COVID update: Dr. Bundrant

Dr. Bradly Bundrant

Vaccinations for COVID-19 have begun. Even if we have not had any in this county, it won’t be long before we do. This represents the most significant victory yet in the war fought on multiple fronts against this disease. I am reminded of the words of Winston Churchill after the victory at El Alamein in 1942. This was the Allies first major victory against the Nazis, and it was undeniably some sort of a turning point, but the great leader wisely said, “This is not the end, this is not even the beginning of the end, this is just perhaps the end of the beginning.” So it was, and so it is now. Then as now, fierce fighting on multiple fronts lay ahead, as well as many – too many – tragic deaths. We are at this moment in the thick of our battle with the virus from China, but we have learned so very much. I want to share with you some facts regarding where we stand and where we are headed, then suggest some things that we should do individually and collectively. Finally, I will give some reasons why these are the things that we should do.

The first and perhaps most important thing that we have learned is that the organizations and institutions we have relied upon for many years are useful, but we must remain skeptical and we must seek truth independently. When this virus first became known by the leaders in the World Health Organization (WHO) they misunderstood or misrepresented it to a tragic degree. When it had spread to multiple parts of the world and people were beginning to die in large proportions, WHO’s advice on treatment was that treatment should be “supportive” but under no circumstances should any patient be given corticosteroids in any form or in any dose. We now know that the single most valuable and well documented treatment is corticosteroids. They are lifesaving in many cases and should be used in any COVID illness that requires supplemental oxygen. We have learned a lot of other things about treating patients in the hospital, and are beginning to have more and more treatment options available for earlier treatment of patients. The WHO has done much to confuse the issue in other ways, including using multiple names for the condition in the early days, and then settling on the magnificently opaque name of CoVID-19 (for Coronavirus Disease of 2019). To further confuse this issue, they insist that the name of the virus be completely unrelated to the name of the disease, adopting SARS-2 (Severe Acute Respiratory Syndrome 2) as the official name of the virus.

We also have learned that school-aged children are exceedingly unlikely to be badly affected by the disease, and when they have it they are unlikely to pass it on to their teachers. The Journal Pediatrics is publishing a study based on more than 57 thousand child-care workers who were compared with similar controls, showing that the child-care workers were no more likely to get COVID than were the comparators. These workers worked with children, more than half under 6 y/o during the pandemic, and there was no association between COVID and working with children (odds ratio, 1.06; 95% Confidence Interval [CI], 0.82 to 1.38; P = 0.66). https://pediatrics.aappublications.org/content/pediatrics/early/2020/10/16/peds.2020-031971.full.pdf

Other studies, using a case identification and tracing strategy have found that teachers who became infected with COVID were exposed outside of school, and it is my understanding that

(as of 2 weeks ago) there had not been a single proven case of transmission from a child to a teacher. From a public policy standpoint we have learned that – if the goal is to not overwhelm the healthcare system – the best metric to use is not the number of cases of COVID in a region, but rather the percentage of available hospital resources that are required to treat COIVID. The threshold of 15% of available hospital beds in a region, or Trauma Service Area (TSA), has come to be a pretty good standard to judge the danger of the system being overwhelmed. We are in TSA K, or Region K, which exceeded the 15% threshold on the 5 consecutive days from Nov. 28 through Dec. 2. These days were the only times that we had trouble transferring critically ill patients to San Angelo. I know this personally. You can find the information on COVID beds as a percent of total hospital beds by going to the DSHS coronavirus dashboard and clicking on COVID-19 Test and Hospital Data, at the bottom right side of the page and then looking under the tab marked Hospitals -Regional.

We have multiple different tests now, and the test for active disease are either molecular (usually PCR) or antigen tests. The Antigen test is rapid and is a good test for anyone who has active symptoms. There are molecular tests that are rapid, and I believe that these are almost as good as the tests that are sent to a reference laboratory. Also, we know that someone who is exposed, and who does develop the disease, will become infectious; and if they are tested the tests will start to show positive at about the same time. This is usually about 48 hours prior to the start of symptoms, and about 3 to 7 days after they were exposed. Most commonly people will develop symptoms about 5 days after exposure if they do contract the disease, but in rare cases they may not show symptoms for as long as 14 days after exposure. Understanding this, the CDC said that persons who have been exposed and are under suspicion of having contracted COVID must quarantine for 14 days from the day of last exposure. They must take their temperature twice daily, monitor their symptoms, and record this information until the end of the 14 days, then they can be released if they have had no fever or symptoms. This guidance has caused great consternation, because a family member who cannot isolate from a spouse or child or parent with the disease may be stuck at home for 24 days, and must wait 14 days beyond the release of the person who we know had the disease! Because there is increasing experience and understanding of both the disease and the costs associated with quarantine, the CDC has given local health authorities the discretion to allow shorter quarantine periods, and also to allow testing to play a role in release from quarantine. (https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-options-to-reduce-quarantine.html) According to the best evidence, if a large group of people are exposed to COVID, and a thousand people actually get the disease, only one of that thousand will be released while still infectious if they follow the 14 day guideline. One chance in a thousand is definition of “sure beyond reasonable doubt”, and that is the legal standard by which people are convicted in a court of law. Alternatively, the CDC has said that quarantine may be shortened to 10 days of the same process (taking temperature and monitoring symptoms), or 7 days, if the person has a test (antigen or molecular) within 48 hours of release. Following this protocol and the same line of reasoning, it is anticipated 50 of 1000 people would be released while still infectious (versus 1 out of 1000 using the 14 day protocol). This seems to me

to be a more reasonable balance of harms and benefits, in most – but certainly not all cases. To be clear, a responsible judgement must be made before using the shortened quarantine period, and I am trusting people to act responsibly.

While the most important number to guide public policy is the percentage of hospital beds filled with COVID patients, the number of cases and the number of deaths are also important, and recently the Wallstreet Journal published a map showing new cases, total cases and total deaths by state and by county, for the entire country. These really make clear that there is little correlation between the closing of businesses or schools and the number of cases and deaths. Similarly, the deaths in nearby counties seems uncorrelated until we take into account the characteristics of the population. When we begin to do that, we see that the numbers make much more sense.

County Cases by pop. Deaths by pop. Death by 75+

The following numbers are the total number of cases in the county, Cases by population, Deaths by population and Death by 75+ age

Runnels: Cases: 452. Cases by pop: 1 in 23: Deaths: 13. Deaths by pop: 1 in 787. Deaths by 75+ age: 1 in 77.

Tom Green: Cases: 10451. Cases by pop: 1 in 11 Deaths:148 Deaths by pop: 1 in 806. Deaths by 75+ age: 1 in 51.

Taylor: Cases:4097. Cases by pop: 1 in 34. Deaths:143. Deaths by pop: 1 in 962. Deaths by 75+ age:1 in 60.

Concho: Cases:129. Cases by pop: 1 in 21. Deaths:3. Deaths by pop: 1 in 909. Deaths by 75+ age:1 in 97.

Coke: Cases: 196. Cases by pop: 1 in 17.  Deaths: 9. Deaths by pop: 1 in 376. Deaths by 75+ age: 1 in 41

Coleman: Cases: 201. Cases by pop: 1 in 41. Deaths: 10. Deaths by pop: 1 in 820. Deaths by 75+ age: 1 in 84

NolanCases: 923.  Cases by pop: 1 in 16. Deaths: 12. Deaths by pop: 1 in 1220. Deaths by 75+ age: 1 in 52

Texas: Cases: 1.389M Cases by pop: 1 in 21  Deaths: 24,143. Deaths by pop: 1 in 1205.  Deaths by pop: 1 in 51.

Note: These figures are true for these populations at a given point of time in the recent past, but they should not be taken to mean that any individual has this chance of dying from COVID 19.

Regarding the things we should do. First and foremost, do these things that we know work:

1. Wash hands frequently and avoid touching face or food with unwashed hands.

2. Use alcohol based sanitizer as a substitute, when handwashing is not practical.

3. Keep a distance of 6 feet in social situations that allow for this.

4. Use at least a double layer mask over mouth and nose in social situations that do not permit a six-foot distance from others.

5. Stay home if you are sick, or if you have had a significant exposure to COVID.

6. Get a flu shot as soon as possible, and get the COVID vaccine when you are able.

We know that these things work, and we know this from multiple lines of evidence. The first reason I will give is the most compelling, because it is based on what each of us knows and can

see for ourselves. Have you had the flu this year? Have you even known anyone who has had the flu this year? The fact is that we have not had a single case of influenza reported in Runnels County this season. That’s remarkable! It’s unheard of to not have any influenza come through either hospital or any medical office in the county by Thanksgiving. Influenza activity is minimal or nonexistent throughout the state*. How can you explain that, other than by the fact that people are following – however imperfectly – the simple steps listed above. The second line of evidence is that of reason and logic, or what is called biological plausibility. We know that the primary way that the SARS virus is transmitted is by droplets that come from an infected persons mouth and nose, that they are produced in greater quantity by singing and talking loudly and that most of these droplets are of a size that causes them to descend fairly rapidly after they are exhaled. This means that they land on the items near that person, and the residue can be picked up when hands touch these items. This leads to transmission of the illness if the hands then carry viral particles to a moist body surface, such as the eyes or mouth. Transmission can also result if your face is one of the nerby items on which the droplets fall. (This is the logical argument for items 1, 2, 3 and to some extent item 4 above.) We know absolutely that wearing a surgical mask greatly decreases the spread of germs from the mouth to others. There is a reason it is known as a surgical mask: long ago studies were performed, showing that the wearing of such masks by the surgical team decreased the surgical infection rate. These masks are always worn primarily to protect other people and not the wearer of the mask. (This is the main reason item 4 has biological plausibility.) To a certain extent the mask may help to protect a clean zone around the mouth and nose, by acting as a physical barrier to those flying droplets.

We know that only a small percentage of the people who actually have had COVID have been tested for it, and there are usually 4 to 8 additional people who are infected for every reported positive case. In some cases these people were totally asymptomatic, but in my experience there was actually some change in their health. Most commonly they think their allergies got suddenly worse for some reason; the second most common story is that “I thought it was just a cold.” If you have a cold or a fever, or increased drainage – until we get good coverage with the vaccine –please stay home. In regard to the flu shot, it is very hard to tell the difference in the symptoms of the flu and COVID, in most people. By getting the flu shot you will be doing another good thing to protect yourself, your family and your community. Please do this for the sake of all of us.

I will address vaccines and treatments in the next installment.

Influenza-like illness graph.

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