop the Pandemic, Vaccine Update, The CDC, Advanced Pediatrics Remains Available and Safely

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
  • 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

A Dangerous Time

This weekend was my wife’s birthday, so we took a drive through Chagrin Falls, a quaint village in Eastern exurban Cleveland, with some food, to find a quiet place in a park area far from anyone and fully masked.   What we saw was frankly frightening.

The day was glorious, sun shining, trees with new leaves, a truly spectacular spring day.  And in the little downtown of Chagrin Falls were throngs of people gathered like on any other great early day in Spring, thrilled to be outdoors and together.  Almost no one wore a mask, and the sense of the crowd was they were proud of that very fact!

We kept our distance, the danger was palpable.  I could almost hear the viruses crackling.

Over the last 8 weeks, since Ohio went into lockdown, we have seen the spread of COVID-19 slowed.  But more than that, our office, along with all other pediatricians, have noticed a dramatic decrease in all matters viral.  We have had fewer calls for concerns about fever, runny nose, cough, sore throat, vomiting, and diarrhea, than any other Spring in my many decades career!  Staying away from everyone keeps all viruses from spreading, not just SARS-CoV-2, and sharply reduces the number of people with all viral illnesses not just COVID-19.

When the president began pushing hard for the nation to re-open, the nation responded, it is re-opening.  And sure enough, within a few days, we began to hear from, and continue to hear more and more from, families with children with viral illnesses.  Viruses are back.  That tells me COVID-19 will be spreading more and more too.

As we watched the crowds in Chagrin Falls as we drove by, I could not help but think once more of the story of San Francisco in 1918, and my heart sunk.   In 1918, early on in the H1N1 influenza pandemic of 1918-1920, the folks of this city entered lockdown with masks, just as we have been.  And just like us, their pandemic seemed to halt.   The citizens of the city roared back outside, threw away their masks, and felt a surge of great relief, the pandemic was gone!  They stepped outside, everyone looked well, there was no virus to be seen, the coast was clear, time to celebrate being together again.  That’s the mood we saw in Chagrin Falls.   In 1918, in San Francisco, the week after the people came out to celebrate, suddenly 2000 people died, because, while they were huddled in their homes slowing the spread, the virus did not go anywhere, and so when they gathered, the virus simply picked up where it left off.

I deeply hope the SARS-CoV-2 virus will not do this.   Who knows?  Maybe it won’t.   But it remains possible that maybe it remains out there.  All evidence suggests it is.  Early indicators show upticks in cases in the US as people gather, and around the world in nation after nation, as people poke their heads out, new infections begin to flare.   One man in S Korea went to 3 nightclubs, exposed 7,200 people to COVID-19, and over 100 got infected, from one man, on one Saturday night.  In northern China where screening and tracking are light-years beyond what we are doing, 8,000 people were exposed and quarantined last weekend.  People who gathered to vote in Wisconsin, and people who gathered to protest having to avoid getting sick, got sick, with COVID-19.

So though I hope that this weekend in Chagrin Falls, and all the other towns of America where we are jumping for joy, rushing to gather again, that nothing happens, my advice to all of us is that this is a dangerous time.   We are getting together without taking steps to find out where this virus will flare.  No one can tell if a healthy looking person is contagious or not, no one, and their are plenty of people who look healthy who are contagious.  These days, these weeks, are not times to let go, they are actually likely a critical time to be careful.  As the nation embraces an almost giddy desire to forget about it all, have some fun, hang out together, play in the Spring, the virus will likely takes its opportunity to start spreading a lot more, making any contact now more likely to transmit COVID-19 rather than the hoped for less likely chance.

What does being careful mean right now?  That’s simple to say (see below for details of how well these steps work):

  • Stay away from people.   If no one is sneezing, at least 6 feet from everyone outside your household.  If someone is sneezing, 20 feet.
  • Wear a mask.
  • Wash hands frequently
  • Stay away from crowds and crowded areas, period!

A Hospital of 75,000 people Stops the Pandemic 

Dr. Atul Gawande, who writes so well on health care challenges, recently put forth this claim:  Take 4 key steps, and you can stop the pandemic.

I am not convinced his 4 steps will actually stop the pandemic in the US, but it has stopped spread in a big hospital in Boston, one I trained in, The Brigham and Women’s Hospital (BWH).   This is a big medical center, with 75,000 people if you count all the patients, all the staff, all the doctors and nurses, everyone.  They have instituted 4 practices, and have reported no spread of COVID-19 from one person to another.

According to Dr. Gawande, no one of these steps would have a huge impact, but put all four together, and you can reduce the chance of spread by 60% (not 100%), and if 60% (not everyone) does these four steps, his claim is that the virus will cease to spread.   My own sense, it will interrupt spread in a hospital, but not clear if it will stop spread in a home where contact is more intense and lasts longer.

Here are the our steps, they will look familiar:

  • Screen everyone who enters your workplace for fever with a thermometer, and symptom screen.   Anyone with a fever or symptom goes home until well, and is considered for COVID-19 testing.
  • Wear a mask, no exceptions.
  • Wash hands before and after any chance of exposure to another person.   To be effective, he estimates one should be cleaning hands at least 10 times a day!
  • Keep distance.  At least 6 feet from everyone, 20 feet if someone is sneezing or coughing.   This is not practicable in medical practice, an exception covered with more intense PPE- gloves etc.

A Surer Path to Stop the Pandemic

A national group of strategists have recently published a guide for America that could very plausibly stop the spread of COVID-19 in the United States.  The astounding thing about their plan is that it could get us to 0 new cases and 0 deaths a day as soon as about 6 weeks from now- by the Fourth of July!  And all this achieved for $74 billion, or about one-tenth the cost of the Payroll Protection Plan.

Here is their report:  https://ethics.harvard.edu/pandemic-resilience-supplement

And here is the news coverage on their report:https://www.washingtonpost.com/outlook/we-could-stop-the-pandemic-by-july-4-if-the-government-took-these-steps/2020/05/15/9e527370-954f-11ea-9f5e-56d8239bf9ad_story.html

Essentially, this plan converts the US away from our current strategy, which is to have everyone stay isolated, towards the strategy of truly isolating those with the infection.  Our current strategy has slowed the spread of the virus, but not very well, costing us close to 100,000 lives already.  The strategy of actually taking the trouble to identify as close to everyone infected as possible, and providing facilities for them to be isolated so no spread occurs works far better.  As noted in earlier posts, 32 countries around the world have adopted this strategy and achieved 0 new case/day rates, i.e., they have stopped the virus.

Severity

Update on MIS-C

There are no reports of significant spread of the rare but serious incidence of vasculitis in children from COVID.  This Kawasaki’s-like syndrome was initially called PMIS- Pediatric Multisystem Inflammatory Syndrome.  But the CDC has now set its name as MIS-C- Multisystem Inflammatory Syndrome in Children.  There was one report of an older child who was able to share that with his MIS-C experience he felt like his veins were on fire.

Two items to update everyone on MIS-C:

  • Though the illness is scary and makes children very ill, it does not appear to be deadly.  There have been a very few cases ending with loss of life, but the vast majority of children with MIS-C recover from it.
  • The entire process of MIS-C seems to be happening after the infection, not during the infection.   The sequence is often that the child has no symptoms or only mild symptoms, the virus comes and goes, and sometime later, after the virus is gone, the very severe rash, high fever, irritability that announces MIS-C has arrived appear.  This sequence suggests that is our own immune system, not the germ, causing these troubles.   This also means children with MIS-C are likely not contagious for COVID-19.

Here is the official CDC webpage on MIS-C.  https://emergency.cdc.gov/han/2020/han00432.asp

Key symptoms and the overall approach to when to worry, when NOT to worry about MIS-C are detailed in this post from Real Answers:

https://www.advancedped.com/special-covid-19-update-pediatric-multi-system-inflammatory-syndrome-comes-cleveland/  [NOTE:  This was posted before PMIS was renamed MIS-C]

Treatment

It is a major disappointment that we have to issue this warning once more, but a recent event demands we do so once again:

DO NOT TAKE HYDROXYCHLOROQUINE, IT CAN TAKE YOUR LIFE.  

For reasons no one can explain the president announced yesterday that he is taking it to prevent getting COVID-19.

There is no evidence this drug can prevent this disease.  There is lots of evidence that it can be deadly.

So, do not take it, please make sure elderly relatives who may be desperate to avoid infection do not turn to this drug.

The last time the president touted this discredited therapy, the nation’s sales of it went up 46-fold.

Use of this drug will almost certainly spike again, please make you and those  you love don’t follow along.

Vaccine Update

The real update is that no vaccine is available today and none will be available for quite awhile, at least until 2021, with a very outside chance of later this year.

There is a flurry of excitement right now because some very preliminary results look promising.   Specifically, a company just announced they gave their very experimental vaccine to 45 people, all young adults, and they found that the blood taken after vaccination from 8 of these adults stopped SARS-CoV-2 virus from infecting human cells in a lab.

The excitement that is real is that this type of vaccine, based on injecting patients with bits of RNA, a new vaccine technology, gave the first evidence ever of doing something to suggest it might work.   That is exciting, and far better than these very early tests being a complete bust.

But it is a very far cry from anyone getting a COVID-19 vaccine and finding they are not going to catch this disease.  No one has achieved this yet.

The CDC

We close today’s post with a word on the Centers for Disease Control and Prevention, the CDC.

One this we have all learned all over again through this COVID-19 pandemic, is that there is an art to stopping a rampaging germ.

All of life is intelligent.   All life only exists because it has found a path to live.  Did you know that 99% of all species that every lived are now extinct?  Not because of humanity’s destructions, but because most forms of life simply fail to stick around and continue to reproduce and thrive.  That means all forms of life that exist today have survived a real gauntlet, they are all top experts in staying alive and spreading.  Viruses are no exception.

So, if a germ pops up, new or old, and gets a chance to go wild, it is far from simple to stop it.   In fact, humanity has had a horrible track record stopping germs.   Every attempt over the last 100,000 years has ended in abject failure with one epidemic after another ripping across humanity.  There were hints that people were curious about whether a particular something spread the plagues and epidemics.  In ancient Greece, Rome, in China, India, in the European Middle Ages, people wondered, but no one every came up with enough evidence to actually stop a disease from spreading, until the 1800’s.

In 1808 Antonio Bassi in Italy, in 1847 Ignazio Semmelweiss in Vienna, in 1854 John Snow in London, in 1860 Louis Pasteur in Paris, and in the 1880’s Robert Koch in Berlin together forged the germ theory of infection, to a level that allowed each to demonstrate that real knowledge could stop a germ from causing disease.

It should mean a lot to us today, as this germ runs rampant killing so many of us, that it took humanity at least 100,000 years to figure out how to stop a germ.   And once we did in the 1800’s, it took a huge amount of work to figure out not just that germs caused infections, but how to really stop them.

But that work has paid off, we have had successes against disease no one could have dreamed of even a couple of hundred years ago.

This success reached a staggering level of success in modern America with the creation of and continued development of our CDC.  At its peak, there was no other agency in the world, really the history of the world, that could stamp out disease better than the CDC.  Its start goes back to the 1940’s, did you know it was that its first success was to eliminate malaria from the United States?    Malaria.  Still raging around the world.  A disease that defined much of US history.  It was malaria that nearly wiped out European colonies in the early British days,  crushed the British attempts to win in the South during the Revolutionary War, and actually defined many realities of the Civil War.  But thanks to the CDC no one in the US has caught malaria since the 1940’s.  And that is just the start, the CDC has won battles against disease all across the US, and around the world.   It reached a peak of power in the Bush and Obama years when it was central to the success of stopping the first round of SARS in 2003/4, the Ebola epidemics of 2013-16, and the last pandemic- H1N1 influenza pandemic of 2003/4 where the CDC achieved a death rate in the US that was 56 times lower than the average death rate globally.

But for reasons that are still unknown, the CDC has been crippled lately.   Its devastation came at a bad time.  Roots of trouble might be traced to the infiltration of politics into science dating back to when stopping AIDS used to be politically controversial.  During the early 1980’s the Reagan administration actually stymied work at the CDC to battle the emerging pandemic leading to a uproar that opened up the gates, but his successor also interfered with basic science by trying to block CDC help in Africa on the spread of AIDS.  These restrictions were lifted by the second Bush presidency which embraced a full-throated approach to halting the spread of this virus in Africa, saving millions of lives.

But for reasons that will have to be sorted out, the world stands in shock at how shackled the CDC has been during this pandemic, the sort of challenge that had once been routine.   In all past major outbreaks of infections since World War II, Americans, and the world, have expected that most announcements, most guidance, most information, most plans, most responses would be issued by leaders of the CDC.  But not this time.  The change has been so extreme, that we now know that a detailed set of guidelines for how to re-open the nation was actually forced into retraction, no one has seen it, just a very weak version.  We do not hear briefings led by the CDC, we do not hear of crack epidemic teams from the CDC working the problem.  Mostly silence.

Well aside from any political considerations, the history of humanity’s fight against epidemics should give us pause.  It took so many thousands of years for humanity to achieve any protection from the wiles of living organisms that happen to kill us- epidemics.   The rise of the CDC represented a great triumph of humanity, using science to stop epidemics.  How strange to suddenly disarm.

We hope that very, very soon, whatever has stopped the CDC from helping humanity stop this new threat, will allow this jewel to once again save our lives.

BOTTOM LINES

  1.  It’s Spring.  The sun is shining.  Can we just forget all about this mess and go have some fun?  NO.  Sorry, but the SARS-CoV-2 is soaking the planet right now, including America, including Ohio, including Greater Cleveland.   Romping about, close to others, with no masks is asking for an outbreak.  If we are crazy lucky, there will be no viral outbreak soon.  But if the virus acts like any other known virus has, I fear for large outbreaks coming soon.   KEY MESSAGE:  We expect this virus to have started spreading a lot more all over, this is not a time to forget, but to remember, being outside the home is likely far more dangerous now than a few weeks ago.
  2.  But our nation has the chance to change all that, by changing our key strategy.  If we shifted from relying on everyone being isolated, to instead isolating all people infected, we could stop the spread of the virus, for as long as this new strategy was practiced.   It has been shown that we could shift our strategy and be in a new world, the world 32 nations currently live in, by this Fourth of July, for a tiny fraction of the cost of not doing so.
  3. DO NOT TAKE HYDROXYCHLOROQUINE to prevent or treat COVID-19 unless you are in a formal trial of the drug or in the ICU.   It does NOT PREVENT COVID-19 and some people who take suffer fatal heart rhythms.
  4.  There is no vaccine for COVID-19.  Some leads are encouraging and that’s great, but that is a world away from actually having a vaccine that works.
  5.  Let us hope the CDC, once one of humanity’s crowning achievements, and a reliable guide to controlling epidemics and pandemics, saving so many lives, is supported once again to take the lead on this pandemic, we need them now.

And at our office, we will continue to be as careful as possible to limit exposures.  We have universal use of N-95 masks and gloves by all doctors and staff, Ready to Room flow, nearly empty office at all times, and strong use of AP Televisits to keep everyone safe, while at the same time we ensure infants and toddlers get their initial immunizations, and remain available to you for all your health needs.

To your health,
Dr. Arthur Lavin

 

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