Category: Spring 2020

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.

The PD Awareness Day might be put on hold this year. I have been delaying announcement of the event that was to be scheduled Saturday, May 9 in Portland because of the situation with COVID-19. Recommendations by the state and federal levels of the CDC, and by MaineHealth, the host of the event, have made the situation fluid, so to speak. The general recommendations tell high risk groups (including older people) to avoid large gatherings until it is safe to do so.

While as of this morning the Maine CDC has posted three presumptive* cases of COVID-19 in Maine, the state only received the test kits this week. Sadly, it is therefore likely that there are others with COVID-19 who have not yet been tested, or for whom tests are pending, though hopefully those numbers will be low. If you would like to keep an eye on the testing in Maine, check here: https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus.shtml

I am hopeful that good public health measures and common sense by Mainers will help limit the spread of COVID-19 in our state. Please remember these general tips to avoid contracting or transmitting COVID-19 or any viral respiratory illness (don’t forget it is still cold and flu season):

1. Consider door handles and surfaces such as counters in public places dirty. You should be doing that anyway. However, in this situation you should be especially aware that this is a “droplet disease,” meaning the virus could be on a surface from a cough, a sneeze, or a dirty hand. Be aware of surfaces around you. It is much less about the air you are breathing than the invisible droplets on surfaces (though the air can be a problem as below).
2. Do not touch your eyes, nose, or mouth with unwashed hands. This is how the virus infects most people. Try to be aware of this behavior. People touch their faces much more frequently than you might think. Viruses exploit this. Beat them at their own game.
3. Wash your hands often with soap and water for at least 20 seconds or use alcohol-based hand sanitizer. Scrub the entire surface of the hands and fingers, creating a soapy lather. As I used to tell my kids, make bubbles with that soap. If you have not previously been an avid hand washer, it is time to change your ways.
4. Always, always, always wash your hands before leaving a restroom. You know who you are.
5. Avoid close contact with sick people. If someone has a respiratory infection it is a good time for “social distance.” Shaking hands, hugs, kisses should not happen. And, stay out of the droplet range (6 feet is minimum, but farther is better) of a coughing or sneezing person. Don’t visit at all if you can help it. They will only feel worse if they infect you too.
6. Especially for those at high risk, it is generally a good time for social distance with well people too. The incubation of time of COVID-19 is 2-14 days. You might not even know you are sick during incubation.
7. If COVID-19 is around, it is not a good time to be in crowded places. Unfortunately, some people do not show significant signs or symptoms of disease, but may still spread the virus (a repetition, I know, but I don’t think I can overstate it). This is especially true of younger people, who tend to have a milder case.
8. Stay home if you’re sick and avoid close contact with others.
9. If you are worried about possible COVID-19 infection, call your doctor’s office. If you have this concern, have a cough or fever, you should have a mask on the entire time you are at the doctor’s office-including the waiting room, unless they take it off to examine you.
10. If you sneeze or cough, use a tissue, and then throw it away. Putting it in your pocket (or up your sleeve) is a bad idea. After you throw that used tissue away, wash your hands. If you don’t have a tissue, sneeze or cough into the sleeve of a folded arm, not your hand!
11. Don’t use your sleeve to wipe your nose. Use a tissue, then wash your hands.
12. Stop what you are doing and wash your hands now.
13. Also clean other things you handle a lot: your steering wheel, your phone, computer keyboards, etc. It is generally a good time to disinfect counters at home also.
14. Don’t forget cash has been in a lot of hands, maybe to buy some cold medicine.
15. Be nice. Although it is a recommendation by the CDC that we all keep extra supplies on hand at home (including refills of medications), don’t be like those people who hoard all the cleaning supplies or toilet paper. Let’s be good to each other and get through this hopefully small scare together. If we are smart, and we all behave, we may limit spread in Maine.
16. Finally, in the words of Douglas Adams, “DON’T PANIC.”

*A presumptive case has tested positive in a lab here in Maine and will be confirmed by the federal CDC in Atlanta.