Author: Bill Stamey, M.D.

According to the Maine CDC, there have been as of today 344 cases of COVID-19 (up 41 cases since yesterday) and a case has been detected in Hancock County, bringing the number of counties affected to 13 (though we should assume there is virus in every county).  Community spread is present in York and Cumberland Counties, where cases are the highest. The number of healthcare workers infected remains at 43.  Since the onset of testing 63 people have been hospitalized, and 80 people have recovered.  Two more people have died from COVID-19, both women in their 80s who were hospitalized, bringing the total to 7 deaths.  A second positive case at the Oxford homeless shelter has been detected. Authorities have been working to identify potential spread at that shelter.

Testing

Maine CDC has supplies to test another 4000 people at present, and there have been 8400 negative tests so far.  As mentioned yesterday, there is a new FDA-approved (Emergency Use Authorization (EUA)) rapid test (taking less than 15 minutes) being manufactured by Abbott Laboratories (based in Illinois with production in Scarborough, ME).  This test will be used in the existing Abbott ID NOW device, a small piece of medical equipment about the size of a toaster.  The availability of a rapid test will be helpful in reducing the amount of personal protective equipment (PPE) used by medical personnel. Dr. Nirav Shah today noted that this week we received our third and final distribution of PPE from the Strategic National Stockpile.

To that end, Maine will be taking possession of 15 Abbott Laboratories ID Now devices, 100 test kits, each able to perform 24 tests, therefore 2400 tests.  Several labs around the state also have these machines, which were designed for rapid diagnosis of other diseases.  As noted yesterday, Abbott can produce 50,000 test kits daily, though as below, it sounds as though the majority will not be allocated for Maine. Miles White, the outgoing CEO of Abbott, told CNBC on March 30, 2020 that in addition to the rapid tests, more tests are coming. “There’s still more, and there’s a need for more.  We have a collection of technologies and formats, we’ve got multiple R&D teams at work.  There are more tests coming, there are serology tests, antibody tests, we’re looking at automated versions of that…all of those are a matter of weeks to a couple of months away.  Those teams are working around the clock…” They are also reportedly working on ramping up production to much higher numbers of tests daily.   “For a while we’ll be allocating and prioritizing to high need areas.”

Vital resources

More and more hospitals are reporting to Maine CDC, and the numbers of vital resources are going up:

• 272 ICU beds, 124 available
• 348 ventilators, 271 available
• Alternative ventilators, approximately 128 available

Stay at home orders

Multiple governors around the country have instituted stay at home orders in the last few days. These orders are an effort to contain the outbreak in local communities, to prevent deaths, and to prevent an overwhelming surge of cases in hospitals and healthcare systems during this most severe pandemic the world has seen in the last 100 years.  I have read that some Mainers feel it is too soon to execute such an order. However, in medicine and epidemiology we know that this is precisely the time to act. And, we know that the numbers of seriously ill people with COVID-19 we are seeing today are people who contracted the disease an average of five days ago. Right now there are likely many more people who are infected but not yet showing signs of disease. There are also likely many asymptomatic carriers who are capable of spreading disease. Some experts have documented high levels of virus in the nasopharynx of people with no symptoms at all.

As an epidemic like this grows, it does so in an exponential fashion. For more on this please read my COVID-19 questions post. Looking at national trends on March 29, 2020 Dr. Anthony Fauci told CNN’s State of the Union audience that this pandemic could kill 100,000 to 200,000 Americans and infect millions. Many different authorities are making projections, and many are keeping track of the rapid spread of this pandemic. As it stands now Johns Hopkins notes that there are 190,740 cases in the U.S.  We are unfortunately the country with the highest number of reported cases worldwide.  Johns Hopkins further indicates a total number of positive tests worldwide of 887,067, with 44,264 deaths since the start of the pandemic.  Some cities such as New York and New Orleans are being particularly hard hit.  Stay at home orders and social distancing should be taken very seriously.   

Conclusion

Check the home page for links to other useful sites on the web. Know that people all over the world are working on this, and advances are happening daily. This is what science is for. And, caring for patients and constantly trying to improve how we do that is what doctors, nurses, and other healthcare workers are trained to do. We are not going to stop.

Please safely check on someone who might be isolated. Use social distancing, a telephone, texting, whatever works to say that you care. We need to stay connected in the ways that we can. Think about checking in on all of your loved ones. They might not be as strong as they seem. None of us has ever faced a worldwide crisis like this.  

Also, please keep up routines and sleep/wake schedule. Make sure you move your body in a healthy way daily with exercise, stretching, and other activities you enjoy.

Finally, I know many of these posts are about frightening topics. Try to also focus on something happy, meaningful, or beautiful to you. There is a reason we have poets, novelists, artists, and musicians. They center us, they bring us peace.  Know too that if you or someone you know is in a states of crisis, there is still help. Call your doctor’s office or call the Maine Crisis Hotline at 1-888-568-1112.

Today the Maine CDC reports there are 303 confirmed cases of COVID-19 in fulltime residents of Maine. Since the start of the outbreak there have been 68 recoveries, 57 patients have been hospitalized, and 5 deaths. Among positive cases, 43 are healthcare workers.  There is a current backlog of 600 tests to run, all patients in the lowest risk category. High risk patient tests are prioritized (more below).  

Positive cases are present in 12 Maine counties with 169 cases in Cumberland County, and 59 cases in York County.  Cases are represented by every decade of life, though over 87% of cases are in people 40 and up.  

Non-residents who test positive in Maine are not listed in the total above, but are instead recorded in their home states. Those numbers (as far as I can tell), are not available on the Maine CDC website.  From an epidemiology standpoint it makes sense to count the number in the state where the disease was contracted.  If presumably a case was contracted in Massachusetts, but the person traveled to Maine and was tested here, MA needs to know not just the number of cases they have generated, but also the identities of cases.  Knowing the identity allows public health officials to track contacts and hopefully limit spread.

From the opposite view, it is not clear to me how many cases we are counting who are Mainers with COVID-19 in other states.  Many Maine residents are currently in Florida for example.  A week ago Governor Mills advised people in other states to stay put, as the risk of encountering the virus would be higher with travel than staying in place.

As far as the numbers go, the total count of infected people in one place still matters.  If an infected person is present in a state where they did not contract the virus, it can be important for the logistics of disease management to count those people, especially if the numbers of sick people become significant. Think of it this way: if you needed to feed a certain number people at a dinner it wouldn’t matter how they got there. All that would matter would be how many plates to set and how much food to cook.  Managing a disease within a population can be the same way.  You need to know how many cases there are so that you can plan on resources like hospital beds, ICU space, ventilators, supplies, and people to care for those patients.

There is another reason to know the total number.  If you have an epidemic of an infectious disease it grows to some maximum number (the peak) before numbers of new cases start to drop off.   Consider the total number of infected cases like a number that needs to fit into a math problem.  If you know that for every person who has disease the overall size of the epidemic will expand in a certain way, then it becomes necessary to count those people.  With relatively small numbers like we are seeing now, I am hopeful that the difference is negligible.   A lot of effort in Maine is being put into predicting the growth of the epidemic and what that will mean in terms of resource and response. 

Maine CDC

At his daily media brief today Dr. Nirav Shah of the Maine CDC noted that overnight two women in their 80s passed away in the hospital.   He noted that two new pediatric patients (who are not school-aged) have been diagnosed.  One person who spent some time at the Oxford Street shelter tested positive.  Health officials are responding. 

The Maine CDC is continuing with a plan to send some samples to an outside commercial laboratory (LabCorp) as a response to the backlog of tests.  There is also an order for a new piece of equipment which should arrive in 1-2 weeks.  Once that new equipment arrives it will take several days to calibrate and integrate into the workflow.  See below for a new test.  

In terms of the mechanics of testing, Dr. Shah noted that the way these numbers are collected is that overnight the commercial laboratories and the state lab combine results.  When this occurs the PCP is contacted for more information about the patients with a positive result, including phone numbers.  The patient is contacted by the Maine CDC and is asked about every contact they have had in the last two weeks.  There is community transmission in many parts of the state. 

“What we know about disease transmission, is that it occurs in places of congregation.” 

Nirav Shah, M.D., Director of the Maine CDC

However, cell phone companies have been reporting to what extent people are straying from their homes (much lower), and traffic patterns have changed to reflect this.  It appears social distancing is occurring, and it is having a curve-flattening effect on the rate of new cases.  To be certain, number of cases is growing, but there are many factors at play.  We are not done seeing a rise in the rate of cases, and we need to take it very seriously. There is of course a concern that if numbers continue to grow we will see a large rise in the numbers before the outbreak peaks in Maine.  We don’t want to overwhelm health systems in our state. This brings us to supplies.    

Yesterday Maine received a third distribution from the federal stockpile, including 60,000 N95 masks and other PPE.  Maine CDC authorities are to soon distribute, primarily to hospitals.   

Vital resources currently in Maine

• 190 ICU beds, 90 available
• 330 ventilators, 262 available
• 89 alternative ventilators (primarily ventilators used in short term medical procedures such as surgeries that can be modified for use in COVID-19 patients)

If those numbers seem like a lot, they aren’t. The Maine CDC is asking hospitals to increase reporting, including available numbers of PPE, and other data.   “In any type of a situation, we have to know where were going, but in order to know where we are going we have to know where we are right now.”

A new COVID-19 test

In other news, Abbott labs has developed a new, FDA-approved rapid COVID-19 test which will give a positive results in 5 minutes, and a negative response in 13 minutes.  Production begins at the Scarborough facility tomorrow.  Abbott reports they will produce 50,000 tests daily, and will be working with the Trump administration in terms of distribution.

Stay Healthy at Home Mandate

Governor Janet Mills this afternoon announced “a series of substantial new mandates to protect public health and safety in the face of COVID-19, including a Stay Healthy at Home directive that requires people living in Maine to stay at home at all times unless for an essential job or an essential personal reason, such as obtaining food, medicine, health care, or other necessary purposes.” This new mandate will take effect 12:01 a.m. April 2, 2020 and will last until at least April 30, 2020 unless changed by the governor. 

In brief, essential businesses and operations that remain open will limit the number of customers in buildings at any one time, implement curb-side pickup, delivery options, and enforce U.S. CDC-recommended physical distancing requirements for their customers and employees in and around their facilities.  The mandate also prohibits the use of public transportation “unless for an essential reason or job that cannot be done from home and limiting the number of people traveling in private vehicles to persons within the immediate household unless transporting for essential activities.”  Classroom and other in-person instruction will not resume until at least May 1, 2020.  It is now mandated that when out of the home or at work at an essential business, “individuals shall maintain a minimum distance of six feet from other persons.”

Essential personal activities defined in the mandate “with relation to an individual, their family, household members, pets, or livestock” include obtaining necessary supplies for household consumption or use, medication or medical supplies, seeking medical or behavioral health, emergency services, providing care, traveling to and from an educational institution for purposes of receiving meals or instructional materials for distance learning, engaging in outdoor exercise activities, such as walking, hiking, running, or biking, “but, only in compliance with the social gathering restriction in Executive Order 14 and all applicable social distancing guidance published by the U.S. and Maine Centers for Disease Control and Prevention.”   For further details please read the mandate.

Conclusion

This is a virus, a deadly virus. For it to spread, it has to be spread from one person to the next. If we could all isolate for two weeks, it would be gone. Do your part, please stay home.

If you have a fever, new cough, shortness of breath, sore throat, or muscle aches, call your doctor’s office.  Watery diarrhea is also seen in a minority of cases, and a new loss of sense of smell or taste has been reported frequently in mild and severe cases. 

Over 80% of cases of COVID-19 are mild, but in high risk groups (people over 60, and people with serious underlying chronic diseases such as COPD, asthma, cardiovascular disease, diabetes, kidney disease, or immunocompromised state), risk of serious illness or death is higher than the general public.  

Mild symptoms

Generally speaking, for MILD symptoms, we encourage patients to monitor their own health at home.   This is in part to avoid spreading the disease, and in part to avoid overwhelming the hospitals in our state.  People with mild symptoms are not usually going to qualify for a COVID-19 screening test at this time because there are not enough tests.  Hopefully that will change soon.  Whatever the case, it is still cold and flu season also, and most tests are coming back positive. Those who come in for a test are also running the risk of exposure to the virus that causes COVID-19.

People with mild symptoms should isolate at home for 14 days as long as the symptoms remain mild (and at least three days free of fever without medications).   One should call back for medical advice if the symptoms become severe, and call ahead before going to the doctor or the emergency room.  Health workers need to know if there is a chance you might have this highly infectious disease. 

If symptoms remain mild, stay home, isolate in one room, use one bathroom that is not shared, avoid contact with others, and do not share plates or eating utensils.  Have someone else bring you groceries and medications. If you must leave the house for any reason, avoid public transportation and wear a mask. Do all that you can to avoid spreading this disease. Wherever you are, cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing.  Throw all used tissues in the trash.  Wash your hands with soap and water immediately after coughing, sneezing, or blowing you nose.  Wash hands often with soap and water for at least 20 seconds to avoid spreading virus to others.   If soap and water are not readily available, use an alcohol-based hand sanitizer that contains 60% alcohol. Always was hands if hands are visibly dirty with soap and water.  Here is one resource to go over these issues: CDC

If you are sick, stay hydrated, and get good nutrition. Please let your doctor’s office know, and ask loved ones to check on you by phone if you do not live with someone.

For people with SEVERE symptoms:

Call ahead to your local ER that you are coming in, or inform EMS of your symptoms and that you might have COVID-19.  Wear a mask immediately upon entering ER or ER registration.  If you have called EMS put on a mask prior to seeing them.

If you haven’t put your code status in writing, it is time

There is no easy way to say this.  We should all know our code status.  For the uninitiated, code status refers to whether you would want heroic measures to be taken if your heart stopped, or if you had serious problems breathing.  In other words, would you want chest compressions, possible shocks to restart or normalize your heart (cardioversion), or a tube down your throat to help you breathe (intubation), and be put on a machine (a ventilator) that would breath for you?  Many of you have thought this through and have an advance directive, POLST form, or similar document.  That is good, as long as it covers code status clearly, and it is available to EMS or the ER. 

Under Maine law, advance directive refers to any spoken or written instructions you have given about the health care you want should you become too ill to decide.  An advance directive will let others know what treatments or interventions you want, and those you do not.  Having decided these issues well before you become ill is helpful to medical personnel, helpful to you, and helpful to your loved ones by sparing them the burden of making tough end of life decisions.

In Maine, anyone 18 years of age or older may use the Maine Health Care Advance Directive Form, (click here to download the .pdf). This form can be canceled or changed at any time.  This document does not take away your rights as a patient.   Once you state your wishes in writing, please let your loved ones know what you want.  The ER and the intensive care unit (ICU) are not good places for surprises.  The key thing to medical personnel is what you want. Your doctor and local hospital should have copies too.  Most people keep the document with their code status handy, perhaps on a refrigerator door, along with a list of medications.  

In our lifetimes there has never been such a threat in our communities.   The percentage of those who experience serious illness or die is much higher in people over age 60.  About 20% of people of all ages with COVID-19 have a severe case requiring hospitalization, with about half of them winding up in an ICU.  About half of those patients wind up on a ventilator (5-10% of COVID-19 cases overall).  We can break the risk apart by age to some degree.  On March 21, 2020 I noted here in MPDN that the state of Washington that day had 1793 confirmed cases with 95 deaths (today the numbers have climbed to 4,896 cases and 195 deaths).  Deaths up to March 21 occurred as follows by age and (percentage):  60-69 (10%), 70-79 (23%), 80 and up (60%).  If a person winds up in the ICU and on a ventilator risk of dying is high, much moreso in older people.

A research letter to JAMA March 19, 2020 noted that at Evergreen Hospital in Kirkland, Washington a case series of 21 people with COVID-19 was admitted to the ICU (average age, 70 years with a range of 43-92 years).  Mechanical ventilation was used in 15 patients (71%) and acute respiratory distress syndrome (ARDS) developed in all of those patients.  As of March 17, 2020, death had occurred in 67%, and 24% of patients remained critically ill. 

In a summary of 72,314 cases from the Chinese Center for Disease Control and Prevention published in JAMA, 14% of cases were defined as severe, and 5% of cases as critical.  The case fatality rate for all ages was 2.3%, but 14.8% for patients over 80, and 8% for those 70-79 years of age.   Of note 3.8% of all cases were healthcare personnel, and 14.8% of them were classified as severe or critical.  Healthcare workers risk exposure to high inoculation of virus particles, especially while performing intubation and other invasive procedures.  All patients in this group who were listed as critical died from COVID-19. 

A study published in The Lancet Respiratory Medicine reported that of 52 critically ill patients (average age 59) at a Wuhan, China hospital 30 (81%) of 37 patients requiring mechanical ventilation had died by 28 days. The age of those patients was not given.

The point is that older people, especially those with chronic illnesses, do not have good outcomes with this disease, especially if they become critically ill.  Please consider your code status carefully. 

The following is a summary of questions I was asked by patients about COVID-19 this week. Please bear in mind that I am a neurologist.  My main concern in writing and posting this articles is to protect public health.  I hope this is helpful.  If you are not finding what you need here, try the Maine CDC COVID-19 FAQ page, or the CDC in Atlanta FAQ page.

Isn’t COVID-19 like the flu?

No, but it is easy to see why people might make the comparison.  COVID-19 and influenza are both respiratory illnesses that can be spread by droplets (coughs, sneezes, talking, dirty hands, dirty doorknobs, etc.).  However, COVID-19 is about twice as infectious as the current seasonal flu in the U.S.   

How do we know COVID-19 is more infectious than the flu?

One way to figure this out is the reproduction number, or R₀ – pronounced “R-naught.”  This basically tells us the number of people to whom an infected person will likely spread the disease.  It is a way to describe how contagious a disease is. When R₀ = 1 then and infected person will infect 1 other person. When the R₀  = 10, then an infected person will infect 10 other people, and so on.  Therefore, a lower number is better than a higher number. As we will see, it is possible to lower the number. When the R₀ is less than 1, the epidemic is likely to stop, because an infected person is unlikely to spread disease to anyone. 

The basic reproduction number of seasonal influenza is R₀= 1.3.  Thus, each infected person spreads the flu to about one other person (1.3 people, but let’s round down to keep it simple).  That person spreads it to another person, and so on.  The spread of seasonal influenza is usually person to person.  So far, the data with COVID-19 is that the R₀ = 2.2, close to twice as high: every person infected spreads it to two people, rounding down again, but it becomes person to people.   That is a real problem, because it means that if nothing stands in the way, the number of cases doubles when it spreads. Based on data from the Wuhan, China outbreak, that occurred about every week during the early stage of the epidemic. (1)  The spread might first go from 1 person, who spreads to 2 people, who spread to 2 each (4 more people), who spread to 8, and those 8 to another 16, to 32, to 64, to 128, to 256, to 512, to 1024, (keep doubling, and in ten more steps you have reached 1,048,576 new cases, and the aggregate  is about 1.5 million). However, there are even more factors that influence an “exponential growth curve.”

Wuhan, China is a city of 11 million people.  The city contains a large outdoor seafood market where the virus that causes COVID-19 is thought to have originated. There were several issues that fostered the growth of COVID-19.  It was the season of the Chinese Lunar New Year (the largest annual mass travel event worldwide).  There were huge crowds, people had come in from all over China, and all over the world.  In the City of Wuhan community spread first occurred in mid-December.   By mid-February, China reported over 77,000 cases.  However, people who traveled to Wuhan returned home, and flights left through the end of 2019 until at least the first week of March, many of them to the U.S., and bringing the virus with them. Remember that many people may not have had any symptoms during travel.  As of this am, Johns Hopkins reports there are 607,965 cases of COVID-19 affecting 177 countries.  There are 104,837 cases in the U.S. This is far worse, and far more rapid than influenza.  For a little more detail on R₀, see footnote 1.

But doesn’t the flu kill more people?

This flu season from October 1, 2019 until March 14, 2020, the CDC in Atlanta estimated 38 – 54 million flu infections in the U.S., with 400,000 – 730,000 hospitalizations, and 23,000 – 62,000 deaths.  (footnote 2)  By comparison, in the U.S. there have so far been 1,711 deaths from COVID-19. (footnote 3)  But, consider the fact that influenza had a six week lead on COVID-19.  We don’t yet know how bad this will be.  And, the case fatality rate (the number of people who will die from an illness as percentage of all those who are infected) is only about 0.1% for seasonal influenza.  In Wuhan, China the case fatality rate was 2.5% (25 times higher than seasonal influenza in the U.S.), and in most parts of the U.S. the case fatality rate appears closer to 1% (10 times higher). In some outbreaks the case fatality has been as high as 5% (50 times higher).   The bottom line is that COVID-19 is much more lethal than seasonal flu. This is why we are trying so hard to avoid it.   

Even if COVID-19 is more deadly than the flu, please make no mistake, you should get a flu vaccine every year unless there is a clear medical reason not to get one.  The numbers I have given for the flu should shock you.  We lose an average of 30,000 Americans to the flu annually (some years much worse).  You can do your part to stop the spread of the flu by getting your vaccine every year.  As I mentioned in the last post, older people should also get a pneumonia vaccine.  Stop the spread of infectious disease.  

Will this be over before Easter?

I don’t think so.  But there is reason to be hopeful that we will get this under control before summer.  All viral illnesses seem to have a “wave” during which they pass through a community or population.  Cases go up, peak, then come down.  China claims to have leveled off the rate of new cases not long after mid-February, with a current 81,996 cases.  I hope that is true.  China also claims 75,099 recovered cases.  Remember also that about 80% of cases are mild.   In the U.S., which is several weeks behind China, we are still reporting growth in the number of cases and have seen nearly 900 recoveries (among those tested).  If the wave of illness lasts about 8-9 weeks, we might see a decline in the rate of cases soon on the west coast.   However, like everything else about this, it is complicated.  It also requires social distancing to flatten the curve.  As above, this disease is very contagious.  Stay home, and avoid sick people. 

Are there parts of the country, or maybe parts of our state that will be able to go back to business soon?

It is possible.  A reasonable strategy might be to identify and isolate all cases in a community if the number is low (such as Montana).  This would mean finding all contacts of sick people and isolating them, and not allowing new cases in. The problem is that we don’t have enough tests yet to do mass screening.  So, the strategy is still social isolation.  Stay home.  

When will we have more tests?

A lot of work is being done.  I understand that vendors are coming online as fast as possible.  The most common test, the rt-PCR, requires a special reagent which is in short supply around the country.  This test checks swabs from the nasopharynx for viral RNA.  As far as I know, home test kits I have seen advertised are not yet FDA approved.   There may soon be a blood test.

Do people develop resistance to COVID-19?

We think so.  We are not yet sure, and there is not enough data to be sure.  There is data that people who have recovered produce antibodies against the virus.  Opinions around the globe are that it is likely that people will be immune to COVID-19 if they have recovered from a prior infection.  The director of Allergy and Infectious Disease at the NIH, had this to say to Trevor Noah on March 27, 2020:

“I feel really confident that if this virus acts like every other virus that we know, once you get infected, get better, clear the virus, then you’ll have immunity that will protect you against reinfection.” 

Anthony Facui, MD

Is there a vaccine?

Not yet, but people all over the world are working on it. We need a vaccine.  For more about why we need a vaccine, see footnote 4. 

Are there treatments for COVID-19?

There are currently no proven treatments.  The strategy is largely supportive at this point.  Fortunately, in the general population, 80% of cases are mild about 15% are moderate, and about 5% are severe, requiring mechanical ventilation.  As discussed in prior posts, the numbers are not the same if we break it apart by age.  Above age 60 the frequency of severe illness increases steeply.

What about hydroxychloroquine?

There has been some data to suggest it might be helpful, by making it less likely for the virus to bind to targeted cells in the lungs and GI tract.   But there is no proof that this works, or that it is even safe to take during this illness.  A drug for any condition should be tested and thoroughly vetted before use.    Hydroxychloroquine is needed for rheumatologic diseases however, and it is unethical to take drugs out of supply that are needed by other people.  Those who are selfishly attempting to take hydroxychloroquine prophylactically are doing so at a great cost to people with chronic disease.

What about ACE inhibitors and ARBs?

There is an association between angiotensin-converting enzyme 2 (ACE2) and SARS-CoV-2, the virus that causes COVID-19. (2)  ACE2 is a co-receptor for viral entry for SARS-CoV-2 (is needed to help the virus get in the cell), and it might be related to pathogenesis (the evolution of disease) of COVID-19. ACE2 is seen in the human lung, GI tract, heart, and kidney.  ACE inhibitors, which are normally prescribed to lower high blood pressure, might directly inhibit ACE2. The problem is that ACE2 is not inhibited by clinically prescribed ACEIs. (3)  And, there is concern that the use of ACEIs and ARBs (angiotensin receptor blockers) might actually increase expression of ACE2, and that might increase susceptibility to the virus.  We know from many animal and human studies that these drugs increase expression of ACE2 in the heart and brain, and there is limited evidence that the same might happen in the lungs.  Still, as we try to find something that might help COVID-19, experts have called for both the use and the cessation of ACEIs, ARBs.  The data is not there yet. 

What about antivirals?

There is no data yet. Some of the antivirals used to treat HIV look interesting, but the same can be said about safety and appropriate use here. 

What about plasma or serum from recovered people?

Data is being collected.  This is a very promising area, and a very old idea. For about a century we have used the technique of collecting antibodies from recovered patients to treat the acutely ill.  I have also read about trails harvesting specialized white blood cells from recovered people. 

FOOTNOTE 1: R₀ is not a fixed number.  Factors within a population such as whether vaccines are used (and to what degree), the status of nutrition in a population, whether people in a community have some resistance to this virus, or whether some other infections are going around all come to bear on how infectious something is.  That is why doctors, scientists, and epidemiologists discuss the effective R_0.   It is also why we ask you to take vaccines (see footnote 4 below).

FOOTNOTE 2:  The reason for the lack of certainty is put by the CDC as follows: “Because influenza surveillance does not capture all cases of flu that occur in the U.S., CDC provides these estimated ranges to better reflect the larger burden of influenza. These estimates are calculated based on CDC’s weekly influenza surveillance data and are preliminary.” 

FOOTNOTE 3: Sadly, the first death due to this infection in Maine occurred this week.  Worldwide, there have been 28,125 deaths due to COVID-19 as of this am, 3/28/20. 

FOOTNOTE 4: Measles is one of the most contagious infectious diseases and can cause explosive outbreaks. It has an R₀ of between 12-18 in the U.S.  The R₀ can be higher in completely susceptible populations.  Consider 1875, when measles arrived in the Fiji Islands. According to Hans Zinsser, in his excellent 1934 book Rats, Lice, and History, the King of the Fijis and his son returned home from a visit to Sydney, Australia, apparently bringing the infection back with them, and killing 40,000 people from a population of 150,000 (28% of the population).  This population was naïve to measles.  If a disease has been present for a while in a population, some immunity develops.  Those people, who have survived an infection are either not susceptible or partially susceptible.  It becomes much more complicated when most adults, but no small children are immune.  And, there are many other factors such as hygiene, nutrition, and medical care that play a role.  Such was the case with measles in the U.S. prior to the introduction of a safe and effective vaccine in 1968.  Measles used to infect 3-4 million children in the U.S., resulting in up to 500 deaths annually. (4)  There have been multiple measles outbreaks associated with unvaccinated children in the U.S. since then, though in 2019 we saw a 25 year high of over 1200 cases in 31 states.  This was fueled by the anti-vaccine movement and those claiming religious exemption. Epidemiologists calculate that we need to vaccinate 95% of kindergarteners to reach a community protection threshold adequate to protect those who are not able to be vaccinated due to medical concerns.  It is the ethical duty of all parents whose children can be vaccinated to do so in order to protect not just their own children, but those who are more vulnerable, and cannot have the vaccine. 

REFERENCES

1. Li, et al.  Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. NEJM 2020;382(13): 1199-1207.  
2. Zhou,  et al.  A pneumonia outbreak associated with a new coronavirus of probable bat origin.  Nature. 2020;579(7798):270-273.
3. Rice, et al.  Evaluation of angiotensin-converting enzyme (ACE), its homologue ACE2 and neprilysin in angiotensin peptide metabolism.  Biochem J. 2004;383(pt 1):45-51.
4. Kohl, K, Gelline, B. Measles as Metaphor-What Resurgence Means for the Future of Immunization.  JAMA 2020;323(10):914-915 

I hope you are staying well and out of harm’s way. I hope that you are safely getting a little sunshine on this beautiful day. Between meetings at work and talking with my colleagues I have spent a lot of time this week on the phone with many of you.  I have heard good stories about how people are holding up, what they are doing to stay safe, and to stay sane. It is hard to socially isolate, and I am thankful that so many of you have loved ones in your home.  I am thankful for the independent and resilient Mainer spirit in those of you who are going it alone or missing the companionship of a loved one.  It has also been so good to hear about people delivering groceries, taking care of, and generally looking out for each other.  These are difficult times, but times like these are precisely when we learn about human character.  We are seeing the best of people lately, and for that I am so grateful.  

Who is at risk?

It is however, still time to stay home.   We are doing the best we can in Maine to flatten the curve, and avoid a surge of cases to our health systems.  Most readers of MPDN news should consider themselves at high risk of severe illness in this pandemic (as defined by the CDC in Atlanta):

• aged 65 years and older
• people who live in a nursing home or long-term care facility
• people with other high-risk conditions, including chronic lung disease, moderate to severe asthma, serious heart conditions, immunocompromised (see footnote)
• people who have severe obesity (body mass index [BMI] >40)
• people with certain underlying medical conditions (particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk)

As for pregnancy, the CDC notes “people who are pregnant should be monitored since they are known to be at risk with severe viral illness, however, to date data on COVID-19 has not shown increased risk.”  I would note that they cannot say the same about related illnesses SARS and MERS. For that reason I would strongly advise pregnant people to consider themselves high risk.

Maine by the numbers

At his briefing today, Director of the Maine CDC Dr. Nirav Shah noted that there are 22 people hospitalized with COVID-19 in Maine.  The number of those who have recovered and been released from isolation is now 16.  We have confirmed 155 cases of COVID-19 in this state, 16 of whom are healthcare workers.  Ages range from under 10 to over 90, and the average age is 55.  Of note, yesterday the state received more of the reagent needed to run the test. As discussed previously, there is a national shortage of that critical substance.  There have been 3,394 negative tests in the state thus far.  As I discussed in my last post, the rate of growth of new confirmed cases is staying low in Maine over the last few days, and that is reason for cautious optimism.   It is not a reason to let our guard down however.   As I have mentioned several times, these numbers do not represent the likely total number of cases, but are limited to the very ill, the very high risk, or exposed healthcare workers. And, community spread has been confirmed in both Cumberland and York counties. To be clear, community spread is possible in all of them, and we should all act accordingly.  

Our hospitals are holding up fairly well so far, but no health system is prepared for what might happen, and here in Maine we are concerned about the need for protective equipment.  The Public Health Emergency Preparedness (PHEP) Team of the Maine CDC has distributed personal protective equipment (PPE) around the state to first responders, healthcare workers, tribal and law enforcement agencies.  They received the second distribution from the U.S. Strategic National Stockpile about two days ago, and are determining what will will go where.  Dr. Shah notes these distributions are a “good start, but they are not sufficient to meet the overall needs of the state.” Unfortunately, there has been some talk from the federal government that we might not receive more. Governor Mills has pushed hard to change that, noting we should not just focus on hardest hit states, but take a luck at “where the puck is going.” We are concerned that it could get a lot worse here.

If you have N95 masks or other medical protective supplies such as paper masks (with ties or elastic), paper protective gowns, protective glasses/goggles (can be previously used), or nitrile gloves, please donate them to your local hospital.

At present there are 86 available ICU beds in Maine out of a total of 151 in service, and 250 available ventilators out of a total of approximately 307.  There are at least 88 respiratory therapists in the state. These are good numbers under normal circumstances. This is not one of them. We need to keep up the good work, and make sure those around us know how delicate this situation is.

“As a state, as a community, as an agency, the things that we thought were utterly inconceivable a month ago, now seem blindingly obvious…  The question on my mind is, what will we be saying a month from now?…But we will get through this, and we will do so partly because our approach is informed not just by science, but by kindness, humanity, and compassion.  We can, and must remain together, even though for now we may be apart.”

Dr. Nirav Shah, Director of the Maine CDC

The incubation period, the time from exposure to illness is between 2 and 14 days. Therefore, there may be many people in our state who do not yet know they are sick, yet are able to transmit disease.  People who have been exposed to a COVID-19 case should quarantine for 14 days. And, as discussed multiple times here, there may be many asymptomatic carriers who may transmit disease also.  We have also learned that some otherwise asymptomatic people may lose the sense of smell and/or taste with this viral infection.  If someone you know has this, stay away from them, and tell them they should be in isolation for 14 days. 

Social distancing

Since we cannot yet do the mass testing we need, the only reasonable strategy is social distancing.  It has worked in other countries, such as South Korea, where the response was decisive and early. South Koreans were, and are very good at social distancing, but also tested a high percentage of the population, tracked down and isolated infected people. You should continue to stay home, stay at least six feet back from others, avoid sick people altogether.  Also, wash your hands, don’t touch your face, and be COVID-aware.   If people bring groceries to your home, have them set them outside the door and don’t pick them up until the delivery person is out of the six foot droplet range.  Again, clean surfaces such as door handles, rails, anything that might be contaminated by virus.   And wash any produce brought into your home.  Wash your hands after putting groceries away. 

If you do go to the store, please go alone at the best possible time, and please consolidate trips.  Governor Mills urged stores to post times for seniors, to mark six foot distances on the floor at checkouts, to consider limiting the number of people in a store at one time.  If you do not see this happening, ask a manager why.  It is for public safety.  By that logic, I have heard that Hannaford’s of Topsham has placed plexiglass shields between customers and checkout personnel. That is a great strategy for reducing droplet risk to store employees (and to customer for that matter).

Be prepared     

If you have not had a pneumonia vaccine, and it is possible to have one safely (at your facility, or possibly at a pharmacy), it is a good idea to have one now.  The reason is that while COVID-19 may cause pneumonia itself, it may also make you more vulnerable to bacterial pneumonia, another potentially deadly condition.  In general, older people should also have an annual flu vaccine, unless there is a legitimate medical contraindication.  Vaccines save lives.   It is my deep hope that we will have a COVID-19 vaccine before this virus has a chance to come back-though I am certain we have not seen the peak of the current pandemic.   Just look at the situation in our country and around the world: nearly a half million cases around the globe, and over a thousand deaths in the U.S. alone.   The hardest hit state in our county is New York, where there are 37,258 cases (21,393 in New York City).  Cases in Seattle and Washington state continue to climb.

You should have refills of all medications on hand. Make sure at minimum you always have a 14 day supply in case you are quarantined. Try to safely go outside a little bit every day. Get exercise, stay positive. Keep in touch with others by phone, text, email, Skype, whatever works. If you can stand far enough away from others in your neighborhood talk to them, ask how they are doing, and check on those that you worry might not be doing so well. We are all in this together.

FOOTNOTE

The CDC in Atlanta notes that many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications

There are 117 cases of COVID-19 in Maine today, up 47 since I posted just three days ago, and the first case was reported just 12 days back. COVID-19 now involves 10 counties in our state.  While this sounds bad, and it is a growing number, I want to cautiously point out that the rate of growth is not as bad as it could be.  And, I want to emphasize again that we are only testing the very ill, high risk patients, and healthcare workers who have come into contact with COVID-19 patients.  We have no idea how many cases there really are. Still, we have a reason to be happy, in that the numbers we are seeing are lower than they could be.  I think this is in large part due to the efforts of people who have stayed home. We have a little bit of a geographic advantage also due to the fact that Maine is the least densely populated state along the eastern seaboard, and in New England.  Businesses are doing their part at a dear cost in those that have had to close, and some have changed to the manufacture of medical equipment.  The entire medical community is making huge, and often heroic efforts in the face of this pandemic. I am proud of my colleagues around the state. Every person who works in healthcare, no matter the position, is being asked to take risk, and is doing their part. My hospital has never seemed more vital. I see every person there as an important member in the fight against this disease. So how are we doing?

First, a look around the U.S.

Yesterday the Surgeon General, Dr. Jerome Adams, advised people to stay home.   He noted that COVID-19 is “going to get bad” this week in the U.S.   This was in reference to the rapid acceleration of cases around the country, and the need to take action at many levels. His message was mostly directed at the individual however. Between the lines, he advised strongly for us to take it seriously, and don’t become part of the problem.

Today the CDC in Atlanta notes there are a total of 44,183 cases of COVID-19 in the U.S., and there have been so far 544 deaths.

Washington state,where COVID-19 was first detected in the U.S., has 2221 cases, about half in King county (Seatle).

As discussed in my last post, New York City, the most affected municipality in country, has 14,900 cases (up 150% in three days, a large exponential growth rate) and FEMA has made a major disaster declaration.  The news coming out of NYC is very troubling, and there are 25,665 cases in that state. We don’t want to replicate it here.  

What are we doing to stop or slow COVID-19 in Maine?

Every health system in the state is grappling with this issue, and there are daily policy and strategy changes.  Most offices have switched to tele-medicine for non-urgent outpatient medicine, and elective procedures are being delayed to free up space, equipment, and providers in medical facilities.   Even in the offices we are attempting social distancing as much as possible.

Our state agencies and government have been hard at work on the issues as well.  Meanwhile, medical and emergency personnel are dealing with shortages of protective equipment.   

The governor and the Maine CDC

Today via a press conference with Governor Janet Mills and Dr. Nirav Shah of the Maine CDC, we learned that there are 15 COVID-19 patients hospitalized in Maine so far.  And, of the 117 positive patients, seven have recovered.   The total number of negative tests in Maine is over 3000.   Dr. Shah wanted to emphasize however, that the “cases we detect in any outbreak setting…merely represent the tip of the iceberg.”  By this he meant there are many more cases that are not tested, people whose illness does not rise to the strict criteria for testing, in no small part due to rationing of the test (see below).   There are also many asymptomatic carriers who would test positive, and are capable of spreading disease.  We simply don’t have enough tests to check everyone.  Thus, the few we test and find positive represent the tip of the iceberg, with a huge mountain (of other cases) beneath.   Because of this, because of questions from Mainers about when to take action he noted, “now is the time to start taking public health action…there is no need to wait…the absence of evidence of cases in your county is not evidence of absence…”   He noted it is time to behave as though the virus is in your town.  

Dr. Shah reported there are now several labs doing tests for Maine, three more added today.  Maine has 1300 tests pending currently, which Dr. Shah noted was unacceptable, and due to a national shortage of the reagent needed to test for the virus that causes COVID-19, affecting labs around the country.  Dr. Shah noted we are working to acquire an additional piece of equipment that hopefully will have a more steady supply of a different reagent.    

As for personal protective equipment (PPE), there is a shortage.  This is because under these circumstances we are consuming unprecedented volumes of the equipment in the testing, evaluating, and caring for potential and actual COVID-19 cases.  Another issue is that we are not receiving the volume of equipment needed from the federal stockpile, as there is need in all directions: every state has cases. One of the stated tasks of the Maine CDC then, is to distribute available equipment around our state fairly.  And, it is not just to hospitals. Yesterday Maine CDC distributed 22,000 pieces of equipment to fire and rescue, local law enforcement agencies, first responders, and regional medical facilities.  This morning Maine CDC received the second distribution of PPE from the federal stockpile.  It was still not enough.  See my last post about a few requests. 

Dr. Shah gave an update on the availability of scarce medical resources.  Currently available are 77 intensive care unit (ICU) beds, 248 ventilators, and about 84 respiratory technicians to assist in using those ventilators.  During the later Q/A session Dr. Shah discussed ventilators, noting they are really a three part issue: the ventilator, the person to operate the ventilator, and the space to put the ventilator and a patient.  In Maine certain ventilators (for surgical procedures) can be adapted to use for these patients also.

Governor Janet Mills spoke of the ways Maine people have met this challenge, noting for example that ND Paper had donated 1000 N95 masks to the state, that “everybody with a sewing machine wants to sew masks,” and “LL Bean workers are helping the Good Shepherd Food Bank.”   She gave several examples and spoke about the goodness of Maine People.   “People are stepping up to the plate.”  For those that are thinking of donating supplies or helping Maine is setting up a portal in the next few days.   It will be on the Maine.gov website. 

Mills noted she has been on the phone with VP Pence four times “stressing needs (of Maine) with the federal government.” 

New steps

Today Mills renewed her previous Executive Order prohibiting gatherings of more than ten people and the closure of dine-in service at restaurants and bars in Maine, extending the timeframe to April 8, 2020 at 12:00 a.m.   More steps are being taken to prevent the spread of the SARS-CoV-2 virus that causes COVID-19.   The governor is mandating a 14 day closure of physical locations of non-essential public-facing businesses (Homeland Security definition), such as shopping malls, fitness and exercise gyms, spas, barber shops, hair salons, tattoo and piercing parlors, massage facilities, nail technicians, cosmetologists and estheticians, electrolysis services, laser hair removal services, and similar personal care and treatment facilities and services. The order closes non-essential business sites that require more than ten workers to convene in a space where physical distancing is not possible. “Non-essential businesses and operations may continue activities that do not involve these types of in-person contact and convenings, and should facilitate the maximum number of employees working remotely.”  The order is effective March 25, 2020 at 12:01 a.m. through April 8, 2020 at 12:00 a.m.

Essential businesses that are excluded from the mandate include food processing, agriculture, industrial manufacturing, construction, trash collection, grocery and household goods, convenience stores, home repair stress,  hardware stores, auto repair, pharmacy, other medical facilities, biomedical, behavioral health and health care providers, child care, post offices and shipping outlets, insurance, banks, gas stations, laundromats, veterinary clinics and animal feed and supply stores, shipping stores, public transportation, and hotel and commercial lodging.

A request from the governor

She did not mandate, but strongly urged, all large, essential, public-facing businesses to immediately employ strategies to reduce congestion in their stores, including limiting the number of customers in the store at any one time and enhancing curbside pick-up and delivery services.  These steps were meant to better protect customers and employees.  She urged physical distancing measures, enhanced curbside pick-up and delivery services, staggering of hours for shoppers of a certain age, closing fitting rooms, cautioning customers against handling merchandise they are not purchasing, marking six-foot measurements by the cashier stations and reminding customers to remain six feet apart while in the store, staggering break times for employees, requiring frequent hand-washing, frequently sanitizing high-touch areas, such as shopping carts.

Stay away from other people.  Just because a store is open, doesn’t mean it is safe to go there, and it doesn’t mean you should take your family with you…the next 15 days are critical for flattening that curve…we are confronting an unprecedented challenge…

Janet Mills, Governor of Maine

She was asked about the rise in out-of-state visitors we are seeing: “if they believe they can escape that by coming here, if they believe they escape the virus, they are wrong, because it is here…” As for whether snowbirds should return home to Maine, she answered “if you’re safe where you are, stay where you are,” noting that you cannot travel without rest stops, and a lot of contact.

As for future restrictions, she noted “I hope that we can avoid taking further steps, but it depends on our collective actions… (it) depends on whether we stay apart today so that we can come back together tomorrow.”  She also noted that in Maine those afflicted are not just the elderly or those with underlying illnesses.  “We have cases of all ages,” but in taking measures, in helping others, “we want people to be cautious and courageous.”  When asked about behaviors of some people in Maine, she responded “I am not going to speculate on what people might do, because I expect them to do the right thing.” 

When asked about Bath Iron Works, which is still in operation, and the subject of heavy public outcry, she noted that she had been in contact with federal officials, and reviewed a letter from the Department of Defense re BIW which was “not satisfactory at all.”  BIW has thousands of workers, and at least one case of COVID-19 has been confirmed in a worker.  There is legitimate concern that the facility may be the cause of a surge of cases due to the concentration of workers and the close proximity of the work environment.  While many employees have opted to take unpaid leave, some steps have reportedly been put in place to reduce risk of spread.

In conclusion

Thank you for all you are doing, and know that it matters. These are difficult times, but we can get through them.  Please stay safe, practice hand washing, social distancing, and flatten the curve.  

In case I haven’t been explicit in recent posts to MPDN, I have suspended the normal format to give public health notices and generally respond to the COVID-19 Pandemic.  This is because the most vulnerable are older people, and those with chronic conditions.  Most people with PD fall into both of those categories and would be at high risk of serious illness or death if they caught the virus that causes COVID-19.  I am very worried about that because I am still hearing from some of you who are not staying home or are not taking on board the seriousness of this situation.  I am still seeing high risk older individuals chatting with other people at the grocery store and ignoring the droplet range distance of six feet, even though it is now common knowledge that infected people may spread the virus while asymptomatic, maybe while just chatting.

Perhaps the pandemic doesn’t seem real to you, or it doesn’t seem as bad as people keep saying. Maybe to you it seems unreasonable to cancel everything and close so many businesses. Maybe to you it seems unreasonable to ask well people to stay at home. It is the best we can do right now because this virus is new, not so well-understood, and dangerous. There is also no vaccine, and no proven treatment.

In an ideal situation when something new like this virus came along we would rapidly test everyone, health workers would have adequate equipment, we would have a strong public health initiative from day one, and we would have leaders who understand that we need to bolster, not reduce the Centers for Disease Control and Prevention (CDC).  That is not the situation we find ourselves in.  We came into this crisis less prepared than we should have, and we are all risk because of it.

We have nowhere near the number of tests we need to find out who is sick and who isn’t.  We therefore cannot selectively isolate sick people and carriers.  Instead, we have shut down all “non-essential” services and ask everyone else to stay home and to practice social distancing. If all of us did this, the virus would stop spreading.   Yet, some people are not getting it right.  There needs to be a mindset change.  My advice to everyone who thinks that they are well is that we act as though any person might be infected, including ourselves. If we do that, if we limit trips out of the house, stay at least six feet away from other people, and don’t spread germs, we will be doing our part.  

Also, for the same reason, I would strongly advise all of us to keep our living spaces as a sanctuary, no visitors.  As I discussed earlier this month, clean surfaces, wash your hands, cover coughs and sneezes, and don’t touch your face.  List of CDC recommendations to protect yourself.

You should also know that as the number of infected people goes up, your chance of catching the disease does too.  If you go out of your living space you are more likely to encounter a sick person, and more likely to encounter droplets left on surfaces such as doorknobs or rails. This is important because we are talking about something that is invisible to the eye but may infect you long after the sick person has departed.  A correspondence to New England Journal of Medicine on March 17, 2020 showed that this virus may stay in the air indoors for up to three hours after a cough or sneeze, all the while remaining viable.  The same authors reported viable virus on copper for up to four hours, cardboard for 24 hours, and plastic or stainless steel for up to three days.   

Some people think the numbers of infected people are not that bad, that their risk is low. In the U.S. every state has cases, and the numbers are growing.  Today the World Health Organization estimated over 300,000 cases worldwide.  Recall that the virus was only reported to WHO by Chinese officials on 12/31/19.  The virus has spread rapidly and continues to do so.  It is overwhelming healthcare systems in Italy and Spain.  There is no doubt that the numbers are bad.

If you already realize that this is the worst pandemic in modern history, and is occurring on a truly unprecedented scale, but have a cavalier attitude about your own mortality, consider the fact that if you get sick you will probably spread the virus to other people.  That is the nature of infectious disease: it jumps from one host to another.  While you might survive, someone else down the line from you might not. 

The numbers today

The state of Maine has 70 confirmed cases of COVID-19 as of today, 3/21/20, and these are only the people who have been tested (a limited number of sick people and others who meet very narrow criteria for testing).  The majority of cases are in Cumberland County, and following in order of cases are the counties of York, Kennebec, Lincoln, Oxford, Androscoggin, “unknown,” Penobscot, and Sagadahoc.  Ten percent of confirmed cases in Maine are under the age of 30, 45% are between 30 and 59 years old,  and 45% are 60-years-old or greater.  We have no idea how many cases have not been tested.  In Maine we have had cases caused by travel, cases with community spread (catching it from someone else who tested positive), and cases in which there is no explanation (likely exposure to an unknown sick contact, droplets on a surface, or seemingly least likely, contaminated air).  Numbers vary from state-to-state in New England.  Massachusetts has 328 cases.  New Hampshire has 65 cases. Vermont has 49 cases.

As I noted previously, serious illness and death as a result of COVID-19 is more likely with increasing age.   To get more of a sense of that problem, let’s look at the numbers from the state of Washington today: 1793 confirmed cases (up over 500 cases in just a few days), and 94 deaths so far.  Deaths have occurred as follows by age and (percentage):  0-39 (0%), 40-49 (2%), 50-59 (5%), 60-69 (10%), 70-79 (23%), 80 and up (60%).   Washington was the first state known to have COVID-19.  However, it is not the worst. New York has 10,356 cases as of today (over 6,000 cases in New York City alone). 

The CDC in Atlanta reported as of yesterday that there were 15,219 cases in the U.S.

We in Maine are in a serious situation.  Remember that per capita we are the oldest state in the nation.  We are trying to flatten the curve of cases so that we don’t overwhelm health care systems. If a surge of cases comes to the hospital, there may not be a way to care for all of them.   

What I’m asking

Stay home as much as possible for now.  It is still early days and we are behind.  We don’t have enough tests to learn the true scope of the problem, and the best thing you can do is not to become a part of it.  We might not be able to help you if the rate of infection continues to increase.  If the rate of infection levels off in Maine and around the country we may be able to “catch up” with test kits and other supplies we need.  We may be able to wait long enough to find out if certain drugs are effective against the virus.  We may be able to develop a vaccine. 

Ask younger family members, friends, associates to take this seriously too.  They could be spreading disease and not know it.  They need to think about the community around them and how they might spread disease within it.  And, while the death rate is low for younger people, they may also become seriously ill.  They should also limit trips out of the house, and when they do leave, wouldn’t it make sense to limit the number of people going into stores?  I keep seeing families and groups of friends together in the grocery store. The more people present, the more likely someone will become ill.  

If you have clean N95 masks, give them to a local hospital.   We are running out fast, and standard surgical masks will not work.  I know that people in the community have boxes of them because they were cleaned out of hardware stores and medical supply outlets, and I see people wearing them at the grocery store.  If doctors, nurses, and emergency personnel don’t have adequate protection we will become ill and be unable to care for you.  This is what is happening in Italy.

Be very careful about news sources.  There is a great deal of misinformation out there from politicians, news anchors, and other non-medical sources. The CDC in Atlanta is the best source for information. 

Finally, remember that what we do matters.  I believe this is a pivotal moment in our history. Let’s try to lead it somewhere good. Let’s learn from this and not make the same mistakes in the future.

That’s all for now. Stay well, keep your head on straight, and as I like to say at the end of visits, stay out of trouble.

Social isolation can be stressful, and the loss of normalcy can make people feel like they are losing control.  We are all feeling it, but some are less protected than others from isolation during this time of social distancing, cancellation of just about everything, and separation from loved ones.  I want to share with you a few thoughts about how to keep your head on straight if you are feeling isolated during the time of COVID-19.  I also talked about this with our behavioral health clinician, Grace Plummer, LCSW. I included some thoughts from her below.

Keep your routines

Get up on time in the morning, eat nutritious foods, and get regular rest at night.  Your daytime routine should continue in some way.  If you normally would go to a coffee shop in the morning and chat with friends, try doing that from home. Make a coffee and phone date with those friends.   Have things to do, make plans (even if they are just around your living space), and do them.   If you have no plan, you might get a little cabin fever.  

Exercise

I covered this a couple articles back.  Don’t stop exercising just because you are stuck at home.  Exercise improves health and mood.  Stopping has the opposite effect.  

Time to work on things

If you have a hobby or other interests, this is a good time to get more involved.  What was that project you needed to do?  Is there some genealogy you meant to look up?  Did you forget to call your second cousin last year?  If there is a book or an article you wanted to read, you may not have realized that you are actually in luck.   

A glimpse from my own life: I was very busy in 2007, living a life of non-stop activity.  Preoccupied by research, patients, writing, meetings, married with two almost-teenagers at home, planning on moving to Maine, I was “straight out” as they say.  However, along came a medical issue.  While recovering at home from surgery I was stuck in bed for a couple weeks.  My colleagues covered the patients, my wife managed the young people (they would say they could have managed themselves), and I was suddenly left with nothing on the schedule.  Though not feeling great for a while, I viewed that time as a gift.  I delved into some things I had always wanted to learn: some medical, some musical.  Looking back I still value that time (and I can still play that Muddy Waters song on the guitar).  What’s the old expression, one door closes?

Learn something new

If you are not caught up on current events (other than this dreaded virus) or political viewing (yuck), there is plenty on the internet, just be careful of your source.  And, Grace wanted me to interject, that you should probably limit the amount of time you are spending watching the news and reading the paper. Good advice.  All anyone is talking about lately is unhealthy stuff.   But there is other news or media you can investigate.  

YouTube is a great resource both for legitimate information, and the other kind.  I think YouTube is a net benefit because of the community of people who have enthusiastically put just about every kind of how-to video.   I have found everything from music theory, to old episodes of Jeopardy, to how to remove the annoying buzzer from Mr. Coffee, to how to fix the exhaust fan in my bathroom.  If you want some excellent distraction, there are entire episodes (I think entire seasons) of Dragnet that you can watch for free.  Just listening to the theme music lifts my mood.  

Favorite music

There is little that transports me as much as music. If you love some music of happy times, listen to it. It can take you places. It can relax, refocus, or help you process your feelings. Sometimes I will go through the entire catalog of an artist, or listen to several records back-to-back while working on a project in the house. Again, YouTube is full of music.

Virtual tours and live webcams

You could also use the internet to visit a virtual museum or peer through a live webcam.  Several museums and other locations around the world offer this.  For example, try some of these:

The National Museum of Natural History: https://naturalhistory.si.edu/visit/virtual-tour  

The Louvre: https://www.louvre.fr/en/visites-en-ligne

Georgia Aquarium live web cams: https://www.georgiaaquarium.org/webcam/ocean-voyager/   I don’t think I have ever watched anything so relaxing on the internet. It might sound a little silly, but knowing it is live makes me feel very connected to those beautiful fish.  

Yosemite Park: https://www.virtualyosemite.org/about-virtual-yosemite/

Stretch, meditate, relax

I would advise all adults, especially people with Parkinson’s, to have a daily stretching regimen.   This can even be done while still in bed, though there are a variety of strategies.  Just remember that we tend to carry stress in the neck and shoulders.  Stretch those muscles out a couple times a day.  

Try this for example: sitting in a chair, start with rolling your shoulders forward.  Hold them there a few seconds, breath in an out deeply, then relax.  Repeat this a few times. Now, imagine you want to hold a tennis ball between your shoulder blades. Move your shoulders backwards and grab that imaginary ball just over your spine.  Hold it there for a few seconds.  Breathe deeply.  Relax.   Gently turn your head left and right, up and down.  Tilt your head back again and gently turn your head from side-to-side in that position.   If any of this hurts of course, don’t do it.  If your muscles are too tight to do this, try a little moist heat first.   

There are many different stretches you may have learned and can call upon. YouTube has sites for gentle stretching and yoga.  Stretching does more than help with flexibility.  It increases blood flow, prevents injury, and makes us feel better generally.   Loosening up the head and neck may stave off some types of headaches.  

Grace wanted to remind people to keep in touch with spirituality, and to add prayer to the list if you are a person of faith.   She also added:

Gratitude practices are known to be helpful too: making a list of five things one is grateful for.  They can be small, tiny things, and you are encouraged to find five new things each day.  That helps us stay focused on what we have, versus what we feel we have lost, whether the loss is temporary or permanent.

Meditation comes in many forms. If you already do it, great. If you do not, there are many resources on the web to help you. I have a form of meditation in which I sit or lie down quietly, clear my mind, and focus on a mental image. I can do this for short or long periods of time. The idea is to stay awake, and to stop thinking, in words and formed thoughts at least. This can be very relaxing. Stressful thoughts and recurrent unhappy themes can wear a person down. Meditation is a way to reset those thoughts, and get your “mind right” (a reference to Cool Hand Luke). I remember once reading a quote from Beatles guitarist George Harrison, who studied eastern philosophy, and said that meditating allowed him to “shut off the chattering monkey” of his mind. Get rid of negative thoughts.

It is okay to just relax. I was happy to hear from a relative who is a hair stylist in Seattle how great her body is feeling with a couple weeks off.

Do some self-care

Take a hot bath. Read a passage or two from a book you love. Watch a favorite movie.

Take it easy with mood altering medications and alcohol

If you are not in a good place with mood these things don’t help.

Stay in touch with loved ones

Grace recommends that families set times for daily phone chats.  It gives you something to look forward to, and it is very calming to hear the voice of someone you care about.  If you use texting, this is also a good way to stay in touch, especially with people who are in other cities.  My wife and I have a group text with our family.  Every day we check in, send pictures to each other, and find out if our loved ones are doing alright.  

This is also a good time to write long letters (or emails).

If you know someone who is isolated, check on them, see how they are doing.  It means the world sometimes. 

So those are a few thoughts.  Stay well. 

COVID-19 is a potentially lethal respiratory infection caused by a novel coronavirus known as SARS-CoV-2 (aka 2019-nCoV), which is in the same family of coronaviruses with SARS.  To be clear, COVID-19 is the disease, and SARS-CoV-2 is the virus.  By comparison, SARS was responsible for infection of 8098 people between 2002-2003, and 774 deaths.  MERS was also caused by a coronavirus, which from 2012 to November 2019 has been found in 2494 cases, and attributed to 858 deaths.  COVID-19 unfortunately has much higher numbers as I will review below.  

While it is true that most people will survive COVID-19, and that many have a mild infection, this is not true for all groups of people. 

The severity of illness, and the incidence of death from COVID-19 increase with age.   This is not to say that younger people are not infected.  It seems likely that younger people, and those without chronic illnesses are better able to tolerate the infection. 

Hence, the population of people who read MPDN should please pay special attention to this article.  I want to limit your risk, and to correct some of the thinking that has been shared with me in recent days.

This is not “just a virus,” and if you are infected, unless you take isolation measures, you stand a high probability of spreading the disease, probably to someone you care about, and to plenty of people you don’t know.

Where did COVID-19 come from?

Coronaviruses were known to medicine for decades prior to SARS and MERS and were typically associated with mild respiratory infections such as the common cold, similar to rhinovirus.  However, viruses can mutate, or have changes in their genetic code, that make them more infectious, and perhaps more deadly.  

SARS-CoV-2 is a mutated strain that has only been known since the end of 2019, when it caused a deadly form of pneumonia in Wuhan, China.  This was around the time of the Chinese Lunar New Year, the largest annual mass travel event worldwide. (2)   December 31, 2019 Chinese officials reported the deadly infection to the World Health Organization (WHO).  By that point, there were numerous cases in China, many having traveled home from Wuhan after the holiday.  

January 2020, the first case of COVID-19 was reported in the United States: a 35-year-old man who had visited Wuhan to see family during the recent celebrations.  He had returned home to the Seattle, Washington area on the 15^th of the month. (3)   Four days later he presented to an urgent care clinic in Snohomish County, Washington (just north of Seattle) with a complaint that since his day of arrival home he had a cough and fever.  He informed health workers of a CDC alert he’d seen regarding a virus in Wuhan, and was admitted to the hospital with pneumonia.  Testing confirmed SARS-CoV-2.

As was typical, there were many flights from Wuhan to the United States, and surely, this man was not the only case to travel from Wuhan to the U.S. and other countries.  Meanwhile, by February 11, 2020 COVID-19 had spread all over China, with more than 72,000 cases. (4)  The U.S. government was slow to respond, and the chief executive declared the situation under control. It was not. By March 11, 2020 SARS-CoV-2 had spread not just in the U.S., but around the globe, and was declared a pandemic by WHO. 

As of March 17, 2020 the State of Washington Department of Health reported 1012 confirmed cases with only 2% under age 20, 7% under age 30, the remaining 91% of cases over 30.  Percentages of those infected increase by small margins with age. (5)  Among those 1012 cases there had been 52 deaths.  In part the numbers were misleading.  There was a delay in getting test kits, and only a limited number of test kits available.  Therefore, only the most ill patients, or those that met very specific criteria had been tested in the hardest hit state in the nation. 

The problem is that almost certainly there were and are, many more asymptomatic or only mildly symptomatic carriers capable of spreading the infection to others.  The incubation period (time from exposure until symptomatic) ranges from 2-14 days.  Complicating matters, Americans travel.  The virus travels with them, and we have had cases in every state.  

The State of Maine has a total of 42 confirmed and presumptive positive cases as of today, March 18, 2020.  However, this is after starting limited testing less than a week ago.  Most of the positive cases have come from Cumberland County, though seven counties are affected so far.   There is a strong likelihood however, that as with other locations, many more people are infected and capable of transmitting the disease. 

Per the CDC there are today 7,038 cases of COVID-19 in the U.S., and there have been 97 deaths.  The worldwide number is staggering.  This brings us to important conclusions: we need to take this seriously and do all we can to limit the spread of the virus.  It is time for social distancing, and we need to flatten the curve.

Social distancing

This means staying home unless it is absolutely necessary to go out.  It also means if you are around other people, stay out of the droplet range (six feet), even if they appear to be well.  This is an airborne disease, meaning it can be spread in the air around you by breathing, coughing, and sneezing.   It can also be spread by droplets on surfaces such as doorknobs, rails, shopping carts, counter tops, and hands.   Don’t shake hands with others, and don’t touch your face unless your hands and your face are clean.  In particular, don’t touch your eyes, nose or mouth with unclean fingers. 

Wash your hands often, especially after blowing your nose, coughing, or sneezing, or having been in a public place.  Soap and water are always best, especially if your hands are visibly dirty.  Hand washing should cover the entire hand and take at least 20 seconds.

To wash hands properly, wet your hands with clean, running water, apply soap, lather your hands by rubbing them together with the soap, covering the backs of the hands, between the fingers, and under the nails. Rinse off soap and dry with a clean towel or air dry.  However, if soap and water are not available, a hand sanitizer with 60% alcohol or higher inactivate kill the virus.   

The CDC also recommends stocking up on supplies such as groceries and medications, keeping away from sick people, limiting close contact, avoiding crowds “as much as possible,” especially in poorly ventilated spaces, but also cruise ships, and non-essential air travel. 

If COVID-19 is in your community, and you are in a high-risk group, investigate ways to get food brought to your home via family, social, or commercial networks.  You should still stay in touch by phone, emails, or texting with loved ones, because social isolation can be emotionally and psychologically very difficult.  

If you have a caretaker, make sure they stay well, and have a plan for the possibility that they fall ill.   Have a backup caretaker in mind such as a family member.

Flatten the curve

When an outbreak of an illness occurs in a community, numbers climb over time, as it is spread from person-to-person. 

With a rapidly spreading and dangerous illness the threat is not just that many people will fall ill, but that the number of sick people may overwhelm hospitals and other health resources, as has happened in Italy and China. 

In that case, a person who needs help might not get it, with disastrous consequences for the person who otherwise might have pulled through with therapy.  I cannot put it any more plainly that to say in that case there will be more death and more disability. That is why we want to “flatten the curve.”  This means slowing the rate of exposure or decreasing the number of cases that happen at once.  If we flatten the curve, likely there will be fewer cases overall, and hospitals will not be overwhelmed, as was the case in Singapore and Taiwan.  If the rate of infection is kept low enough, everyone gets a chance for treatment.  

Imagine a hospital with 150 beds.  If 300 people come in with a severe illness, half of them might not be helped.  Under normal circumstances we would call around the state or to neighboring states for help.   But, if hospitals are all experiencing a surge in cases at the same time, there will be no help. 

Now, imagine everyone in the state practicing social distancing, washing their hands, using common sense and care to avoid spread.  The disease spreads very slowly, and the hospital and health workers are not overwhelmed.  Everyone gets a chance.  We all fare better.    

This is flu season, and hospitals are already dealing with a lot of infection and respiratory illness.  Because of this, and because of COVID-19, elective procedures in hospitals and clinics around the state are being put on hold in order to free up hospital beds for a potential surge in patients.  In fact, many doctors’ offices are not seeing anything but urgent patients, to limit risk for healthy patients.    

If you think you have been exposed to COVID-19 by a known case and/or develop a fever and symptoms, such as cough or difficulty breathing, CDC recommends you call your healthcare provider for medical advice.  However, you should be aware that doctors’ offices are receiving very high volumes of calls, and many offices cannot keep up with this.  Please do not contribute to that burden unless you meet the above criteria.  Many of the questions people are asking can be answered online at Maine CDC (6) or at the Federal CDC (7) websites.

Many people in the U.S. with mild symptoms are staying home and weathering the illness, but should be in isolation within the home.  Such a person should have their own room, ideally their own bathroom, and wear a mask when around others-which should be limited, to limit the spread of droplets. Surfaces in the home they have touched should be cleaned.

In conclusion, I don’t mean to be alarmist. This is a serious situation which warrants concern. We have only to look to China and Italy to see how bad this can get. However, it does not have to be that way here. I suspect however that it will not be over in weeks, but will take months for this spread to stop. You can help by social distancing, and by flattening the curve.  These are the right things to do.   

REFERENCES

1.  https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html
2. Phelan, et al.  The Novel Coronavirus Originating in Wuhan, China.  Challenges for Global Health Governance.  JAMA 2020;323(8):709-710.
3. Holshue, et. al. First Case of 2019 Novel Coronavirus in the United States.  NEJM 2020;382 (10):929-936.
4. Novel Coronavirus Pneumonia Emergency Response Epidemiology Team.  Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Weekly.  http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51
5. https://www.doh.wa.gov/emergencies/coronavirus
6. https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/documents/Public-COVID19-FAQ-16March2020.pdf
7. https://www.cdc.gov/coronavirus/2019-ncov/index.html

These are strange times. The COVID-19 pandemic has led to calls for closures of businesses, schools, and even exercise classes-even PD exercise classes. That social distancing, and attempts to “flatten the curve” of the outbreak are appropriate. The CDC is advising older adults and others at high risk to “avoid crowds as much as possible.”

But this doesn’t mean you should stop exercising during this hiatus. Exercise has been shown over the last few decades to improve parkinsonian motor symptoms, and to likely slow down progression of disease. Aerobic exercise in particular seems the most beneficial, but core strengthening, balance training, weight lifting, stretching, yoga, and tai chi can all be helpful.

In addition to benefits in PD, regular aerobic exercise can improve vascular health in the body, including the brain and the heart, protecting against heart attack, stroke, high blood pressure, diabetes, and high cholesterol. And, there is ample evidence that exercise improves mood. Stopping a regular exercise routine might have the opposite effect. Also, with exercise in PD, it is a “use it or lose it” issue. Unused muscles atrophy. We don’t want that, do we?

So, how can you get exercise without access to your class or your gym? You might have to be creative. If you have a stationary bike or other safe equipment at home, use it. If you do not, it is time to look at the objects around your living space and ask “are you a piece of exercise equipment?”

I met a man in his 90s while I was in medical school. I advised him to get some aerobic exercise, and he had every possible “old guy” excuse along the lines of: “my back hurts, my knees give out, my balance ain’t so good, I don’t like it,” and what he thought was the deal-breaker: “I can’t afford it.” I challenged him to be creative, to try chair exercises, something that would cost nothing but his time, and would improve his mood and his health. The next time I saw him he had an exercise routine. In each of his hands he held a large can of beans that he used to do sets of biceps curls (bending at the elbow to flex the biceps), triceps extensions (raising his elbows to the level of his ears and then extending the cans high over his head), “punching” the cans slowly into the air, and other moves that brought his heartbeat up, and the sweat out. The key was to do sets of the exercises, such as 10 curls, 10 lifts, 10 punches, rest and repeat. After doing five sets of each, he could tell something good was happening. After doing this daily for a few weeks, he noticed he generally felt better.

For those that would prefer to use their arms for chair exercises an alternative is the table-top pedal machine (like the pedals of a bicycle, and built on a tripod) can be used by the hands. The same thing can also be placed on the floor for the feet, if you are not limited to the arms.

Leg lifts can be done from a chair. Again, repetition is usually the key, though sometimes simply holding your foot in the air (extended at the knee) for an extended period of time is good exercise. If it doesn’t sound true, I challenge you now to try it for 30 seconds. Alternate sides, repeat.

A lot of older athletes enjoy planking, basically holding the push-up position with elbows extended for so many seconds, then rest, then repeat. You have to be careful not to let the hips sag with gravity, as this may strain your back. But believe me, doing a plank properly will get your heart beating. Many people don’t feel strong enough to get into the the plank position and will do a milder exercise: getting prone on the floor and then balancing on the elbows and knees, with the belly button a few inches off the floor. If you do this enough, you will get stronger.

Holding onto a counter and doing leg lifts can be hard work also. Try facing a sturdy counter with both hands firmly placed for balance, then bring one of your legs up away from your body (like Bruce Lee in a side kick) with the knee locked. Hold in position for three seconds, then bring your foot back to the floor. Do sets of these on both sides.

There are so many home exercise routines. The Parkinson Society Canada has this free download you could take a look at. YouTube is also a good resource for Parkinson exercises. For example, the St. Louis APDA has an hour-long exercise class online you can watch and work out along with the participants. Like my old friend from medical school, be creative.

Remember also, always warm up to exercise, and stretch after.