Author: Bill Stamey, M.D.

A neurologist trained in movement disorders, Dr. Stamey has no relevant financial or nonfinancial relationships to disclose. His artistic rendering is by Emily Stamey. Maine PD News receives no outside funding. www.mainepdnews.org

Online this week: Understanding Parkinson’s Disease For the Newly Diagnosed

To learn more about your diagnosis, the options available and the services we offer at MCH, join the following speakers online:
• William Stamey, MD
• Grace Plummer, LCSW
• Tina Phillips, PT
• Lisa Clark, MS, OTR, CLT

Wednesday, June 9, 2021, 3-5p.m.
Registration at www.midcoasthealth.com/understanding-pd

TOPICS INCLUDE:
• Parkinson’s diagnosis
• Medications
• Emotional issues
• Quality of life
• Caregiver concerns
• Movement and assistance
• Programs and resources

For more information about these programs, call (207) 373-6585
www.midcoasthealth.com/wellness

Please get the COVID-19 vaccine

Some public health experts anticipate that no more than 50% of eligible Americans will be fully vaccinated against COVID-19.  That is a dispiriting thought when you consider that in the early days of the pandemic it was estimated that somewhere between 70 and 80% of Americans would need to be vaccinated in order to reach herd immunity.  However, with the arrival of new variants such as B.1.1.7., which is estimated to be at least 50 times more contagious that the variants that circulated around the US last year, it is quite possible that we may never reach herd immunity, and instead we might wind up with  endemic COVID: ongoing disease in our communities and our country.

In the first 100 days of the Biden administration around 220 million doses of vaccine were given.  We had reached an average of 3-4 million doses vaccine per day in this country, but have lately seen a decline to fewer than 3 million doses per day.  Vaccinations have been opened to younger people and we should have been able to keep the number of vaccinations at a high rate.  The main reason that we are seeing the numbers trail off is because of hesitancy among those who have not gotten the vaccine.  This is a problem because the B.1.1.7. variant is circulating among young people.  Many of them have very serious complications and are being hospitalized.  In fact, we learned last week on Maine Public’s program “Maine Calling” (from Drs. Jim Jarvish and Dora Mills) that among hospitalized cases of COVID-19 in the state, over half are winding up in the ICU, and most on ventilators (a year ago 20% were in the ICU, and 5-10% on vents).  This is a more aggressive variant, and there are others-some of which don’t look good at all. In Maine hospitalized patients with COVID-19 are sicker, younger, and coming in from more rural areas.  At the time of the show 135 Mainers were hospitalized with COVID-19, average age in the 40s! The 40s! A year ago the average age was in the 70s.  Finally, we learned that none of these people were fully vaccinated, meaning they have either not had the vaccine at all, or have not made it 14 days past the final dose (dose 1 of Johnson & Johnson, or dose 2 from Moderna or Pfizer).  The good news is that more than 80% of Mainers over 60 have been vaccinated.   

It is time for trusted messengers to emphasize the need for vaccine among hesitant people.  If you have a family member, friend, or caregiver who has not been vaccinated, please encourage them to get the COVID-19 vaccine.  I know that they might have a lot of reasons why they feel concerned about this, mostly to do with safety.  There are a few key points that you could stress.

First, the vaccine is far safer than a COVID-19 infection.  When people have side effects to the vaccine, they are usually because the person’s immune system is working.  Flu-like symptoms are a good sign after the vaccine, and do not mean a person is infected.  And, there is no truth at all to rumors that the vaccine will contain a tracking device or alter your cell’s DNA-absurd inexcusable lies like that have been circulated by public figures.  I always advise people to stop listening to these people, and to get information about COVID-19 from credible medical sources.  Talk show hosts, radio personalities, commentators, politicians, and conspiracy theorists are not good sources of information regarding medical facts around the pandemic.  If your loved ones still have questions they should ask their medical doctor, and know that 95% of medical doctors got the vaccine as soon as they could. My most significant side effects after the vaccine were senses of relief and joy. 

Second, although COVID-19 infection of unvaccinated people might be mild or asymptomatic in many, those people might spread the virus to others for whom it could be deadly.  For more on that see prior articles in MPDN on asymptomatic carriers. We should recall that a year ago asymptomatic spread accounted for 40% of infections. I worry that now the number may be higher.  We are still seeing numbers of new cases in the hundreds daily in Maine. 

Third, when viruses reproduce inside of people they have the chance to mutate and form new variants.  The risk in a scenario like that is that a much more deadly variant might arise.  That is what happened during the third wave of the 1918-1919 influenza pandemic.  People were fatigued and tired of physical distancing and mask wearing. They wanted to open things back up, to gather, to go on with normal life.  Along came a more deadly wave of influenza.  In total, that pandemic killed over 50 million people across the globe, more people than bullets in World War I (1914-1918).  This was at a time when the world population was estimated to be less about 1/4 of what it is now.  Viruses kill, especially if allowed to infect as many people as possible.  We are lucky we haven’t seen a variant as deadly this time.

So please, if there is no legitimate medical reason to avoid it, get the vaccine.  Alternatively, if you think you can do it, be a trusted messenger to someone who has not been vaccinated.  Tell your loved ones that they need the vaccine too. 

Why herd immunity without a vaccine is a bad idea

There have been recent reports that Trump appointee Paul Alexander, Health and Human Services aide to Assistant Press Secretary Michael Caputo, advocated for herd immunity over the summer, even as cases were rising and people were dying.  He wrote in an email “Allow the nation to develop antibodies. Infants, kids, teens, young people, young adults, middle aged with no conditions etc. have zero to little risk… So we use them to develop herd… we want them infected.”    (1)

Normally, I would not discuss the ramblings of an unqualified person with no training in the area under discussion. In this case it matters because that person was involved at the federal level, and apparently, many others felt the same way. I have also heard from several patients in my office who stated that they would prefer “natural” or herd immunity without the vaccine.  

Herd immunity occurs when a high proportion of the population has had either prior infection or vaccination.    The 1918 influenza pandemic, which killed at least 50 million people is an example of “natural” herd immunity.  There was no vaccine.  The Black Death, which killed up to half of Europe over a three year period of the 14th century is another example. (2)

Another reason to discuss this is that outgoing POTUS as late as September signaled positively about “herd mentality” (misnomer, he likely meant herd immunity). (3) Whatever he meant by that, the lack of CDC protocol at White House meetings and the massive in-person campaign rallies (including a “surprise” rally in Maine) (4) we saw before the presidential election, and his other misstatements about herd immunity and how to gain it fit into the playbook of intentional infection.  It appears that has been the plan. The problems with this, and Alexander’s thoughts are several. 

First, young adults and children are not immune to COVID-19.  They may be less likely to develop serious illness, but some do get very ill, and some have died from the illness. (5)  People under 30 have represented over 20% of COVID-19 cases in the U.S., and may spread the virus more easily than people in older age groups.   In one study of over 3000 people between the ages of 18-34 who had COVID-19, 21% wound up in intensive care, 10% on a ventilator, and nearly 3% died.  (6)  There are also many reports of young children with severe cases. (7)  It is not a no-risk situation.   And don’t we care about young people (or any people for that matter) with underlying conditions making them at very high risk?  Making everyone around them sick and infectious is a dangerous thing to do.  The virus that causes COVID-19 is an invisible threat that spreads very effectively from asymptomatic and pre-symptomatic carriers. (8)

Second, anyone with the virus can spread it.  Alexander’s proposed strategy to infect as many young people as possible in order to develop herd immunity shows how little he understood about viral infection.  Having young people infected would not stop those young people from spreading COVID-19 to parents, grandparents, coworkers, neighbors, and so-on. Mass infection of young people would kill more people overall, and it would overwhelm hospitals, with predictable dire consequences.   Allowing an epidemic to spread unfettered is a recipe for disaster, and a foolish thing to suggest.

Finally there is a lot more to say about this, but let’s part with this thought. Viruses mutate when they reproduce (known as replication). They can only reproduce, or copy themselves, in our bodies.  In fact, that is the purpose of infecting us: to hijack our cells and make copies of the virus, a staggering number of copies.  The problem is that errors occur at a predicable rate when making these copies. In other words, you expect mutations.  Thus, the more people are infected, the more viruses copy themselves, the more mutations will occur.   It also means it becomes more likely that some horrible mutation will develop that makes the virus a more effective killer, more contagious, or some other awful outcome.  We don’t want those results, and we certainly don’t want to push the situation.  Giving the virus to more people intentionally means asking for mutations and new strains. It is a roll of the dice, a bad gamble.  We are already seeing a new strain in the U.K. (9) that is more contagious than the strain we have already been fighting. (footnote) It is almost certainly here now.  Another possibility is a mutation that makes the virus so different that the current vaccines we are finally starting to get become useless.  Remember from my last post (10) that a vaccine triggers an immune response to some part of the virus that the body can recognize as foreign.  If that part changes, the existing vaccine will not help, because the immune system will not see it. Think of it like this, the police is looking for a man, but they have only a photograph. Like Humphrey Bogart in Dark Passage, the man gets plastic surgery. The police does not recognize him.

It is a lot to think about.  

Do your part please.  Wear a mask or appropriate facial covering, stay at least 6 feet apart, wash your hands, don’t touch your face unless your hands are clean, don’t congregate in groups, and be COVID-aware.   Please be very careful on Christmas and the other holidays.  Public health officials are asking people not to travel and not to gather because the epidemic in the U.S. (and in Maine) is worse than it has ever been, even as above – we likely face a more contagious strain from the U.K. circulating around us.  If you must see others over the holidays, remember risk is compounded by time and exposure. (11) The more exposure, and the longer the time, the more likely you are to catch the virus.  Be smart.  Even writing this I know that it hurts not to see the ones we love, but isn’t avoiding risk a way of saying “I love you”?  And for that matter, isn’t getting the vaccine the same?  Herd immunity without a vaccine is a bad choice.  Make a good choice. 

Stay tuned to the Maine CDC for a schedule of vaccinations, or check with your doctor.

footnote: for a discussion of the contagiousness of COVID-19 and the reproduction number, see COVID-19 questions in MPDN, March 2020  https://mainepdnews.org/2020/03/28/covid-19-questions/

REFERENCES (as of 12/23/20)

1. https://www.theguardian.com/world/2020/dec/17/trump-appointee-urged-herd-immunity-covid-paul-alexander   

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4013036/#:~:text=The%20Black%20Death%20was%20one,1%5D%E2%80%93%5B3%5D.

3. https://www.usatoday.com/story/news/politics/elections/2020/09/15/herd-mentality-trump-again-asserts-coronavirus-disappear/5812463002/

4. https://mainepdnews.org/2020/12/06/covid-19-on-the-rise-what-to-do/

5.  https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too

6. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2770542

7. https://mainepdnews.org/2020/07/16/covid-19-update-in-and-out-of-maine/

8. https://mainepdnews.org/2020/05/29/risk-and-the-asymptomatic-carrier-of-covid-19/

9. https://time.com/5923758/new-covid-strain-uk/

10. https://mainepdnews.org/2020/12/17/are-you-planning-to-get-a-covid-19-vaccine/

11. https://www.erinbromage.com/post/the-risks-know-them-avoid-them

Are you planning to get a COVID-19 vaccine?

According to polls, up to half of Americans will answer “no” to that question.  There are a variety of reasons for this.  Fear of the unknown is a common problem.  It is also impossible to make an informed decision about something that is not understood.  Maybe we can get a little bit of a handle on that here in a few words.  Let’s get to know this vaccine.

First of all, we are actually talking about more than one vaccine.  The first vaccine against COVID-19 to be approved by the FDA was the Pfizer vaccine.  Close on its heels, and likely to be approved any day now is the Moderna vaccine, which was discussed in the July MPDN article “Some good news about a promising COVID-19 vaccine.”

Pfizer and Moderna are both messenger RNA (mRNA) vaccines.  These vaccines use the machinery of the cell to manufacture proteins that the body can then recognize as foreign.  That is important, because this is how the immune system works (and using the immune system is how you fight off viruses). Under normal circumstances, if you are infected by a virus, for instance a cold virus, the virus will have proteins on its outer surface which are different from normal proteins in the human body.  Our immune system monitors the body for unusual proteins.  When these are found and recognized as foreign, the body targets and destroys the virus.  One way to imagine this might be to think of a hospital. The staff all wear a hospital ID. A person with the wrong ID would be recognized by security as someone who doesn’t belong. Hopefully, they won’t be destroyed, but you get the picture, right?

How do RNA vaccines work?

In the body every living cell contains DNA, the genetic code.  This genetic library contains all the information needed to make you, to repair injuries, to make proteins, and so on.  It works like this: DNA is a template.  Your cell can use small sections of your DNA to make mRNA.  That mRNA leaves the nucleus where the DNA is located to be used in machinery within the cell called a ribosome to make proteins. I know, it sounds complicated, but stick with me. Usually proteins serve some function in the body, for example building muscle cells. So, again, DNA makes mRNA, which makes proteins, which build things like muscles, or maybe tiny proteins on the surfaces of things.

Some very clever people have taken a look at the virus that causes COVID-19 and found that when we have an immune response to this virus we make a lot of antibodies against something called the spike protein.  The spike protein is the business end of the virus, and if it is targeted the virus will likely be destroyed. 

The Pfizer and Moderna vaccines contain mRNA that will be used by machinery of the cell to produce a molecule that looks like the spike protein. After doing this, the mRNA will degrade. To those that keep saying it will change your DNA, no, it will not do anything to your DNA-wrong direction!  Cells will then kick the new foreign protein made from mRNA out, and the immune system will see this foreign protein and develop antibodies against it.  The great thing about the immune system is that it tends to remember foreign invaders.  That is immunity. While we are not sure how long this memory will last for this particular invader, most of us believe vaccination will stop this pandemic if enough people take it. That is why we need you.

Some people are worried about potential side effects. Fair enough, but so far the data doesn’t show a lot of reason for concern. In studies some people experienced flulike symptoms following injection of the vaccine.  Flulike symptoms actually mean the immune system is working, not that the person was infected-as I have heard people guess. Those people couldn’t be infected by the vaccines, because no virus was injected. 

Amid the billions of people vaccinated over the next several months we might wind up having a relatively few people with serious side effects. If you give every person on Earth an aspirin the same thing will happen. That level of risk is not a good reason to skip the vaccine. Think of the odds in relation to you. The overall risk associated with receiving the vaccine has so far been very low (usually only minor symptoms among a minority of patients); whereas the risk of serious illness from COVID-19 is about 20%, and death from COVID-19 is somewhere around 2-3% for the general population (much higher for older and chronically ill individuals). Generally, your odds are much better with the vaccine than without. 

Finally, be careful where you get your information about this.  Talking heads, politicians, some commenters on Facebook, and other uninformed sources are not where you should be getting medical advice.  Defer to an expert.  Talk to your doctor, check with the Maine CDC (or listen to the updates). And, get in line for a vaccine. This is how we are going to defeat COVID-19.

COVID-19 on the rise, what to do?

As of yesterday, the date for which the latest data is available, there have been 11,801 confirmed and 1547 probable COVID-19 cases among Maine residents since testing for COVID-19 began.  This is a combined 13,348 cases, but does not include positive test results from out-of-state visitors or part time residents whose official residence is in another state.  The total also does not include those that were never tested and told to shelter in place unless symptoms became severe.   And yes, that still happens.  If a person has a known infection and a household contact becomes symptomatic, many are not being tested.  There are also those who are asymptomatic (maybe four-fold the number of symptomatic infections) who are typically not being tested unless part of a mass-testing operation at a congregate care facility, for example. 

The point is, while we are still doing better in terms of numbers than a lot of other states, there are a lot of cases in Maine, and the numbers are rising rapidly. 

The last time I reported on this on September 9, we had been seeing relatively low daily numbers: that day just 23 new cases. Generally, in August, September, and the majority of October, we would sometimes see over 50 new cases, but other times we would see a number in the teens, and the daily average was low.  Starting around the end of October we began to see higher case numbers: October 30: 103 cases, November 5: 183 cases, November 13: 244 cases.  In fact, we’ve broken 200 new cases a day regularly since mid-November.  Today there are 221 new cases. Thursday, December 3 we saw an all-time high of 346 new cases.  How did we go from 380 active cases of infection on September 9 to 3,041 today?  What changed?

It may be true that seasons had started to change and people were beginning to go indoors more toward the end of October.  I don’t think the effect was that great though, because the weather was actually pretty mild, and most days were nice.  I cannot stress enough that congregating with other people who are not part of your household is a bad idea, indoors or out. 

The virus is highly contagious, and as I have pointed out several times in MPDN, asymptomatic carriers can spread the virus and not even know it. 

You cannot tell by looking at someone that they are an asymptomatic carrier.  They cannot tell either.  Everyone should assume that they, and everyone around them can either catch or spread the virus that causes COVID-19. 

We should be standing at least six feet apart from people not in our household. We should be PROPERLY wearing and handling masks or facial coverings, wearing eye protection (yes, cover your eyes), washing hands, not touching our faces, and generally being COVID-aware.   Avoid indoor spaces with those outside of your household, and stand at least six feet apart, even if you are outdoors.    

Another issue with the rise in numbers is that people were getting together more in late October.  I don’t have data about this, but I kept hearing that friends would gather, or two different “bubbles” would meet up.  There were larger gatherings also.  One particularly egregious example was a “surprise” rally for Donald Trump at the Treworgy Family Orchard in Levant on Sunday, October 25.  According to NBC (1) “Supporters lined the streets along the route from Bangor, where he landed about half an hour earlier, to wave to the presidential motorcade… Hundreds of supporters greeted Trump at the orchard despite the event’s lack of publicity ahead of time.” 

According to the Independent (2) and other sources, the crowd grew to approximately 3,000 people.  Widely shared news coverage showed people crowded together, most not wearing masks, and voices raised.  Was this really a surprise?  That is a high number of people.  I suspect they did not all come from Bangor or Levant (Levant, which is just 10 miles from Bangor, has a population of about 2,900).  

I have made the point here before: louder voices generate more droplets, and project them farther too.  Droplets from infected people, even asymptomatic infected people, contain virus. If you are raising your own voice you have to breathe more deeply-and are more likely to inhale the droplets and virus in the air around you. 

This rally was an unbelievably reckless and unconscionable thing to do in the middle of a pandemic. I don’t think that rally alone was responsible for the massive increase in numbers, but it and other human contact has to be the answer.  And, it was the most obvious example of risky behavior in our state at the time. Speaking of time, look at the numbers: October 25, the day of the rally, the number of new cases in Maine was 64. Remember, it takes time for the virus to incubate, and for people to become ill and seek care. On November 5 the number was 183.  The rise in cases has been steady since, as have hospitalizations, and as have deaths due to COVID-19.  December 1 there were 20 deaths in one day, a record for Maine (3). The previous high number was 12 deaths on November 24.

Flash forward to Thanksgiving Day, November 26.  While apparently most people did not gather for the holiday this year, many did.  I think we all saw footage of busy airports on the news. I have had the unpleasant of circumstance of hearing about it from a minority of patients. Eating with others is a particularly effective way to give or receive an infection with COVID-19.  The CDC is clear about this when discussing food from restaurants, for example (4). The highest risk is when people eat together and seating is not spaced at least six feet apart.    Not to put too fine a point on it, but eating generates saliva.  Saliva generates droplets.  People tend to gather for Thanksgiving with loved ones, and you can’t eat with your mask on.  There is talking, laughing, etc.  If a virus is present it is likely to be spread. 

The problem is that we are beginning to stress hospitals in Maine, and if numbers continue to rise the way they are, we will exceed capacity in the coming weeks.  Think about what that means.  Put it into perspective.  During the first wave of COVID-19 in Maine our peak for hospitalizations was on May 26, when we had 34 patients in non-intensive care unit (ICU) hospital beds, and 26 in the ICU (5). For our purposes, consider the terms “ICU” and “critical care beds” interchangeable.  October 26, the day after the above rally in Levant, we had 8 non-ICU patients and 5 patients in ICU beds across the entire state.  We had sustained period of low hospitalization numbers since July.  That all began to change at the end of October, and by December 4 there were 119 patients hospitalized in non-ICU beds, and 45 in ICU beds in Maine. Today the Maine CDC reports 171 hospitalizations and 50 in an ICU. 

According to Dr. David Seder, intensivist at Maine Medical Center, about 30% of those who end up in an ICU bed at MMC will die.  As of today, 227 people have so far died from COVID-19 in Maine, about 2% of confirmed cases.  

The capacity of hospital critical care beds in Maine is 385.  At any given time there are many other critically ill patients in ICUs for a variety of reasons such as stroke, heart attack, injury, and so on.  Currently, 282 critical care beds are in use (6). Imagine when those beds are full.  If the hospital is at or past capacity your COVID-19 infection might not be treated, or at best will not be treated the way it would ideally, and neither will your stroke, your post-surgical complication, or any other illness.  In a system over-burdened, problems start to happen. And some of those problems include difficulty safely containing the virus in the hospital itself.

And, what if infection spreads through the hospital staff?  Face it, the more COVID-19 patients we see, the higher the risk of infection.  As of Friday, December 4, the Maine CDC reported 1,722 healthcare workers in Maine had been diagnosed with COVID-19 since testing began. These are confirmed cases.

What should we do with this information?  Simple, stay home.  Don’t congregate.  Don’t gather over the holidays.  Don’t go to a New Year’s Eve celebration.   Do all that you can to avoid catching or spreading COVID-19.  If you have relatives who are treating this like it doesn’t matter, talk to them. It does matter.  They might not get sick, the truth is, most infections result in only a mild illness.  But, 2% of people die. That is a lot of people, and if someone spreads COVID-19 they will have had a hand in those deaths. If they believe the absurd idea that we should all just catch COVID-19 and develop natural herd immunity, that is also a flawed premise. Maine has a population of about 1.3 million.  If 2% died, the number of deaths would be 26,000 people. But make no mistake, in a nightmare scenario like that the numbers would be much higher because the hospitals would be overwhelmed.

Do the right thing.

REFERENCES

  1. https://www.nbcboston.com/news/politics/trump-scheduled-for-surprise-visit-to-maine-sunday-after-nh-rally/2217738/
  2. . https://www.independent.co.uk/voices/the-maine-district-trump-has-become-obsessed-with-b1562898.html
  3. https://www.pressherald.com/2020/12/01/twenty-deaths-reported-as-covid-19-storms-across-maine/
  4.  https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/business-employers/bars-restaurants.html
  5. https://www.pressherald.com/2020/12/01/twenty-deaths-reported-as-covid-19-storms-across-maine/

Webinar with Janet Edmunson, M.Ed.

Join us for a FREE Webinar on September 29, 2020  
Getting Better Sleep as a Caregiver
by Janet Edmunson, M.Ed.  

For family and professional caregivers  

Tuesday, September 29, 2020 (The webinar also will be recorded for viewing later)   7:00 p.m. (Eastern) 6:00 p.m. (Central) 5:00 p.m. (Mountain) 4:00 p.m. (Pacific)  

Webinar will be approximately 30-40 minutes in length.
Register online today by clicking the link below. 
Or paste the link into your browser.

Registration Link:  https://tinyurl.com/sleepforcaregivers
Or paste this link into your browser:  https://attendee.gotowebinar.com/register/367055869464547074

Active cases update

As of 9/8/20, the latest date for which the numbers are available, the Maine CDC reported a total of 4734 Mainers who have had COVID-19 since testing began over 180 days ago.  Among those cases, 4135 have recovered (87%), and 134 have died (2.8%).  Active cases totaled 465 (9.8%).   Also since testing began 999 health care workers (21%) in Maine have been infected with COVID-19, 933 of whom have recovered.  This means there are likely 66 active cases among health care workers. As of the end of July there had been no deaths among health workers, but I don’t think that information has been updated since.  And, take a moment to consider that “recovered” simply means the infection is over.  It does not mean the person is well.  We have seen many cases with what appears to be permanent lung damage, or other ravages left by the virus.  It is serious.

As of yesterday, a total of 429 people had been hospitalized with COVID-19 in Maine since the start of testing.  The number of hospitalizations is not just Mainers, but all hospitalizations of COVID-19 within the state.  If we add an estimated 200 out of state cases to the overall total the percent of cases hospitalized in the state is 8.7%.  In Maine on 9/8/20 6 Mainers were in critical care, and 2 on ventilators with COVID-19.

So, what does this tell us?  If we look at the graphic for this post (view on the website if you cannot see by email), the number of active cases is down from the peak of 714 (May 24), but is unfortunately trending up currently.  This is for the most part due to a series of widely reported preventable outbreaks.  We just had Labor Day, and hopefully will not see a spike following holiday gatherings. 

We are not done with COVID-19 yet, and we need to be careful because fall is approaching, and with it, cold and flu season as people head back indoors. Please continue physical distancing, hand washing, covering coughs and sneezes.  Please use good sense and wear a mask or facial covering.  If you can’t do that, stay home.  Wearing a facial covering limits the spread of droplets which contain the virus that causes COVID-19.   To those of you who complain about wearing a mask when you go out, imagine those of us who wear one all day, every day.  We like it even less, but we do it for a good reason.  We still do not know who the asymptomatic carriers are.

Please don’t argue with health professionals about whether you can accompany a loved one to a doctor’s visit.  There are criteria in place meant to help everyone, including us, to limit the spread of COVID-19.   Yet, doctors, nurses, and office screeners at the front door have to deal with very difficult people about this topic daily.  It helps no one, and creates additional risk.

Also, if you can take one, get a flu vaccine as soon as you can.  If you are eligible for the pneumonia vaccine, please get it.  COVID-19 can be hard enough to fight by itself.   

That’s it.  I hope you are healthy in body, mind, and spirit.  

More on active cases

Nine days back I wrote about active cases of COVID-19 in Maine.  Recall that the active infections we are tracking are among Maine residents who have either had a positive test, “confirmed” cases, or are “probable” (close contact with a confirmed case and meeting certain clinical criteria as defined by the CDC).  These cases have not recovered or died, and are thus actively ill. As of yesterday there had been 424 probable cases and 3287 confirmed since testing began 131 days back.   These numbers do not reflect those who were ill but never tested, and likely do not reflect the majority asymptomatic carriers, who for the most part have not been tested.  The numbers also do not reflect out of state visitors who test positive in Maine.   

In the July 11 post I discussed the bump in cases seen after Father’s day, and expressed concern about the possibility of the same following July 4.  We have now passed two weeks since that holiday, and numbers of cases among Maine residents have been shared by the Maine CDC, as outlined in the above graphic (view the article on the website if you cannot see that).   What the numbers tell us now is that we did fairly well for most of that two weeks.  The number of active cases dropped to 385 on July 14, which was the lowest level we have seen since April.   However, those numbers have since been slowly climbing, and the current number of active cases is 435.  Recall that in Maine the peak of active cases so far was 714 on May 24.  The current 7 day average is 22 cases per day (up from 15 on July 11).  So far, 117 Mainers have died from COVID-19. 

On Friday of last week Maine was one of three states in our country whose numbers were going down.  My concern is that it appears our numbers might be starting to go up again.  And, though it appears to me the number of out-of-state visitors is lower than normal, there are still many here.  The concern expressed by many of my patients and their family members is that visitors tend to have a false sense of security when they visit here, saying to Mainers that there are practically no cases here, or that they don’t need to worry when they come here because the risk is so low. It seems lost on them that they are a risk to Mainers. Many are also not wearing masks, and don’t appear to be quarantining.  This is how the virus is spread.  Remember, a significant number of people will be asymptomatic carriers of this disease.   

We are not doing a good job dealing with this virus in our country.   The CDC found in late June that antibody tests in six different states showed viral exposure at a much higher magnitude than prior testing had revealed. After reviewing thousands of blood tests in each state, CDC estimated the differences between reported case counts and actual was as follows:  western Washington State (11x higher than reported positive tests), New York metro area (12x), southern Florida (11x), Missouri (24x), Utah (11x), Connecticut (6x).   But this is nowhere near the levels of infection we would need to see to have herd immunity, which would require somewhere north of 50% of the population immune (more likely over 70%). 

As of today there have been 14,608,517 cases of COVID-19 across the globe, with 3,808,104 in the U.S. (26% of cases though we have just 4% of the world’s population).  Our case numbers are now 11 times that of Mexico, 15 times that of Italy, 19 times that of Germany, 34 times that of Canada, and 45 times that reported by China-who hosts 36% of the world’s population.   We have had several days with over 60,000 new cases of COVID-19 in the U.S. lately and the trend is going up.  Over 137,000 Americans have already died from COVID-19, and the CDC estimates the overall case fatality rate of COVID-19 to be 2.3%.  That means for each day that we have 60,000 new infections, we can expect close to 1,400 additional deaths. 

We are seeing more young people around the country with COVID-19. The problem with this is that although they are still at risk of serious illness or death, they are also more likely to have a minor illness or be an asymptomatic carrier.  We need people to take this seriously. 

It seems to me that although everyone knows about the virus, they are getting information from a lot of suspect sources.  The CDC is a good source but I don’t think everyone is listening.  There should be PSAs in all kinds of media about COVID-19 telling people how to avoid catching or spreading disease, how to wear a face cover or mask, how to do their part. 

Some good news about a promising COVID-19 vaccine

In April I wrote about vaccine development  for COVID-19.  That article outlines some of the background information you might want to read if you are not familiar with this topic.  At the time the frontrunner, the Moderna messenger ribonucleic acid (mRNA) vaccine, had been in trials for about a month.  This week the New England Journal of Medicine (NEJM) published an article outlining the phase I trial of the Moderna vaccine against COVID-19. 

The vaccine was given to 45 healthy adults ranging from 18 to 55 years of age, as two injections given 28 days apart, with mRNA-1273.   The vaccine was developed by researchers at the National Institute of Allergy and Infectious Diseases (NIAID, the trial sponsor) and at Moderna (Cambridge, MA). Participants were enrolled at Kaiser Permanente in Seattle, Washington, and Emery University in Atlanta, Georgia.

Researchers measured blood levels of antibody responses in the participants. Recall that antibodies are the tiny molecules our immune system produces to protect us from reinfection by an invader such as a virus at some point in the future.  Think of them as a sort of weapon the body uses.

In this study, following the second injection “serum-neutralizing activity was detected.”  In other words, antibodies that would neutralize SARS-CoV-2 were seen in all participants.  Side effects including fatigue, chills, headache, muscle aches, and pain at the injection site were reported in more than half, though none significant enough to limit the trial were detected.  

Researchers found that a type of so-called binding antibody called IgG against the viral spike protein increased rapidly after the first vaccination in all participants by day 15.  After the second vaccine all participants likewise produced a volume of antibody similar to that seen in patients who produce convalescent serum. That implies a good immune response, what you need to stop an infection.   For more on that topic, see this MPDN article.  And, in case you are wondering, the participants were also tested for antibodies prior to vaccination, and all found to have no detectable antibodies, indicating antibody formation was all but certainly due to vaccine exposure.

Finally, a type of immune cell in the blood called the CD4 T-cell was activated by the vaccine, again indicating a robust immune response.

A large phase III efficacy trial is starting at the end of July to determine if the vaccine is effective.

To listen to a 7/17/20 podcast (or read the transcript) of Drs. Anthony Fauci, Abraham Verghese, and Eric Topol discussing this and other topics on Medicine and the Machine, please click here. 

COVID-19 update in and out of Maine

On Tuesday of this week Dr. Nirav Shaw of the Maine CDC reported that since testing began in our state there had been 111 positive tests among non-residents.   Dr. Shaw took care to note that “many” of these cases are from people who live in New Hampshire but get their healthcare in Maine.   Further, he noted that among the total of 374 people who have so far been hospitalized with COVID-19 in Maine, some of the cases were out-of-staters, though the number was not given.  As of today, he notes that there are 13 people hospitalized in Maine with COVID-19, 11 of whom are in ICUs, and 4 of whom are on ventilators. 

Today the total number of cases given (posted as of midnight last night) was 3598 cases among Maine residents since testing began (391 probable cases).  Subtracting 3094 recoveries, and 114 deaths, we are left with a total of only 390 active cases.  The current 7-day average of new cases is 15 per day.  Overall, numbers are falling in Maine.  

The total number of healthcare workers who have been infected in our state since testing began is 844.   As always, if you cannot see the graphic in the email of this post, please view the post on the website.

Maine is doing so much better than many other parts of the country. But those problems can come here. A surge of cases in another state can for example deplete resources such as PPE or testing materials needed everywhere. Speaking of that, it has been a strange week in our country for COVID-19.  Every week of this pandemic has been for that matter, but a few points really stand out. 

  • On Tuesday of this week there were 64,000 new cases in the U.S., and the Trump Administration unilaterally removed the ability of the leading public health agency -the CDC – to collect hospitalization data on COVID-19-requiring hospitals to report elsewhere.  That information will now be given to a central database in Washington, in part run by a private company.  Health experts around the country are calling this an alarming and unprecedented move because public health data is being taken from the experts who need it.  There is also concern the information will be suppressed, spun or politicized. 
  • The White House and Trump have made disparaging remarks about the country’s leading infectious disease specialist, Dr. Anthony Fauci. We are no longer hearing from Fauci via the the White House. America needs to hear from an expert. I have a feeling that most of America trusts Fauci.
  • Georgia’s governor Brian Kemp has sued Atlanta  over a mask mandate, even as cases there climb. And, Kemp banned cities in Georgia from ordering people to wear face masks.  There have been 127,834 cases of COVID-19 in Georgia (almost 24,000 in the last seven days).
  • Nearly a third of the 54,022 children tested for COVID-19 in Florida have been positive (16,797 kids).  Four of the children have died, and 213 have been hospitalized.  The Trump administration is demanding that schools reopen in the fall. 

There are other concerns, lots of them.  Where are the checks and balances in our government? Where is the leadership? Where are we going with the out-of-control exponential growth down south and the failure of politicians to recognize it is an emergency?

Note, the links are current as of the time of posting, and are subject to change.