November, 2020 - COVID UPDATES
Misinformation & Politicization of the Pandemic
It is honestly impressive the extent of misinformation and politicization has been running rampant since the start of the COVID-19 pandemic. People taking "sides" on an issue that to most in the medical community shouldn't have any sides. My goal here is not to politicize anything, I'm strictly going to stick with facts as we currently understand them. As research continues our understanding may change along with how we approach them. I hope that I can be a source of up to date information for you that you can actually trust to give you the truth.
Is COVID-19 Really as Dangerous as the Media Portrays?
I understand that it is difficult to understand what all the fuss is about. The media, regardless of what channel you watch or trust, has to sell their story and narrative to you as a viewer. Fear mongering, spin, and false narratives have become all too common in today's age. So, let's just stick to facts and see if we can understand what makes COVID dangerous. COVID-19 has been labeled a "novel" coronavirus. The reason it has been labeled as "novel" is that it is new. While there have been similar viruses in the past such as SARS, MERS, and others, this one, in particular, is different enough from anything else that we have seen that it is considered an entirely new virus. The problem with something new is that there is no known and accepted way to properly treat it. When you look at a virus like Influenza, there have been cases of Flu for generations. The last great pandemic was the Spanish Flu over 100 years ago. In that time we have developed vaccines, Tamiflu, treatments, and various other protocols to keep people alive, safe, and get them back to their lives. We have studied the Flu sufficiently enough that a majority of cases of patients with flu with mild, moderate, and even severe disease can be successfully managed. None of that experience applies to COVID-19. The antiviral medications, treatment protocols, and everything else we have used to manage the flu does not work with COVID-19. In time, as treatment protocols are developed, COVID-19 may become less dangerous and more successfully managed but the problem is that currently, there is no known treatment. There is no known antiviral, no known steroid, no known medications, vitamin, or lifestyle change that can guarantee an improvement in the course of illness... yet. That's the problem. There is no known treatment. If you catch COVID-19, for all intents and purposes, our ability to intervene and save your life is extremely limited. We treat the symptoms as they emerge, give oxygen when your short of breath, ventilate when you can't breathe on your own, but overall the course of illness you go through as a patient is unchanged and we do not know how to change that yet.
Why are people passing away from COVID-19?
COVID -19, is causing a multitude of effects that is causing fatalities. The actual statistics of which can be debated endlessly which one can see in the evening news, but suffice it to say, that it is generally considered more infectious, transmittable, and fatal than influenza. And influenza has claimed well over 50 million lives. This is a hard number to take at face value since medicine has progressed far since the time of the Spanish Flu, however it is still good to understand the numbers.
At the current state of our understanding of COVID-19 patients are dying from a variety of effects. COVID-19 has been found to cause respiratory failure, organ failure, blood clots, and a host of other effects. The exact mechanism in which it is doing this is not known and therefore the best way to treat and prevent it is likewise either unknown or currently not possible.
Let's start with the Blood clots, for some reason, COVID-19 is causing the blood to coagulate and form clots. These clots are presenting inside of organs, tissues, and various other places causing mass damage and organ failure. Currently, it is being proposed that patients coming into the hospital are placed on blood thinners to prevent these clots. However, this treatment is experimental. It is a proposed treatment that is being tried but not necessarily accepted yet. What this means is that they are giving it to patients in hospitals under the close scrutiny and observation a hospital can provide as opposed to in an outpatient primary care clinic.
Next, let's talk about Respiratory failure. Respiratory failure is essentially when a patient is unable to breathe. They take a breath but no matter how hard they try they cannot get oxygen into their bloodstream. Again, the problem is here is that we are not entirely clear on "how" it is doing this. Currently, our understanding is that it is causing what is known as a "cytokine storm". Cytokines are inflammatory markers that our bodies use to manage inflammation in the body. A cytokine storm is when these markers are released in such an abundance that the virus and normal tissue alike are destroyed in the process. Respiratory failure ensues as the normal structures of the lungs become obstructed, damaged, and destroyed. Here is where we see reports of the Dexamethasone in the news. Dexamethasone is what one might call a double-edged sword. It has one major effect - suppress the immune system. So in patients who are at risk of a cytokine storm, it is useful to suppress the immune system from creating the abnormal response that is proving fatal. However, it also the fact that you are suppressing the immune system means it is unable to properly fight the virus. There is a delicate balance of suppressing the potential for cytokine storm effect and actually inhibiting your body's ability to fight the virus. This is why again, only hospitalized patients are receiving Steroid treatments, and to give it on an outpatient basis is proving more fatal than not getting treatment at all.
Why is Fort Collins shutting down again?
Our lovely town has seen an uptick in numbers over the past few weeks as numbers across the nation are exploding. For most of the past week, new cases across the nation have surpassed 100,000 per day. The past 3 days have been over 150,000 per day. (https://www.worldometers.info/coronavirus/country/us/) In addition to these numbers exploding across the nation, we have also seen an uptick in the number of hospitalizations. Last week I received an urgent message from the DORA medical board projecting overloading of our Intensive Care Units to treat severely sick patients. Current projections are suggesting that we will reach statewide ICU capacity by January 1st if no changes are made. What it means if ICU capacity is reached is that if you become seriously injured or ill, there would be no hospital in the state that could accept you. There would be no ventilator machines, no nurses, doctors, or other providers with the ability to help you. There is not an infinite supply, the resources are, unfortunately, limited. There would be nothing to do except hope for the best. To curb this potential scenario after advisement by the medical boards the local government has decided to upgrade "safer at home" to level 2 with further restrictions on gatherings and as of today shut down all grade levels in the Poudre school district to remote learning only. You might be asking, why shut down the school districts? It has become well known that by in large, the young and healthy are not as affected by COVID as other populations. To our current knowledge, this is absolutely the case. While children are not necessarily at risk to be a serious patient, they are super spreaders. By their nature, children share and spread more germs than any other population. And all children come home to their parents. The goal here is to reduce the caseload, to reduce the number of ICU admissions so that we do not reach capacity and let people suffer through COVID at home on their own. This measure, good or bad, is intended to "flatten the curve". That's all the mask-wearing, closures, and other measures governments around the world are for - is to reduce the number of cases at any given time to levels where we can maintain our access to hospitals and Intensive care units. Some countries, such as New Zealand have been able to control to the point of near-total elimination of COVID-19 through lockdowns. This unfortunately may not be possible at this point in the USA. Though it can be controlled if proper precautions are taken
Current ICU Projections in Colorado.
What about the Vaccine Projections?
There are many vaccines currently in clinical trials. Many of them are showing early promise. As with anything they take time to develop, manufacture, and maintain. The most promising of the bunch currently in trials is a vaccine by Pfizer which is showing a potentially >90% capture rate of immunity profiles and another by Moderna with a projected 94% capture rate. Both of these are excellent numbers. But there are things to keep in mind as we all journey through this pandemic together.
1) Mutations - Despite all the political speculations of the origins of COVID-19, the fact is that all viruses mutate. That is their nature and design. It can be a blessing or a curse depending on which direction they mutate. Some form symbiotic mutations that can work beneficially with the human hosts, others seek to conquer and destroy. At this time, there are several mutations already present in COVID-19 and therefore several strains of this already new virus. So far, the mutations have been minor, and including the new strain discovered in Denmark on the mink farms, the mutations have stayed stable enough so as not to drastically interfere with the vaccines that are currently under development. This may not always be the case, it is possible that a more significant mutation could alter COVID-19 to such a degree as to make the current vaccinations under development ineffective. This is the case with influenza, it mutates so much each year that new Flu vaccines are required to address the strains that are predicted for that year. It is possible COVID-19 could follow this pattern, though if it remains stable this may not be the case
2) Safety - No matter your take on vaccinations whether you approve or not, the fact is that all vaccinations are medications, and all medications have the potential for side effects. Part of the purpose of clinical trials is not just to determine their effectiveness but to also address their stability and safety. Unfortunately, being a new virus it is impossible to know the long-term safety of COVID-19 vaccines. No vaccines will be released to the general public until the risk of long term effects is sufficiently low to allow mass inoculations
3) Manufacture and Distribution - Even if a vaccine was developed tomorrow that was 100% effective with no side effects or long term complications from it, there is the problem of manufacturing the vaccine and distributing it nationwide. Anyone who has ever operated a manufacturing facility knows there are limits on how many doses can be produced per day, packaged, quality control, and shipped. As manufacturing ramps up, there will likely be phases of distribution, those at highest risk including Healthcare providers, the elderly, patients with pre-existing conditions, and immune-compromised populations are likely to receive the first wave of doses when ready. The general population will likely be delayed a significant and unknown amount of time until a vaccine is ready for them.
At the end of the day, the take-home is that it will take time before you can walk to your pharmacy or local doctor's office and get your COVID vaccine. The exact amount of time is unknown
Do masks actually work?
Unfortunately, masks themselves have become politicized in addition to everything. Again, we are not going to get into politics and just state some facts. I would argue that both sides of the political spectrum have valid points, but they are incomplete. Let's take for example the common statement that cloth masks do not work because the virus is smaller than the pores in the cloth. Our current understanding of the COVID-19 is that the virus tends to clump together in larger droplets. They are typically heavier than air and will normally fall to the ground naturally after about 6 feet away from another person. This is a gross overestimation and does not take into account airflow, wind, and other factors but can be considered an approximation. So without any impediment virus expelled from people's nose or mouth will float on the air approximately 6 feet until landing on the ground. They can travel this far because of the momentum they have when exiting the body. Patients who cough or sneeze can actually spread a virus further than 6 feet because of the velocity viral droplets leave the body. So when you place a mask over your nose and mouth you are placing a screen in the way. While yes, the pores are indeed larger than the virus itself, they can act to deflect the virus. Imagine throwing a racquetball through a normal chain link fence. The ball is smaller than the links in the chain and theoretically could pass through it, but if you actually threw the ball, you are more likely to hit the fence and deflect the ball in a way that it could bounce backward or lose all its momentum. Most masks have multiple layers of fabric so even if you passed through one screen, you are likely to hit another. The mask can simultaneously capture viral particles and deflect those that pass through and disrupt the air flow enough so that the momentum is lost and viruses can fall to the ground within inches of a person as opposed to 6 feet or more. This effect can be demonstrated with this video
The mask does not block everything, but can sufficiently reduce the airflow and momentum of viral particles enough to allow it to fall to the ground faster, and more efficiently, thus reducing transmission. When all parties in a group of people are all wearing masks the safety factor is much higher
I hope this gives you some semblance that you can feel informed about some of what is going on in this crazy world. We are learning more every day and hopefully, as our knowledge and understanding of COVID-19 increases, we will be able to treat it more effectively.
Stay safe.
- Jason Rogers, PA-C