What we need to do to live with COVID: An update

Dr. Bradly Bundrant
Dr. Bradly Bundrant is a physician at Ballinger Memorial Hospital. Dr. Bundrant is also the chairman of the Health & Wellness Coalition of Runnels County.

We have learned a lot about COVID over the last 18 months, and the truth is that most of us would prefer to forget all about it! But we can't afford to. That being the case, I have put together a short summation of the best and most pertinent information for easy reference.

First, COVID is an RNA type of virus that mutates moderately fast, and new mutations will replace older varieties if the new ones are better able to reproduce themselves. Consequently, we are facing a new wave caused by the delta variant, because it is more transmissible. Last year we had disease due to COVID-19 but no influenza in our community, because we were doing things to reduce the transmission of respiratory viruses, and COVID was 2-4 times as transmissible as the viruses that cause flu. Because flu, COVID and virtually all respiratory viruses are spread by droplets, a mask worn by someone who is shedding virus is useful. Also, virus particles that land on surfaces can be picked up on the hands and carried to a mucosal surface and the person can then be infected. Therefore, it is important to wash or disinfect hands before touching ones eyes, mouth, nose or food/drink. What we were doing was completely effective at stopping flu, but not COVID. The delta variant is 2-4 times as transmissible as last year's COVID, and it is more likely to cause severe disease in the unvaccinated. Therefore, we are seeing a more rapid rise in case counts than at any time in the past. According to information recently provided by Texas DSHS (on July 20, 2021), Texas had an 82% increase in cases in the prior week and a 180% increase over the prior two weeks. There was a 40 % increase in hospitalizations and a 26% increase in deaths due to COVID over the preceding week.

Second, having the disease of COVID or getting one of the vaccines for COVID results in relatively good immunity in most people. At one time we were afraid that people who got COVID a second time might have a worse course, but that does not appear to be the case. The evidence indicates that COVID vaccines usually result in higher levels of antibodies than does infection, but having the infection probably causes the body to have other protective responses in addition to antibodies. It is also important to distinguish between a positive test and having the disease. The usual method of identifying COVID is by a molecular test that uses a very sensitive methodology of Polymerase Chain Reaction (PCR), and for that reason it lacks the capacity to distinguish between virus that is intact and functional versus virus that has been killed by drying or other means. That means a positive PCR test is significant in certain settings, but not in others. There are other testing methodologies, but proper interpretation of a positive or negative test result requires context and other information. A PCR test in someone who has recovered from COVID in the last 90 days is not useful for two reasons. The protection against COVID infection appears to be excellent in almost everyone for at least 90 days, and also it is known that people can shed viral particles for up to 90 days, without being infectious. Immunity is probably the only reliable way of limiting the spread of disease, because delta is so much more transmissible.

Third, we have learned more about spread:

· All of the COVID vaccines are highly effective at preventing the spread of COVID.

· The most common way that COVID spreads is through close contact between unvaccinated individuals. The definition of close contact is any intimate contact or being in close proximity

(within 6 feet) without proper Personal Protective Equipment (PPE) for a total of 15 minutes over a 24 hour period.*

· We can limit spread of COVID through quarantine and isolation.

· Isolation refers to people known to have the disease, and it is recommended that these people stay at home, limit close contact with other people and keep a temperature log of twice daily temperatures (morning and evening). This isolation may be ended in 10 days after the onset of symptoms, if they have had no fever for 24 hours and are not using any medications that would block a fever, such as Tylenol or ibuprofen.

· Because we are in a pandemic, people who develop fever, loss of taste or smell, runny nose or other nasal symptoms are considered to have COVID until proven otherwise, and must be medically evaluated or else isolate just as if they had been diagnosed with COVID, as outlined above.

· Someone who gets sick with COVID is most contagious on the day symptoms begin, and they have been capable of passing on the virus for the prior 48 hours. This is the pre-symptomatic period. They remain capable of transmitting the virus for up to a week, but rarely more than that. For good measure, the CDC has chosen 2 days before and 10 days after onset of symptoms as the beginning and end of the infectious period, for individuals who were previously healthy.

· Quarantine refers to an individual who has close contact with someone during the 12 day infectious period, as defined above.

· Except in certain circumstances, people who have been in close contact with someone who has COVID-19 should quarantine. However, the following people with recent exposure may NOT need to quarantine: o People who have been fully vaccinated (see fully vaccinated, below) o People who were previously diagnosed with COVID-19 within the last three months

· The CDC says, "Local public health authorities determine and establish the quarantine options for their jurisdictions. CDC currently recommends a quarantine period of 14 days. However, based on local circumstances and resources, the following options to shorten quarantine are acceptable alternatives."

1. Quarantine can end after Day 10 without testing and if no symptoms have been reported during daily monitoring. With this strategy, residual post-quarantine transmission risk is estimated to be about 1% with an upper limit of about 10%.

2. When diagnostic testing resources are… available… quarantine can end after Day 7 if a diagnostic specimen tests negative and if no symptoms were reported during daily monitoring. The specimen may be collected and tested within 48 hours before the time of planned quarantine discontinuation (e.g., in anticipation of testing delays), but quarantine cannot be discontinued earlier than after Day 7. With this strategy, the residual post-quarantine transmission risk is estimated to be about 5% with an upper limit of about 12%.

· As the Health Authority for Runnels County, Dr. Bradly Bundrant MD, MPH affirms that the alternatives 1 and 2 above may be used in this County. Therefore, an exposed individual may obtain a test as early as day 5, and they may end quarantine at the end of the 7th day following their last close contact, provided they keep a twice daily temperature log through day 14, and remain completely free of fever or symptoms of COVID.

· Many people who have COVID actually have symptoms, but they believe that their cough or runny nose are due to allergies or a cold. Although exact studies are lacking, a good estimate is

that 1/3 to ½ of spread is due to people who have symptoms, and the rest is due to people without symptoms.

· Because we are in a pandemic, people who develop fever, loss of taste or smell, runny nose or other nasal symptoms are considered to have COVID until proven otherwise, and must be medically evaluated or else isolate just as if they had been diagnosed with COVID, as outlined above. ALSO, anyone who has ANY symptoms of COVID should consider getting medical evaluation and, as a minimum, they should take their temperature twice daily, wear a mask and minimize close contact with others, until all symptoms have resolved.

· Spread by people without symptoms is due about equally to truly asymptomatic (those who will become infected but never have any symptoms) and pre-symptomatic (people who will go on to develop symptoms, and are able to spread the disease in the 48 hours prior to developing symptoms).

· Masks (cloth or surgical) worn by infected persons, reduce the spread of respiratory viruses, because masks deflect the stream of expired air, and in doing so they catch a large proportion of the respiratory droplets on which the viruses ride.

· Cloth or surgical masks are less effective at keeping out droplets that are suspended in the air, as these droplets can still be inhaled if most of the air comes around the sides/top/bottom of the mask.

· A fresh, properly worn N-95 filters 100% of the inspired air, and therefore is quite good at stopping virtually all respiratory droplets. The CDC no longer advises re-use of N-95 masks.

· Children less than 12 y/o are unlikely to spread the virus to adults and are also very unlikely to be very sick with COVID. For that reason, I do not believe that the expected benefit is worth whatever risk is associated with the vaccine.

· It is debatable whether the benefits of masks exceed the harms, in children under 12 y/o.

Finally, there are medications to prevent and treat COVID, including the variants. We know that the vaccines are almost as effective against the delta variant as against the original type. The Johnson and Johnson vaccine was originally about 70% effective, it is about 67% effective against the delta variant. The Moderna vaccine was about 94% effective and it is about 94% effective against delta. The Pfizer vaccine was about 96% effective and it's about 88% effective against the delta variety. All of the vaccines are more than 90-95% effective at preventing death d/t COVID of all known types. All vaccines have some failure rate, and they are all more likely to fail in people who have a suppressed immune system, including those who have had organ transplants, are on chemotherapy, are getting biologic treatments for arthritis or are taking corticosteroids such as prednisone.

It takes two weeks for the body to mount an effective antibody response, therefore a person is considered fully vaccinated two weeks after they received the Johnson and Johnson shot or two weeks after the final shot of the series for the other two vaccines. The best news about vaccines is that everyone who needs one – that is everyone 12 y/o and up – can get one. In Ballinger call the Ballinger Memorial Hospital Clinic at (325) 365-5737, and you have your choice of any of the three shots for which you are eligible. Similarly, in Winters, call the North Runnels Hospital Clinic at (325) 754-1317. Supplies may be limited.

All of the treatments that we have, including Regeneron and ivermectin, are equally appropriate in individuals who are sick with COVID, whether they have previously been vaccinated or previously had COVID. It is of interest to note that a new oral agent, molnupiravir, is under consideration by the Food and Drug Administration or Emergency Use Authorization (EUA), and if molnupiravir receives this EUA Merck will receive approximately $1.2 billion to supply approximately 1.7 million courses of molnupiravir to the United States government. However, molnupiravir would not be eligible to get an EUA if ivermectin or any other oral agent were to be recognized as effective treatment for COVID-19.

Remember, call the Clinics above if you think that you want vaccination or if you need to be evaluated or treated. Call 911 if you are having trouble breathing.

Please stay safe, and do all that you can to keep well and help others do the same.

* Exception: In the K–12 indoor classroom setting, the close contact definition excludes students who were within 3 to 6 feet of an infected student (laboratory-confirmed or a clinically compatible illness) where o both students were engaged in consistent and correct use of well-fitting masks; and o other K–12 school prevention strategies (such as universal and correct mask use, physical distancing, increased ventilation) were in place in the K–12 school setting. https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan