COVID-19 Newsletter #2

In an effort to keep you informed, I am writing my second newsletter on the COVID-19 pandemic.  Below is a list of topics that will help you stay safe, better understand the testing issue and help you plan for what is to come.

1. COVID-19 Testing in Tucson:  There has been a lot written about the shortage of tests for COVID-19 in the U.S.  Everyone wants a test and they are in short supply.  However, the testing problem is much greater than not having enough of the nasal swab tests.  What you will read here, and what has not been discussed in the press, is that these tests are not very sensitive.  They are not good tests to rule out having the disease.  This is not just my opinion.  It was addressed 9 days ago in the NEJM Journal Watch:  https://www.jwatch.org/na51116/2020/03/17/pharyngeal-and-nasal-swabs-may-not-have-adequate  So as not to bury you in the numbers, I will not delve into the statistics of Bayes’ theorem.  But I will tell you that the sensitivity of the nasal swab test is only about 60%.  What this means is that if you had 100 people in a room with proven COVID-19 by viral culture, 40 of those 100 infected people would have a false-negative nasal swab test.  This is a big problem.  Furthermore, depending on your clinical symptoms (what we call the pre-test probability of disease), the predictive value of a negative test in an individual can easily be less than 50%.  In other words, if you get a negative test result at Banner with classic symptoms of COVID-19, you could still have more than a 50% chance that you were infected.  In this scenario, you would be sent out with a negative test, only to infect those around you.  If you want to know how I calculated these numbers and you want to verify my statistical analysis, you can contact me.  Otherwise, accept that I’ve done the math correctly.  The good news is that there are several companies developing point-of-care, antibody blood tests, with sensitivities and specificities of over 90%. These tests will improve the accuracy of testing and give test results in about 15 minutes.  This kind of testing will also help to establish how many asymptomatic people in the community have antibodies of immunity.  
2. What to do given that testing is flawed?  For practical purposes, if you get sick, you should call me and skip the test.  Based upon your symptoms, I will tell you what you should do.  If you have symptoms consistent with COVID-19, and if you are stable, you should stay home and self-quarantine for 14 days.  If you have shortness of breath, suggesting that you may have pneumonia, then I will direct you to go to the ER.  This is the branch point in the decision algorithm.  Unless you are seriously ill, based upon the assessment of a physician, stay home and most people will get better.  If you are seriously ill, you run the risk of respiratory failure and you must go to an ER, no matter what problems they may have there. 
3. My Patients’ Experiences:  I have had one patient so far who has had a very clear case of COVID-19.  He experienced a high fever, loss of taste, cough and fatigue.  He lives in Manhattan, where the disease is running rampant.  I did not need a test to know that he was almost certainly infected, and a negative test would not have changed my diagnosis.  I advised him to stay home.  Thankfully, he is strong and is recovering.  I have stayed in close contact with him and he knows to call me for new symptoms.  I have had 3 milder cases – I’ll call them possible cases of COVID-19 – and I’ve advised these people to stay home as well.  I told them to self-quarantine for 14 days and to presume that they were infected to reduce the risk of spread. 
4. How Best to Protect Yourself:  Let’s go back to the basics.  As I said in my first newsletter, you get this infection by sharing air with an infected person or touching an infected person or a contaminated surface.  We now know, from recent cruise ship studies, that this COVID-19 virus can live on some surfaces for up to 17 days.  The fact that it is so contagious suggests that you probably don’t need a lot of viral particles to become infected.  However, because viruses are too small to see with the naked eye, they almost seem like an invisible enemy.  Are they real?  What the hell does it mean that this virus is spread by aerosols when you breathe?  You can’t see the breath of another person with the naked eye.  However, if you click on this link and watch the video made by scientists in Germany, you will get a good visual of what happens in the air when someone breathes, coughs or sneezes.  https://www.uni-weimar.de/en/civil-engineering/news/news/titel/abstand-halten-neues-video-der-bauhaus-universitaet-weimar-verdeutlicht-wie-sich-atemluft-ausbreite-1/  Just how small is a virus particle?  Well, you can fit about 20-million virus particles on the head of a pin.  To put this in perspective, the Norovirus that causes severe diarrheal illness on cruise ships requires as few as 18 virus particles to cause infection.   So, you want to stay away from people in closed spaces.  Continue to wash down all surfaces in your home every day – the doorknobs, light switches, kitchen surfaces, etc.  Continue to wash your hands meticulously.  And because people with infections could be handling your food packages at grocery stores or through delivery services, they could contaminate the packages that you are bringing into your home.  So, assume containers are infected and throw them away.  Keep washing to reduce virus that may be transferred to your home surfaces. 
5. Why are there pockets of COVID-19 infections?  As you know, the first large pocket of disease showed up in Seattle, Washington.  Now New York City has an even bigger problem.   The reason for pockets of infection is that the closer people are packed together, the more easily the virus spreads.  The outbreak in Seattle started in a nursing home.  Nursing homes are small incubators for COVID-19.  Similarly, people in NYC live on top of each other in cramped quarters, sharing the air and surfaces with others in small spaces like apartments, taxis, elevators, etc.  As a result of this rapid spread, many emergency rooms in NYC are on diversion.  This means that ambulances cannot bring any more patients to a hospital that is on diversion – FOR ANY REASON.  It doesn’t matter if you are having a heart attack, a stroke or respiratory failure from COVID-19.  That ER is out of commission.  Doctors and nurses do not have enough protective gear in NYC.  And some hospital morgues are already full.  Temporary morgues have been set up in refrigerator trucks outside both Belleview and Elmhurst hospitals.  The next cities to experience a crisis will probably be New Orleans and the San Francisco Bay area.  And each one of these cities will have their own unique viral curves, depending on the rate of transmission. 
6. Possible Treatments:  Despite news reports to the contrary, doctors are not withholding potential treatments for severely-ill patients in the hospitals.  The combination of hydroxychloroquine and azithromycin is being used across the country, as is remdesivir, an antiviral drug developed to treat Ebola.  However, we still do not know how effective these drugs will be.  Fortunately, as they are being used, patients are being enrolled in clinical trials, so that we can learn which drugs might be more effective in specific patient groups.  At the moment, there is no recommendation to treat people with mild to moderate symptoms in the outpatient setting.    
7. Office visits:  Many of you have cancelled your annual physical exams and routine visits with me.  This is prudent.  I have given younger, healthier patients the option of keeping their routine appointments with me and I’ve advised others who are at higher risk not to come in unless they have a serious, non-COVID medical problem.  Most of my recent office visits have been for urgent or emergent medical problems, in an effort to keep my patients out of the ERs.  For less serious problems, I am doing visits by phone.  If you want to speak to me about a medical issue, but don’t want to take the risk of coming in, you can feel free to call my staff to make a phone appointment with me.  This will be scheduled just like an in-person visit.  As always, if you have an emergency, you can call me anytime, 24/7.  For those of you who need blood draws, we are still doing this.  We clean the office meticulously throughout the day, so your chances of getting the virus from our office are certainly less than getting the virus at a Lab Corp or Sonora Quest center. 
8. Managing Fear:  As we all know, when people are afraid, they tend to make bad decisions.  They behave irrationally.  Like what?  Oh, I don’t know, like hording toilet paper.  I’ve been practicing medicine for a long time and I’ve never seen a case of toilet paper deficiency.  Some people have become understandably anxious after scouring the internet for hours.  Trust me, there are no secrets hidden on the internet about this virus.  I know, you are smarter than any doctor you’ve ever met (including me) and physicians just don’t think outside the box.  You, on the other hand, practiced accounting at Ernst and Young for 30 years.  You understand data, damnit!  You are going to find the secret to this thing!  Well, good luck with that.  Just don’t call me with your crazy ideas (you know who you are), because I will make fun of you again.  Finally, if you have a sense of humor, this would be a good time to use it.  If you don’t have a sense of humor (and some of us do not), hang out with family members who do.  Give your crazy uncle Louie a call and ask him to cheer you up.  Play a prank on someone.  Walk up next to your husband or wife and start coughing…well, maybe not that…but you’ll think of something.