Category: Spring 2020

Should you wear a mask or face cover in public?

As we have previously discussed here, the CDC in Atlanta has recommended that people wear a cloth face cover when out in public (see footnote). A face cover is not meant to substitute for social distancing, and the recommendation that people remain at least 6 feet apart remains.  Because so many people still don’t seem to understand the reason for wearing a face covering, I will go over that here. Specifically, I am trying to address people who believe they are not infected, don’t think there are sick people around them, and therefore think they don’t need to wear a mask in public.  

The point of wearing a face cover or mask in public or around others who are not close contacts in the home is to limit the spread of SARS-CoV-2, the virus that causes COVID-19.  To date this disease has claimed over 115,000 lives in the U.S., where there have been over 2 million cases (over a quarter of cases worldwide).   

How a face covering prevents the spread of COVID-19 is simple.  It is a barrier.  We need that because  even healthy people release moisture in the form of respiratory droplets when they breathe or talk. Some people release more droplets than others – loud talkers for example.  We usually can’t see these droplets because they are so small, from 0.1 to 1000 μm (a micrometer is a millionth of a meter).  These tiny droplets tend to fly a certain distance before falling to the ground or some other target – hence the 6 foot rule.   Droplets <5 μm can form aerosols and hang in the air. The droplets and aerosol may contain viral particles if a person is infected.

To be clear, although a mask or face covering is a barrier, it still does not stop all droplets. This should not lead one to think masks are useless (as I have also heard several times).   We are not likely to get an infection unless we inhale or otherwise become infected with a certain number of virus particles, (likely a number in the 1000s).  The point of the mask is to limit the number of particles released.  It also probably helps limit the number you might breathe in, or at least block a few droplets flying at you. 

Now, back to those who think they are healthy, and don’t see sick people around them.  I hope they are all healthy, but the truth is there are asymptomatic carriers of this infection who can spread disease and not know they are infected. As I previously discussed here, if someone is infected with the virus that causes COVID-19, it can be up to 14 days before they show symptoms (the average time to symptoms is 5 days).  However, they often start shedding virus in as little as 2 days.  Thus, they are “presymptomatic,” spreading disease, and don’t know they are ill anywhere from 3-12 days.  And, there are those who become infected, shed virus, and never develop symptoms. Wearing a mask would at least limit their ability to unknowingly make someone else sick.

Unless you have just been tested, you don’t know whether you are infected.  You can’t tell just by looking at someone if they are infected either. Thus, the only thing we can recommend for now is that you wear a mask or face covering to prevent the spread of disease.  It tells others that you care about their well-being. 

FOOTNOTE:  The CDC recommendation regarding wearing a cloth face covering in public was for everyone except children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

To put on a face covering, grip the cover by the draw strings or elastic material used over the ears. It is okay to adjust to tightness around the nose, but try not to touch the material through which you will breathe. In general, try to limit touching the mask while wearing, and if you do so, use clean hands. If you accidentally touch your mask while wearing, clean your hands. Keep in mind that any cloth face cover should be washed regularly, depending on use. It follows then that any material you select should be capable of being laundered and machine dried without damage or change to shape.

There are different types of masks and facial coverings. The CDC recommends a cloth face covering for non-medical people. This should be made of cloth such as old T-shirt or a bandana. Paper surgical masks are worn by health care workers. Typically, the colored side goes out (somewhat waterproof to stop droplets from the outside), and the light side to your face (absorbent to to trap your own droplets), and the piece over the nose bends to conform to the bridge of the nose. Doctors wear these to prevent getting respiratory droplets on patients, but also to protect against droplets or other fluids. N95 masks are specialized respirators that filter particulates (95% of small particles). Wearers must be fitted, and the respirator does not work well (if at all) over a beard. Masks with one-way valves that make it easier for the wearer to exhale do not filter and do not prevent the wearer from spreading the virus-defeating the purpose of the CDC recommendation.

Wash your hands!

Vitamin D and COVID-19

Vitamin D deficiency is common in Parkinson disease (PD).  In fact, as previously discussed in MPDN, this vitamin is involved in dopamine production.  Generally speaking, we also need adequate stores for the health of our bones, heart, and metabolism. Vitamin D is also involved in innate immunity, a part of our immune system that includes physical barriers (for example, skin), compounds found in the blood, and certain white blood cells that directly attack foreign cells and substances in the body, so-called antigens.  Vitamin D can lower inflammation and help fight certain viruses.  It is also known that vitamin D deficiency is associated with respiratory infections. Normalizing vitamin D levels seems to help prevent these infections.  A meta-analysis (a comparison of multiple studies)  of 25 randomized clinical trials of vitamin D supplementation found that among the nearly 11,000 patients supplementation correlated with 12% reduced risk of respiratory tract infections. In people with severe vitamin D deficiency at baseline adding vitamin D supplementation was associated with a 70% lower risk of respiratory infection. 

Now, there is data that vitamin D deficiency is associated with COVID-19.  And, severe outcome was eight times more likely among COVID-19 patients with vitamin D deficiency compared to those with normal levels in a report from three Asian hospitals. It should be noted that generally, people with severe vitamin D deficiency tend to have underlying have underlying health issues also.  Nonetheless, vitamin D levels may play a role with severe outcomes of COVID-19, such as the “cytokine storm” that usually precipitates critical illness in this disease.

The problem is that many people with PD are not getting out to exercise or get a little sunshine.  This is a bad combination.  Low exercise is associated with poor outcomes in PD.   Not getting appropriate sunshine (and therefore the UV light needed to convert vitamin D to its active form), is associated with vitamin D deficiency.  So please, get a few minutes of sunshine daily, eat foods that contain vitamin D, and if your vitamin D is low, please replace it with the direction of your doctor.  Some authors have suggested vitamin D supplementation should be universal with PD patients, at least during the time of COVID-19.  I would caution however, that you avoid vitamin D toxicity.  

COVID-19 and the week ending June 6, 2020

It is the 6th of June, the 76th anniversary the D-Day landings in Normandy.  This should be a time for reflection, and a time to place our country and our society in perspective.  I find myself thinking about all the World War II vets I met during training-many of whom led me to study Parkinson disease.  I wonder about those that I never had the chance to meet, and what they would say about what America did with the opportunity paid in blood by the soldiers of our greatest generation.  

This is also the end of a week of unrest and protest in our country, triggered by the May 25, 2020 Minneapolis Police killing of George Floyd. Thousands have gathered in U.S. cities (including those in Maine) on multiple occasions since his death to say it is time for a change.  The timing is terrible of course, for gathering in large groups, for chanting, for shouting.  That kind of activity places everyone present at risk, and in turn, their later contacts.  There is after all, a pandemic.  There is still a deadly virus in our country, a country which is still reporting more cases than any other in the world by far.

I hope only good comes of these protests.  And, if you find yourself joining a gathering, please wear a mask, maintain at least a 6-foot distance from others (ideally much farther if voices are raised), and be aware of your surroundings.  As I have discussed here, louder voices, singing, etc. project more respiratory droplets, and the distance increases with effort.  If someone is not wearing a mask, move away from them.  Avoid shaking hands, linking arms, hugging, and other physical displays so common to these groups.  If you protest, do so with you head and your heart.    

The same should be kept in mind for political rallies.  Yesterday Donald Trump visited Maine and was met with what appeared on White House social media coverage to be an indoor crowd of cheering supporters.  Of note, he toured Puritan Medical Products, which produces nasal swabs for testing.  Per USA Today, Trump was not wearing a mask while visiting the production floor (also seen on WH social media), and the swabs being made that day were to be discarded.

The current numbers in our state per the Maine CDC include 2,524 cases since testing began, with 1,845 recoveries, and 98 deaths.  The number of current active cases is 581, a number which has been declining since a peak of 712 on May 26, 2020.   The 7-day average number of active cases stands at 628.  This is a trend in the right direction.  I hope it continues this way in spite of reopenings and gatherings.

This week the Maine CDC also began listing cases by zip code in order to give a more clear picture of where cases are, or have been, concentrated.  Zip codes in which the number of cases were very small were excluded in order to protect the identity of the afflicted.  There has been a great deal of discussion about this in news media, regarding where the cases “are,” and how some towns have “no cases.”  However, a point that seems missed by most commentators is that these numbers only represent positive results among those who were tested, or those who are presumed on narrow criteria to have had COVID-19 due to close contact with a known case and symptoms consistent with disease (271 of the total).   

It should be remembered that there was a long delay in getting test kits to states. While the first case in the U.S. was confirmed January 20, Maine has only been testing since March 12.   There was thus a gap of 67 days after that first case in which we could not test anyone in this state.   Recall also, that after testing began, it was very limited.  In the first several weeks of testing in Maine only those who met strict criteria (usually the very sick) were offered a test.  Many others who were presumed infected were told to shelter at home.  We don’t have an accounting of those numbers (though it was not a small number). 

I know also of presumed cases among people who lived in towns now reported as “no cases.”  The point is, don’t be over-confident in seeing those numbers.  Continue to act as though you might be capable of either contracting, or asymptomatically spreading COVID-19 until we have a better handle on this situation.  We need a vaccine and better treatments, or at least much more widespread testing. Please continue to follow guidance by the Maine CDC and Governor Mills.

Please wear a mask when visiting your doctor. We need to do all we can to limit spread and protect each other. As of the last reporting by the Maine CDC, about 25% of cases in Maine were among health care workers. We are doing the best we can for you. Please help us by wearing a mask, not just around your health care providers, but please also wear a mask or facial covering around others too. It is what smart people do.

If you cannot view the graphic at the top of this post (a chart of cases in Maine), please read the article on the website.

COVID-19 update June 1, 2020

Today many businesses around the state are reopening as part of a staged process under Executive Orders from Governor Mills.  Social distancing and mask or facial covering requirements are still in place to prevent spread of the virus.  Just to recap the last few days, on May 28 Dr. Nirav Shaw, Director of the Maine CDC, started giving daily briefing updates remotely due to a cluster of complaints at the Maine Emergency Management Agency (EMA): “a number of individuals…have developed signs and symptoms consistent with symptoms consistent with COVID-19.” He and EMA Director Peter Cook noted the 7 individuals reported fever, chills, aches.  They team deployed to alternate work sites away from the Emergency Operations Center, and the individuals were tested.   On May 29 Dr. Shaw noted all the tests had come back negative for the 7 individuals.  They planned to run other tests for other potential viruses and bacteria.  It is possible that some other organism infected the workers.  It is not clear which modality of testing was used for these workers. 

The U.S. passed the horrible marker of 100,000 fatalities due to COVID-19 last week.  We still stand apart as a country in terms of cases and deaths.  In fact, by comparison with one of our neighbors, on May 31, Canada reported 92,479 cases, which from a population 37 million represented 0.25% of Canadians. The same day, the U.S. counted 1,806,813 cases from a population of 328,239,523, representing a case rate of 0.55% of the general population, a rate over double that of Canada.  The U.S. has four times the number of cases of any other country in the world, and over 104,000 Americans have died with COVID-19 in the last four months.

Today in Maine the total count of cases since testing began stands at 2349, including a little over 200 “probable” cases” (discussed in MPDN on May 20, 2020), 1586 recoveries, 89 (3.8%) deaths.  The number of health care workers infected since testing began is 563 (24%). 

In the 12 days since I last reported on trends in case rates here in Maine, the number of new cases per day has averaged 45 (on May 20, 2020 the prior three week average number was 40 cases per day).  Overall, since testing began 83 days back, we have averaged 28 new cases per day. Sixteen Mainers have died from COVID-19 over the last 12 days.   

To date there have been 284 hospitalizations in Maine due to COVID-19 (12% of all positive cases).  The current number of active cases is 674 (29% of cases since testing began).  Of the active cases, 52 (8%) are hospitalized. Among the 52 hospitalized, 17 (33%) are in intensive care unit (ICU) beds (a higher percentage), and 10 (19 %) on ventilators, also a higher percentage.  The highest number of active cases occurred on 5/24/20: 720 cases.

To be clear, Maine has had an increase in the case rate since I last reported on this topic.  This is in part due to outbreaks and testing at congregate care facilities. Per Dr. Shah on Maine Calling last week, congregate care facilities represented about 40% of total cases.  Today Dr. Shaw gave an update on the Cape Memory Care Center, which has had a total of 84 cases (23 of whom were staff, the remainder residents).  Also listed were outbreaks at four new facilities.  Birchwoods at Canco Assisted Living has 5 staff members who have tested positive for COVID-19.   One of the John P. Murphy Homes in Auburn has 5 cases.  The Family Shelter in Portland has 15 cases.  The Barron Center in Portland has 4 cases. 

Presumably, the new cases at congregate living facilities are being brought in by staff or some other visitor (a vendor, for example).  Since patient visitors are not allowed, the numbers must be small.   However, I know from facilities with which I have had contact, that there is screening, that staff with signs or symptoms disease, or travel out of state, are not being allowed in facilities unless first quarantined or tested negative. 

This means many (or probably most) cases at these facilities are caused by asymptomatic carriers who do not know they are ill and are bringing the virus into the facility.  As discussed in my last post, asymptomatic carriers are those people who are infected but not showing symptoms.  Asymptomatic carriers represent a significant number of people, people who can spread disease without knowing it.  So, why not institute a policy of regular testing of all employees at congregate living facilities? The limitation has been the number of tests available.  In May the state testing lab increased capacity to 1000 tests per day.    This is a lot, but perhaps not enough.   We need more tests, but we need to use them wisely also. That would mean regularly testing of all health care workers, workers at meat packing plants, any place where people congregate.

And, we still do not know the number of asymptomatic carriers in the general population-a great reason to keep wearing that face covering, and keep on social distancing.  To figure out the rate of asymptomatic carriers, the state could conduct tests on samples of the population, for example, 100 people each in several communities. These would have to be volunteers, of course. This sentinel testing could make a big difference and guide the reopening of businesses, schools, and so on.  Such tests would also allow notification, isolation, contact tracing to try and curb other outbreaks.  To date, the state of Maine has run over 54,000 tests in a population of 1.3 million.  As mentioned previously in MPDN, many of the tests were repeats of patients who for example, had a syndrome very suspicious for COVID-19, but initially tested negative.  Or, these may have been patients with confirmed COVID-19 who recovered and needed a negative test for discharge from a hospital. The Maine CDC is in the planning stages of sentinel testing.

Note, to view the graphic associated with this article, please view it on the website.       

Risk and the asymptomatic carrier of COVID-19

Asymptomatic spread of the SARS-CoV-2 virus that causes COVID-19 is a big problem.  And, this problem  does not behave the same as with many other viruses, even the close relative SARS-CoV-1, the virus that caused SARS in 2002-2003.  When SARS struck, health authorities controlled and eventually stopped the epidemic by using symptoms to detect cases.  Typical symptoms of fever, cough, and shortness of breath about 5 days after exposure led to testing, isolation, and quarantine.  Similar to COVID-19, transmission of SARS was primarily via respiratory droplets.  In less than a year after approximately 8100 people were infected (primarily in Asia), and about 10% of those infected died, the epidemic ended.   

So how has SARS-CoV-2 spread all over the world to over 5.8 million people (1.7 million in the U.S.)?  This grim week, how has COVID-19 killed over 100,000 U.S. citizens?  One big issue is that screening without testing is inadequate with this virus because there are too many asymptomatic and unknowing cases who are just as capable of spreading the virus as are the symptomatic cases.  COVID-19 can be spread by people who appear and feel well. Far worse, if one does not know they are infected, they might not be taking precautions to prevent spread.  A significant minority of people don’t wear masks in public and ignore, or are too lax with, social distancing.  As I have said before in MPDN, it is so important that everyone act as though they might be capable of spreading or contracting the virus, and take appropriate steps to prevent that until we have a vaccine or at least good therapies for prevention or treatment.

Why doesn’t COVID-19 behave like SARS? 

One major difference between SARS and COVID-19 is that the SARS-CoV-2 virus infects, replicates, and sheds in the upper respiratory tract of infected people with and without symptoms. (1) This means coughing, sneezing, talking, or simple breathing might shed virus.  The SARS-CoV-1 virus on the other hand, replicated primarily in the lower respiratory tract (2), and cases of SARS were infectious during their symptomatic period, not during the incubation period (the time it takes between exposure and illness). (3)  What I am again getting at here is that people with and without symptoms are spreading COVID-19, and this is an important point to understand.  For the sake of definitions, an infected person who is symptomatic has symptoms; whereas as an infected person who is asymptomatic does not.  Both might shed virus and infect others.  An asymptomatic person can remain that way until the infection stops, or the person might be presymptomatic, meaning they are on their way to having symptoms, getting sick, in the incubation period (see below).  Viral load (the amount of virus measured from some source such as blood or sputum) in SARS-CoV-1 was usually elevated at symptom onset and made symptom-based detection more likely and more effective. If you had symptoms, you could be isolated, tested, and contacts could be traced, etc. The same is not true for SARS-CoV-2, wherein viral load may be high before a person is symptomatic. (4)  This makes detecting cases much more difficult.    

Consider the COVID-19 outbreak in a skilled nursing facility in Washington State. (5)  Authorities first learned of the outbreak when a symptomatic health care worker tested positive for infection on March 1, 2020.  Universal testing of residents in the facility took place with the nasopharyngeal swab test: real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) on two dates: March 13 and March 19–20.  Note the delay in testing, which if not ideal, would have at least allowed time for many of those exposed to develop into infection, making the test more likely to detect infections. (footnote)  Note also that RT-PCR detects the RNA of virus.  You have to have the virus in the nasopharynx (that place very far back in the nasal cavity where test swabs collect a sample) at the time of the test to get a positive result. 

The residents were all asked about symptoms over the prior two weeks, including fever, cough, and shortness of breath.  From the 76 residents tested, 48 (63%) were positive, 27 (56%) asymptomatic at time of testing.  Within an average of 4 days after testing 24 of the 27 became symptomatic.  This means  24 had been presymptomatic, and 3 remained completely asymptomatic.  Therefore, it is important to note that more than half of those who tested positive overall had no symptoms at the time of the test.  Note also that 3 patients were infected but never developed symptoms, very dangerous in a congregate living situation.   

This is not like SARS. Asymptomatic spread is a worse situation.  And, health authorities wanted to know about levels of virus at the time of these tests.  The thought was, and is, that a higher viral load in the nasopharynx is more likely to spread disease.  They checked this by measuring quantitative SARS-CoV-2 viral loads, which showed high levels of virus whether the residents were symptomatic, presymptomatic, or completely asymptomatic.  And, among the presymptomatic patients 17 (71%) had viable virus 1 to 6 days before the start of symptoms. In other words, live coronavirus was shedding in high concentrations from the nasal cavity before symptoms developed for up to 6 days.  Asking people about symptoms did not detect over half of infectious cases.  This is why universal testing in congregate living facilities is so important, and why mass testing generally would be much more effective than what we are doing now.  This is why health authorities keep saying we need more tests, a lot more.

This congregate living facility is not the only example by far.  Another study looked at 94 patients with laboratory-confirmed COVID-19 and found the highest viral load in throat swabs at the time of symptom onset, which the authors interpreted as consistent with a peak of infectiousness at or even before symptom onset. (6) They estimated that 44% of cases had been infected by people who were in a presymptomatic stage: they contracted the virus from another person who they thought was well.  In this study, the incubation period averaged about 5 days, while infectiousness started about day 2 or 3 after exposure (rapid in the infectious disease world).  In other words, people were spreading the virus for 2-3 days and did not yet know they were sick.  

There have been several other reports of asymptomatic carriers infecting others. In one report an asymptomatic 20-year-old woman who tested positive by RT-PCR (but had negative chest imaging) infected friends and relatives. (6) She was kept in isolation for a month and never developed symptoms.  In another case an asymptomatic 10-year-old boy with COVID-19 and abnormalities on chest CT spread infection to members of his family. (7)

A paper published this week reported a cruise ship which left Argentina in mid March. (8)  On board there were 128 passengers and 95 crew.  Before boarding everyone (passengers and crew) had been screened for COVID-19 symptoms and body temperatures were taken.  No one on board had passed through China, Macau, Hong Kong, Taiwan, Japan, South Korea, or Iran in the 3 weeks prior.  Multiple hand hygiene stations were placed in the ship, including the dining area. The two physicians on board screened all passengers and crew with “regular body temperature reviews.”  The first fever of the outbreak, a passenger, was recorded on day 8.  Immediately isolation protocols began: all passengers confined to cabins, surgical masks issued to all, full personal protective equipment (PPE) used for any contact with febrile patients, N95 masks worn for any contact by crew with passengers in their cabins.  But the outbreak was spreading, or at least incubating.  Additional fevers were detected in 3 crew members on day 10, 1 crew member on day 11, and 3 passengers on day 12.  The ship had been on its way back to Argentina, but the country had closed its borders due to increasing regulations with the COVID-19 outbreak, and was refused permission to disembark at Stanley, Falkland Islands.  The ship sailed to Montevideo, Uruguay, arriving day 13.  Passengers were kept on board.  Among them 8 (6.2%) required medical evacuation due to impending respiratory failure.  For the remaining 217, on day 20 universal testing for COVID-19 with RT-PCR took place (supplied by Uruguay), revealing 128 (59%) positive. Remaining passengers and crew did not disembark until day 28, and the stats on that day are as follows: among the positive 104 (81%) asymptomatic, 24 (19%) symptomatic.   That is a staggering figure, and very troubling given the amount of time passengers had to become symptomatic, and the steps taken to prevent spread as soon as the first fever was detected.  

This is a complex problem. 

Not all asymptomatic carriers seem to pose the same risk.  Some seem to pose very low risk.  (10)   The reasons for this are likely multi-faceted.  One interesting reason might be immunity. As previously discussed in MPDN, the coronaviruses are a family of viruses that have been known to science since the 1960s (though likely much, much older than that), and until 2002 were known to cause epidemics of mild upper respiratory tract infections (URI), or sometimes diarrhea.  There are two subsets that infect humans: alpha coronaviruses (HCoV-229E and HCoV-NL63) and beta coronaviruses (HCoV-HKU1, HCoV-OC43).  Infections with these “benign” viruses would usually cause a cold.  But, if a person had been infected with one of these strains, they would usually make antibodies and be immune to re-infection for 2-3 years.  The viruses that cause SARS and COVID-19 are newer beta coronaviruses. 

The two “benign” beta coronaviruses are recognized by the human immune system, which induces antibodies that can protect us against either virus.  In other words, infection with one of those viruses results in antibodies against either. That is known as “cross-reactivity.”  And, it is known that SARS-CoV-1 infection can also result in neutralizing antibodies against at least the HCoV-OC43 virus, and that HCoV-OC43 infection results in cross-reactive antibodies against SARS-CoV-1.  (11)  We don’t know yet if this cross-reactivity protects some people from developing COVID-19, but it is a hopeful thought, that could lead to protective treatments. It might also explain why so many cases of COVID-19 are mild. If you have had a cold due to HCoV-OC43 in the last year or two, you might be protected. We still don’t know, and the issue with antibody testing is too complicated to get into here.

Opposite to these issues are the super spreading events (SSE), when case numbers explode after some episode of people congregating, such as at a church  (12) or a nightclub.  There are several factors that can lead to super spreading.  One factor could be changes with the virus itself.  There is at least one preliminary report suggesting SARS-CoV-2 could have 2 distinct genetic subtypes, one more aggressive than the other.  (13) There are also super spreaders. An infected person might have a long duration of infection (more time to spread disease than normal), a higher amount of virus in the upper respiratory passage, a high degree of coughing, lots of sneezing. Even loud talking or singing can shed more virus.  There are also environmental factors such as the density of the population present (for eg, a crowded market, a party, or a funeral), and whether infection prevention and control measures are being used such as social distancing and wearing a mask.  Closed environments such as gyms, restaurants, offices, may drastically increase the risk of infection by trapping air (or recirculating it through ventilation).  SARS-CoV-2 has been found in stool (14), meaning toilets need to be kept clean, and hands washed after using the bathroom.   And, there are so-called high emitters, who shed many times the amount of virus that is seen in average cases. (15)  This obviously increases risk of spread. 

So what should we take from this knowledge?  One big point is that unless they have been tested, we don’t know who the asymptomatic carriers are.  We should continue social distancing and wearing a mask where appropriate.  This is especially due to the increasing growth of active cases in our state (currently over 700).  This is not simply the effect of increased testing, though that is part of it.  We are seeing more cases in our hospitals in Maine, currently 58 people hospitalized, 22 in critical care, and 14 on a ventilator per the Maine CDC.   So, take it seriously, follow guidance from the Maine CDC, be careful where you get your information, and be COVID-aware. 

FOOTNOTE: In early March testing was very limited, even in Washington State, where the first case in the U.S. was identified.  View this episode of Frontline to learn more.

Please note that URLs were collected on date of publication and are subject to change, as are statistics regarding infection, as with any ongoing epidemic.

REFERENCES

  1. Wölfel, et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020 April 1 (Epub ahead of print).
  2. Cheng, et al. Viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome. Lancet 2004;363:1699-1700.
  3. Guang, et al.  Infectivity of Severe Acute Respiratory Syndrome during Its Incubation Period Biomed Environ Sci. 2009 Dec; 22(6): 502–510.
  4. To, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis 2020 March 23 (Epub ahead of print).
  5. Arons, et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. N Engl J Med 2020;382:2081-2090.
  6. Xi, et al.  Temporal dynamics in viral shedding and transmissibility of COVID-19 Nature Medicine. 2020:26;672-675
  7. Bai, et al. Presumed Asymptomatic Carrier Transmission of COVID-19  JAMA. 2020;323(14):1406-1407. doi:10.1001/jama.2020.2565
  8. Chan, et al.  A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster.   Lancet. 2020;395(10223):514-523.
  9. Ing, et al.  COVID-19: in the footsteps of Ernest ShackletonThorax Published Online First: 27 May 2020. doi: 10.1136/thoraxjnl-2020-215091  https://thorax.bmj.com/content/early/2020/05/27/thoraxjnl-2020-215091
  10. Ming, et al.  A study on infectivity of asymptomatic SARS-CoV-2 carriers  Respir Med. 2020 May 13 : 106026. doi: 10.1016/j.rmed.2020.106026 [Epub ahead of print]
  11. Kissler, et al. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period Science  22 May 2020:Vol. 368, Issue 6493, pp. 860-868  DOI: 10.1126/science.abb5793
  12. South Korean city on high alert as coronavirus cases soar at ‘cult’ church. New York: The Guardian, February 20, 2020 [cited 2020 Mar 8]. https://www.theguardian.com/world/2020/feb/20/south-korean-city-daegu-lockdown-coronavirus-outbreak-cases-soar-at-church-cult-clusterExternal Link
  13. Tang, et al. On the origin and continuing evolution of SARS-CoV-2. Natl Sci Rev. 2020;nwaa036; [Epub ahead of print].
  14. Gu, et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020;Mar 3:pii: S0016-5085(20)30281-X. Epub ahead of print].
  15. Tsai, D., Riediker, M. (2020). Estimation of SARS-CoV-2 emissions from non-symptomatic cases. medRxiv. https://www.medrxiv.org/content/10.1101/2020.04.27.20081398v1

COVID-19 update May 20, 2020

Today the Maine CDC is reporting a total of 1816 cases of COVID-19 among state residents since testing began on March 12, 2020.  The total numbers now include not just confirmed tests, but 187 probable cases (essentially those with close contact to a confirmed case who have syndrome consistent with COVID-19).   Tests are not used on these patients unless they become ill enough for hospital admission.  Meanwhile, the overall increase in numbers is also in part due to a policy of testing all staff and residents of congregate living facilities where outbreaks occur (three or more cases).  In these cases it is likely that asymptomatic or pre-symptomatic cases will be detected, thus increasing the numbers or positive tests in a way that would not have been possible prior to the policy.  This policy of mass testing is meant to limit spread within facilities where more vulnerable people are living. We don’t have to look far in the news to understand why that is a good idea.  Congregate facilities are not the only groups that are now being mass-tested, as outbreaks have occurred at a food processing plant, a construction company, an apartment building, and a jail. 

The total number of Maine healthcare workers with COVID-19 since testing began has risen to 417, (23% of the total number of cases). 

To date, there have been 40,609 tests conducted in the state.  Note that this number is not the total number of people tested, but the total number of tests conducted.  The number is different because in some instances, such as when a person under interest (PUI) has a condition that looks convincingly like COVID-19, the initial test might come back negative.  This means a second test may be necessary, especially if that person is hospitalized or in a high-risk situation.  It is also typical that a person who is hospitalized with a positive test result will in turn require a negative test result to lessen the use of personal protective equipment (PPE) by staff taking care of them during hospitalization, or before discharge of the patient to home or rehab. 

In Maine 231 people have been hospitalized with COVID-19 since testing began, and 40 are currently hospitalized, with 12 currently intubated and on a breathing machine (a ventilator).  The total number of deaths due to COVID-19 currently stands at 73, with an average of one death per day in the last three weeks.  

The current number of active cases in the state stands at 633, up by 148 cases since I discussed these numbers on April 27.  As above however, the growth in numbers is measured differently now, and the comparison is thus unequal. The state is casting a wider net, there have been new outbreaks, and the numbers are therefore higher.  Because of all of this testing, we had 75 new cases today.  In the last three weeks the average number of new cases per day has been 40. 

Among those positive tests to date, the state has used polymerase chain reaction (PCR) on 37,725 tests.  This is a form of amplification of viral genetic material.   It is only positive if the virus is present in the sample taken from the patient (usually a nasal swab).  The state has also used antibody testing for 2,884 tests. Antibodies are evidence that our body has either and active or a past infection with the virus. 

The state has increased testing capacity due to a partnership with IDEXX in Scarborough.  The IDEXX PCR Test Kit allows Maine’s Department of Health and Human Services Health and Environmental Testing Laboratory (HETL) to process up to 1000 tests per day.  This means that HETL is now taking specimens ordered by a physician for any person who has one or more symptoms consistent with COVID-19, or any person who may be at risk for spreading COVID-19.  This could include asymptomatic close contacts of confirmed cases from an outbreak setting, asymptomatic health care workers who have had contact with or exposure to a confirmed case, or asymptomatic people tested as part of a sentinel COVID-19 disease surveillance program by the Maine CDC. 

The expanded testing means that in the last week Maine has tripled its daily testing capacity.  That is a good thing.  But take a moment to consider what this really means.  We have still tested less than 3% of the population of our state.  Maine had in 2019 1,344,212 citizens.   If we tried to test everyone at a rate of 1000 tests per day, it would still take over three and a half years.   We need a lot more testing.  Alternatively, we need a vaccine, much more effective treatments, or preventives that work.

More to come. Until then, be patient, don’t listen to pseudo-science, and stay out of trouble.

Something we should all read

As the state is trying to slowly reopen I highly recommend you read “The Risks – Know Them – Avoid Them” by Erin Bromage, Ph.D.   This essay covers the risk of contracting the SARS-CoV-2 virus in various situations, and is written in clear language.  Though I have touched on many of these points in my writing, I am impressed with this collection of thoughts and information to consider before venturing out into the grocery, the restaurant, a park, work, a public restroom, or church.  These mental tools will help to protect you from COVID-19. I wish everyone would read and understand what is being said in this article by a well-credentialed expert.  Dr. Bromage is an associate professor of biology at the University of Massachusetts Dartmouth, and teaches courses in immunology and infectious disease, including one on the SARS-CoV-2 virus.  Please do yourself a favor and read this heavily circulated discussion.  At the time I referenced it today, the link had nearly 13 million views. 

PD and the risk of COVID-19

Recent publications have indicated that people with PD are not at increased risk of the complications of COVID-19 compared with others of the same age (1-3). Advanced age itself seems to be a risk factor for severe disease.  However, this week a paper was accepted for publication in the journal Movement Disorders which reports that people who have had PD for an average of 12 years or more may be more likely to become seriously ill or die after catching SARS-CoV-2 virus that causes COVID-19 (4).  The statement is based on a small case series of 10 people with PD, average age 78.  The report was written in collaboration with two European academic movement disorders centers. 

The Parkinson and Movement Disorders Unit in Padua, Italy reports a catchment of 1022 patients with PD from the province, which also had 3407 cases of COVID-19 in the general population.  Among the infected were two women with advanced PD, both nursing home residents.  One of the women was asymptomatic aside from a limited fever, and the other died from respiratory complications of COVID-19. 

The Parkinson’s Foundation Centre of Excellence at King’s College Hospital in London, UK has a catchment of 4000 PD patients, and reported eight cases of COVID-19 among that cohort: six men and two women, all with advanced disease.  Most of these patients required additional levodopa while sick with COVID-19.   Anxiety, orthostatic hypotension, cognitive impairment, and psychosis worsened during the infection.  Fatigue was the dominant complaint. Three of these patients died from COVID-19 pneumonia. 

 The authors noted that people with advanced therapies such as infusions of levodopa (the dopamine pump), or deep brain stimulation seemed to be high risk.   The risk among people with advanced disease likely relates to worse overall health condition in people who have advanced in both disease and age.  In advanced PD muscles are susceptible to rigidity (stiffness) and this can include the ones associated with breathing. At baseline some patients have trouble clearing secretions, trouble coughing, an impaired cough reflex, or shortness of breath.  When regular exercise is halted, these issues may worsen, making one less able to fight off COVID-19. 

SARS-CoV-2 is a member the coronavirus family.  In 1992 it was shown that some people with PD had antibodies to much more benign strains of coronavirus in the cerebrospinal fluid (CSF) (5), which raised the question of whether an infection might trigger or cause PD.  Some researchers have questioned whether coronaviruses might infect cells high in the nasal passage, cause the loss of the sense of smell (anosmia), and then enter the brain. SARS-CoV-2 binds to angiotensin-converting enzyme 2 (ACE2) receptors, which are present on dopamine neurons, and are reduced significantly in PD.  There has been no evidence to date of direct infection of the brain of PD patients.  

Please take precautions and avoid infection. I think the preceding paragraph is interesting, but far from anything more than associations. And, we should be careful not to draw strong conclusions on the basis of such a small case series. It seems more likely that those who have poor health (including advanced PD) generally are at higher risk of complications of COVID-19, rather than some facet of PD that makes COVID-19 more dangerous. I will monitor for any more reports of COVID-19 in the PD population worldwide.

REFERENCES

  1. Helmich RC, Bloem BR. The Impact of the COVID-19 Pandemic on Parkinson’s Disease: Hidden Sorrows and Emerging Opportunities. J Parkinsons Dis. 2020;10(2):351-354.
  2. Stoess, et al. Editorial: MOVEMENT DISORDERS IN THE WORLD OF COVID-19. Mov Disord. 2020.
  3. Papa, et al. Impact of the COVID-19 pandemic on Parkinson’s disease and movement disorders. Mov Disord. 2020
  4. Antonini, et al., Outcome of Parkinson’s Disease patients affected by COVID-19. Mov Disord. 2020, doi: 10.1002/mds.28104 
  5. Fazzini E, Fleming J, Fahn S. Cerebrospinal fluid antibodies to coronavirus in patients with Parkinson’s disease. Move Disord 1992;7(2):153-158

COVID-19 update, flattening the curve on April 27, 2020

Today the Maine CDC is reporting a total of 1023 cases since testing began on March 12, 2020.  Congregate living facilities have accounted for 26% of the total.  In Maine there have been only eight new cases since yesterday.  The current doubling rate of the epidemic is 19 days, which has improved from a doubling rate of 14 days on April 17.  The state reports 549 people have recovered from COVID-19, and there was one more death overnight, bringing the total number of deaths since testing began to 51. More than half of deaths have come from long term care facilities.  Over the last 10 days, Maine has averaged 2.2 deaths per day.

The results covered include Maine residents who met criteria for testing, but probably exclude many others who have, or have had, COVID-19 because they were never tested.  It is likely that the actual number of cases in Maine is closer to 3-4 times as many as this total.  And, it is likely that 25% are asymptomatic carriers capable of spreading disease.  During this outbreak, that would mean that roughly, about 1000 people in Maine have, or currently are infected and don’t know it. 

Among the total number of positive cases of Maine residents, 244 have been healthcare workers (24% of the total number of cases), including people who work in congregate care facilities.  

In the last ten days the daily average number of new cases in Maine has been 20 people (down from a 10-day average of 30 on 4/17/20, which was down from the prior 10-day average of 32-the peak during this epidemic so far).  As the average number of new cases has gone down, so has the number of active cases, which peaked at 446 on 4/17/20.  The total number of active cases currently is 423. 

Numbers are trending in the right direction, all the result of efforts to flatten the curve.  It has meant stopping a lot of business, changing the way people get groceries, asking people to use social distancing, wearing masks or face covers, and many other steps.  People are frustrated and want to go back to normal, to restart the economy, to at least make a paycheck. The dollar amount in stimulus from the federal government across this nation is staggering: the CARES Act for example, amounted to 2.2 trillion dollars.  There is also a fringe of our society that think this is all some sort of hoax.  It is not.

There have always been conspiracy theorists.  Now they have the internet, and a lot of mixed signals, even from the highest offices of government.  To be clear, household cleaners and disinfectants should not be taken internally unless you want to die.  Ultraviolet light inside the body can be a fast way to cause cancer.  Hydroxychloroquine is a potentially dangerous drug, and anyone telling you to try it without a medical license is committing malpractice, even if that person is the president.  There is a saying in medicine: when you don’t know what you don’t know, you’re dangerous.  

We have to be cautious.  Because we are so painfully far from adequate testing, we do not know who is an asymptomatic carrier, who is sick and does not know it yet (but is probably contagious), and who is immune.  We don’t want to reopen businesses as they were before with the likelihood of thousands of infected people in our state.  That would mean a rapid growth of the epidemic, and a much worse situation. 

Leaders in our state are trying to figure out how to slowly and safely open back up for business.   The economy might climb out of this slump, but it has to be done the right way.  Doctors are also trying to catch up on patients who have not been seen in the last several weeks. To do these things successfully we need everyone to be very COVID-19 aware.  Wear a face cover in public, wash your hands, practice social distancing, and do not touch your face unless your hands and face are clean. The virus is still here. It is dangerous and for some, deadly. And, it is not just a risk for older people, though they seem the hardest hit. All age groups have been infected, 36% of those sick enough to be tested have been under age 50 in Maine. Our numbers are small relative to many other states. Across the nation we currently stand at 985,433 cases and 55,952 deaths. The U.S. has more cases than any other country by a wide margin, over four times as many cases as Spain, the country next after us. This weekend there were reports in the Washington Post of people in their 30s having strokes due to COVID-19. Medical journals have reported many different systemic illnesses associated with this disease. It is serious. Act accordingly. Also have faith that we will get through this. I hope we are all paying attention and learning. We need leaders who understand science, who value experts, who know what they don’t know.

Note that URL links are to sites with changing data tracking the outbreak and represent data at time of this post.

Note also that if you cannot see a graphic associated with this post, it can be viewed on a desktop computer.

Are you ready to meet virtually?

As you must have noticed, medical offices and hospitals during the time of COVID-19 have postponed or canceled most non-urgent visits, tests, and procedures.  This has meant a massive backup in patient care and we have tried to reach many people by telephone.  Phones are not ideal for movement disorders, however.  It helps for us to see your tremor, dyskinesia, or what have you.  Fortunately, the Center for Medicare and Medicaid Services has approved virtual appointments with video.  This means that if you have a smart phone, tablet, laptop, or a computer with a camera, you can probably have a virtual office visit with your healthcare provider from own home. 

I am not sure what platform every office in the state is using.  MaineHealth (including my practice recently) is using Zoom, an app (application) that you can download onto your device.  I am sure many of you are familiar with this, as it is being used all over the country for other types of virtual meetings (offices, families, and so on). I understand that some Parkinson’s support groups are even meeting by Zoom.  If you are not familiar with this app, it is free (on the end user side) and very easy to download.  On iphones visit the App Store, on Android phones visit the Play Store, and if using a desktop computer go to https://zoom.us/download   to download the software.

We are not sure when we will be back to normal office scheduling, and there is still a risk of contracting the SARS-CoV-2 virus that causes COVID-19 in our state, especially when people congregate.   In order to avoid a second wave of cases we are planning on trying to gradually reintroduce safe office encounters, but it is going to come along in stages, and there may be a long delay.  One thing we want to avoid at my office right now is a group larger than ten people, or a failure of social distancing, which would occur if all five doctors starting booking full appointment days in the clinic again. A video “telehealth” appointment is a good way to see your provider for now without that risk.  And, that technology is likely here to stay.  The genie is out of the bottle, so to speak. Further, becoming comfortable with this software would mean that you too could visit love ones with the computer or your phone.  So, put aside your computer discomfort, embrace the future, and get ready to meet virtually.