Where Can I Get the COVID-19 Vaccine?

or
This Pandemic Will End in Tiers

Sunday, January 17, 2021

Yours truly receiving my first dose of the Pfizer vaccine at Cedars-Sinai on Dec 24
Yours truly receiving my first dose of the Pfizer vaccine at Cedars-Sinai on Dec 24

The Short Version for Readers Who Want Clear Instructions and Little Else

[This section was updated on Friday, January 22, and will be updated periodically.]

  • Keep an eye on the LA County Dept of Public Health COVID-19 Vaccine Distribution site. Know your phase and tier. If you’re 65 or older, scroll down to Phase 1B and click on the “Persons age 65 and over How to get vaccinated” button. That will take you to another page that lists the documents required for a vaccination appointment. Read it, scroll to the bottom and click on the “Make an appointment to be vaccinated by LAC DPH and partners” button. That site will let you choose a location and (if available) make an appointment.
  • The County Dept of Health has a call center for residents without computer access. Call 833-540-0473 between 8:00 am and 8:30 pm 7 days a week for assistance with appointments.
  • Carbon Health, one of the vaccine distributors in charge of some of the vaccination locations (including Dodger Stadium) has a website that can be reached directly. The LA County link above will also get you to the same website if you choose one of their locations, but if you want to try their website directly, it’s here.
  • If you want to receive the vaccine at Cedars-Sinai Medical Center and you don’t already have a My CS-Link account, create one here. They do not yet have doses or appointments for patients 65 and over, but people with My CS-Link accounts will be informed as soon as they do.
  • Consider signing up for email newsletters with vaccine updates from the LA County Dept of Public Health.
  • Please don’t call your doctor’s office with questions about vaccine scheduling. If you can’t find the information you seek online, it’s likely that your doctor doesn’t know either. If you must reach out to your doctor’s office about this, please make every effort to use an asynchronous method (email, patient portal, fax). Leave the phone lines for the poor folks with medical problems.

The Long Version for Readers Who Enjoy More Education / Editorializing / Bloviating

Vaccine distribution has become a mess. But that noun is terribly inadequate for the situation.

The pharmaceutical industry has just completed one of the greatest scientific and logistical marvels of my lifetime. Pfizer and Moderna, with Johnson and Johnson and others right behind them, have created, tested, and manufactured millions of doses of safe and effective vaccines for a disease that only came into being 13 months ago. Drunk with the euphoria of that accomplishment, I had assumed that state and local governments, working with local hospitals and pharmacies, would rise to an equally demanding project – administering the vaccine to hundreds of millions of people.

It is still early days, but so far, vaccine distribution in LA County is a mess. But a mess is what happens when you drop an egg. To describe what happens when millions of patients have no reliable centralized source of information, when they circulate rumors of where vaccine might be available, when by the thousands they call their doctors whose poor receptionists don’t know any more that what the patients have heard on the news, to describe that situation one must reach for military acronyms or foreign words. So far, vaccine distribution in LA County is fubar. It is a big snafu. It is a balagan.

The centralized place that was supposed to contain up-to-date information about vaccine distribution in LA County is the LA County Dept of Public Health website. Please take a look at it. It’s clear. It’s organized. It lets you see which phase and tier you’re in and provides a rough guess as to when that phase and tier will receive the vaccine. What could go wrong?

Well, it sounds like private companies who have volunteered to distribute the vaccine, like Ralphs, Rite Aid, and others, worked with the State to organize their vaccine administration schedule and request vaccine doses. That’s a very good thing. The more options there are to get a vaccine the better. Also, last week Gov. Newsom changed phase 1 to include all people 65 and older. (Prior to that the cutoff was 75.) That’s also a good thing. The sooner we can vaccinate all older patients, the better. The problem was that the County website didn’t reflect any of these changes for days.

Patients, on their own initiative (or following links from the California site), found that Ralphs was already making appointments for the vaccine. This information spread like wildfire and I soon heard from patients that the site was inundated and working poorly. There was no longer any reliable comprehensive centralized source of information, leaving patients to act on emails from their sister-in-law’s accountant, who’s a very nice guy. To make matters worse, some officials were telling the public to call their primary care doctor with questions, when we were as in the dark as the public. So our long-suffering receptionist spent most of last week telling frustrated callers “We don’t know either,” while patients clicked the refresh button on the Ralphs site like rats in a cocaine experiment.

The dust hasn’t yet settled. What is clear is that the vaccine will be distributed through large medical centers and large pharmacy and supermarket chains. (It is possible that some private doctors’ offices will carry the vaccine too, and we’re still trying to figure that out for our office.) The logistical complication thus far is that a patient has to choose a vaccination site prior to making an appointment. Meaning, vaccinations at all Ralphs will be scheduled through Ralphs’ website; vaccinations at Cedars will be scheduled through the Cedars patient portal, etc. What would be far superior is a single centralized place where a patient can enter her demographics and be given a list of the soonest appointments available at any vaccination site close to them. That would require cooperation between all the vaccination sites to have one integrated scheduling mechanism, and it would require a few programmers to build such a thing. Oh, and it would require local leadership.

For now, your best bet (probably) is to sign up with the patient portal of the large medical center closest to you (or the one you frequent most). Cedars-Sinai Medical Center’s patient portal is My CS-Link, and if you don’t have an account you can create one here. They recently sent an announcement to all patients that included the following.

When you have the option to receive the COVID-19 vaccine, we encourage you to get vaccinated. Like all positions Cedars-Sinai has taken during the pandemic, this position is based on the latest scientific data—which favor the vaccine as a safe and powerful way to stop the spread of COVID-19.

At present, we don’t know exactly when we will be able to offer vaccines to our patients. We do want you to know, with complete confidence, that when we are authorized to proceed, we will notify our patients immediately. We also want to remind you that your My CS-Link™ account is the fastest, most reliable way to receive up-to-date information about the vaccination process and will help to streamline appointments when scheduling becomes available.

That may be the simplest option for now. Pick the medical center where you’d like to receive the vaccine. Sign up for their patient portal. And wait. Occasionally, take a look at the LA County site to get an idea of when to expect your tier to get vaccinated. And wait some more.

If I learn of a better information source that lists all the available vaccine administration sites, or if a centralized vaccine appointment scheduling site is developed, I’ll let you know. Until then, please continue to stay out of each other’s homes, maintain distance from others in public places, and, as much as possible, stay home. Please stay well.

[This post is dedicated to the memory of Dr. Anny Jacoby, my aunt, who died last week at the age of 89. She had a long career as a pediatrician in Jerusalem. She was an inspiration to me as a brilliant and caring physician and as a devoted spouse and parent.]

Learn more:
COVID-19 Vaccine Distribution in Los Angeles County (County of Los Angeles Public Health)
COVID-19 Vaccine information, including sign up for email newsletter (County of Los Angeles Public Health)
My CS-Link (the patient portal for Cedars-Sinai Medical Center)
Ralphs COVID-19 vaccine appointment website

More

A New Hope

7-day average of daily LA County COVID-19 cases and deaths calculated on Sundays
7-day average of daily LA County COVID-19 cases and deaths calculated on Sundays
7-day average of daily LA County COVID-19 cases and deaths calculated on Sundays

How’s it going in Los Angeles with the pandemic?

The numbers in LA are absolutely dreadful. Daily new cases, hospitalizations, and deaths are at all-time highs.

The current case numbers make the mountain of cases this summer look like a molehill. In July I worried that a COVID death rate in the 40s per day would make COVID a contender for the leading killer in LA County. The current death rate is twice that. Many LA ICUs are at or near capacity.

But a vaccine is on the way. Everyone’s talking about it!

Actually, several vaccines are on the way. A vaccine developed by Pfizer-BioNTech has just been approved. Healthcare workers and residents of long-term care facilities have been receiving it for about a week. Moderna’s vaccine was authorized this week, and its first doses should be in peoples’ arms by the time you read this. Other manufacturers have vaccine candidates that will seek approval once their testing trials are complete.

I’m worried that the vaccines were developed so quickly. I don’t want to get a vaccine if they’re cutting corners in the testing.

No corners have been cut. The candidate vaccines are going through the same phases of trials that any other vaccines have gone through. These trials are subjected to the same peer-review and published in the same journals that other new vaccines and medications are published in. The trial of the Pfizer vaccine involved more than 40,000 participants and was published in the New England Journal of Medicine. The speed to market wasn’t accomplished by skimping on the research. It was accomplished by starting the manufacturing of doses while the trials were still going on. Operation Warp Speed guaranteed purchase of hundreds of millions of doses of candidate vaccines, so that the manufacturers could start working immediately. That way, as soon as the vaccine is approved, lots of doses are already available.

Does the vaccine work?

Yes. The Pfizer vaccine involves two doses given 21 days apart. (Different vaccines might have different dose schedules.) In the randomized trial, the vaccine was 95% effective in preventing COVID-19.

I’m worried about side effects. Is it safe?

It’s very safe. In tens of thousands of doses there were no serious side effects. The most common side effects are pain, swelling and redness in the arm, and fatigue, headache and chills. The informal hubbub from my doctor friends who have already received the first dose is that it’s much less side-effecty than Shingrix, the vaccine that prevents shingles. There was a single report of a mild allergic reaction, so everyone will be watched for 15 minutes after administration to monitor for that. I’m scheduled to get my first dose on Thursday. I wouldn’t do it if I didn’t think it was safe.

Will I grow a third eye?

That hasn’t been reported yet. However, that would be very cool. Having two eyes gives you depth perception, so, if I’m doing my math right, a third eye should let you see in the fourth dimension.

Where do I get it? Will your office give it out like the flu shot?

Unfortunately, the Pfizer vaccine has very complex storage, distribution and reporting logistics. Because of that, it’s being distributed primarily through large medical centers. Cedars-Sinai has received tens of thousands of doses and has begun vaccinating healthcare workers and long-term facility residents. Future vaccines by other manufacturers will have different requirements. If any are appropriate for distribution in a small doctors’ office, we’ll definitely ask to get some.

Do I have to get the vaccine?

No. COVID vaccination will be completely voluntary, but you should get it, both to protect you and those around you.

When can I get the first shot?

The goal is to vaccinate everyone who wants to be vaccinated by the middle of 2021. So you’ll get it in the next six months. Since that many doses are not available now, local and national health authorities are making priority lists of groups of patients. The details of those lists are not yet known, but it’s assumed that older and sicker patients will be prioritized.

As soon as I know that doses are available to the general public, I’ll email all my patients with all the information I have. I know many of you are very eager to get the first dose ASAP. I’m eager to help you do that. We just don’t know anything yet.

I’m a 107-year-old essential worker. Can I get the vaccine before everyone else? I don’t want the hoi polloi getting it before me.

Everyone who wants to be vaccinated will be vaccinated. I’m not the one making up the priority list of which groups get the vaccine first. Even if a future vaccine is distributed through our office, it will be done according to recommendations from the LA County Dept of Health and the CDC. We’ll give it in whatever order they say. Please stop calling me to remind me how important you are. I love all of you the same. This is a race against time, not a race against your neighbor. We’re all going to get there.

I know this holiday season will be disappointing for many of us. But the end is in sight. Please help keep the ICUs less full by staying out of other peoples’ homes and avoiding gathering with people who don’t live with you. I know that we’re bored and lonely and frustrated. But we just need to keep our most vulnerable loved ones from getting infected for a few more months.

In the midst of all this loss, we might forget what has been achieved. A novel virus made the leap to infecting humans in December 2019. Within one year of that event, multiple safe and effective vaccines have been developed. That is an extraordinary scientific, technical and logistical accomplishment. Distributing it to hundreds of millions of people will be another one.

I hope your Hannukah was bright. I hope your Christmas is merry. I wish all of you a much much better New Year.

Learn more:
Frequently Asked Questions about COVID-19 Vaccination (Centers for Disease Control and Prevention)
Information about the Pfizer-BioNTech COVID-19 Vaccine (Centers for Disease Control and Prevention)
Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine (New England Journal of Medicine, by subscription)

More

The Beginning of the Middle

Wednesday, November 11, 2020

LA County 7-day average COVID-19 cases calculated on Sundays

After staying quite low through much of September and October, COVID-19 case numbers are rising again in LA County, as are hospitalizations for COVID. The LA County Department of Public Health warned last weekend that “transmission of COVID-19 is widespread and increasing in L.A County”. And if you think that’s bad, what’s happening in much of the rest of the country is worse. Regions across the South and the Midwest that didn’t have widespread COVID transmission this spring are seeing exponential growth in their case numbers. New daily cases in the US are at record levels, even higher than the bad-old-days in April when New York hospitals were inundated. Some hospitals, especially in less-populated areas, are approaching their capacity. So COVID-19 infections and hospitalizations are rising. The increase is fastest in regions that were previously spared but is happening here in LA also. Europe is experiencing a similar widespread increase in case numbers.

Why the dramatic increase now? Dr. Michael Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota, blames the worsening numbers on pandemic fatigue. He posits that many people who previously were meticulous about physical distancing and masking are increasingly tired of adhering to the restrictions after 8 months. People are beginning to gather with family and friends who are not in their households, and these gatherings are fueling COVID transmission.

We are all tired of the pandemic. Grandparents miss their grandchildren. Kids miss their friends. Teachers miss their students. We want to go over to a friend’s house for pizza and a movie. We want to hug a loved-one. We want to pat a colleague’s shoulder. Physical distancing has taken a lot out of us. We want to believe that we’re close to the end of the pandemic, but the numbers tell us otherwise. We’re not at the beginning of the end of the pandemic; we’re at the beginning of the middle. Some tough months are still ahead.

So as hard as it’s been, there’s nothing to do but to return to what we know prevents COVID transmission. Avoid crowds. Avoid physical proximity (6 feet) to people not in your household. When in public places, wear a mask that covers your nose and mouth. The LA County Dept of Public Health reminds us that “Public celebrations and protests where people are close to each other, unable to remain six feet apart, cheering and shouting, especially without face coverings, are places where it is very easy and very likely for COVID-19 to spread.”

There are ways we can make it easier to live with these restrictions. Gather outdoors with those you miss and stay 6 feet away from them. As I wrote last time, stop worrying about contaminated surfaces, since it’s increasingly clear that COVID is transmitted by inhaling respiratory particles, not by touching surfaces. Don’t bother wiping down packages, doorknobs and counters. It won’t protect you from COVID and it will expend energy that should be conserved for the effective measures above.

So while we’re not yet at the end, the end is in sight. There are multiple companies working on promising vaccine candidates. By the first quarter of 2021 many of them will have completed trials showing that they are safe and effective. Pfizer’s vaccine has had some very encouraging early data, suggesting that their vaccine protected 90% of patients from COVID-19 infection. After we find out in early 2021 which vaccines are safe and effective, the monumental logistical challenge of manufacturing and distributing tens of millions of doses of vaccine will commence. This is likely to take months, and many questions and technical hurdles remain. Some of the vaccine candidates will need to be transported and stored in ultra-cold freezers which many medical facilities lack. The priority groups that should be first to receive the vaccines have not yet been determined. But despite these challenges, it’s reasonable to believe that enough people will have been vaccinated by the middle of next year to greatly slow the spread of the pandemic.

That could mean a return to the classroom for students in Fall 2021, and a return to movie theaters, restaurants, and friends’ homes for the rest of us. In the meantime, I wish you a Thanksgiving that is joyous and full of love and gratitude, but I pray you wait until 2021 for a Thanksgiving that is crowded with people who don’t live with you. So be of good cheer, for the worst is yet to come. But after that, it’ll get better.

Learn more:
Public Health Cautions Residents to Avoid Crowds with COVID-19 Spread Increasing in L.A. County (LA County Dept of Public Health, 11/7/2020)
LA County Daily COVID-19 Data (LA County Dept of Public Health)
U.S. Posts Fourth Straight Record as Daily New Coronavirus Cases Top 127,000 (Wall Street Journal)
Record Covid-19 Hospitalizations Strain System Again (Wall Street Journal)
The Osterholm Update podcast (Center for Infectious Disease Research and Policy)
Contagion and Contrition (my post reviewing how COVID-19 is transmitted)
Pfizer’s Covid-19 Vaccine Proves 90% Effective in Latest Trials (Wall Street Journal)

More

Contagion and Contrition

Good news! You can stop sterilizing your counter tops with a blow torch.
Photo credit: pxhere.com, public domain.

What’s happening now?

In LA County, COVID-19 cases, deaths, and hospitalizations have been steadily declining for the last two months. Hospitalizations and deaths from COVID-19 in LA are at lows not seen since the early months of the pandemic. This contrasts with a recent increase in cases nationally, including in cities like New York. Whether this new resurgence of cases will spill into Los Angeles remains to be seen.

What can we do to keep the numbers here improving? Continuing to do what we’re doing is clearly working, but with many suffering from “pandemic fatigue”, I thought it might be helpful to review how COVID-19 spreads so we can focus our efforts on what works.

How is COVID-19 transmitted?

A very useful review of what we know about COVID-19 transmission was published in the Annals of Internal Medicine two weeks ago. The review stressed that this virus is transmitted through respiration, that is through someone inhaling a particle recently exhaled by someone else. Physical proximity and ventilation are major determinants of transmission risk. That’s why many clusters of transmission happen in crowds, and most clusters of transmission happen inside. So physical distancing helps reduce risk, and gathering outside rather than inside helps reduce risk. Studies also suggest that wearing a mask, both in health care settings and in general, decreases the risk of transmission.

A poorly known but important conclusion of this review is that transmission of COVID through contact of surfaces not been conclusively documented. When the pandemic began, since we didn’t know how the virus was transmitted, many people took it on themselves to disinfect packages, clean doorknobs in their house, and generally treat all surfaces as if laden with cooties. After studying many transmission clusters over all the months of the pandemic, we can confidently conclude that the virus isn’t usually spread that way.

In July, The Atlantic published an interesting article reviewing the “hygiene theater” (decontamination for good PR, rather than for health) that developed during the pandemic even as it became clear that surfaces were not a threat. It also made the good point that resources devoted to disinfecting surfaces (for example on subways) are depleting resources better devoted elsewhere (for example, by letting subway cars run for more hours instead of being cleaned daily). I’m hoping that alleviating anxieties about this issue will conserve our physical and emotional energy to concentrate on what works in the coming months – physical distance, ventilation, masks.

So as a gift to yourself, please stop cleaning your packages, stop Windexing your produce, and lose the gloves. Handing someone a credit card, touching an elevator button, or opening a door might transmit Staph or lots of other germs, but it’s unlikely to transmit the novel coronavirus. It’s OK to use your bank teller’s pen to sign something. (But, according to my local branch, it’s not OK to absentmindedly insert it into one’s nose. Another reason to wear a mask.)

Yes, between patient visits we’re still meticulously cleaning surfaces in our examination rooms. But that’s because (1) we have low enough patient traffic to do the extra work, (2) we are intentionally being more cautious than necessary, and (3) we want to reassure patients who are simply frightened, regardless of the data. That is, we don’t only want patients to be safe; we also want them to feel safe.

A personal note

With Yom Kippur hours away, I wanted to acknowledge what an awful year many of us are having. Some of my patients have lost thriving businesses. Many of us had healthy habits which were carefully constructed over years to keep us physically and mentally fit. These habits toppled overnight, and are hard to recreate. Many of us miss seeing our grandkids or our parents in person. We are more isolated, more frightened, and less optimistic than we’ve ever been. None of us are at our best.

So for all the times I was cranky when I should have been calm, for all the times I spoke when I should have listened, for all the times I tried to explain how you should think before understanding how you feel, for all the times I was short when I should have been patient, I sincerely apologize. Please forgive me. I’m confident there are better days ahead. We must remember that in life (unlike math) truth is frequently self-contradictory. We are all doing the best we can; we can all do better.

Learn more:

LA County Daily COVID-19 Data (LA County Dept of Public Health)
Transmission of SARS-CoV-2: A Review of Viral, Host, and Environmental Factors (Annals of Internal Medicine)
Hygiene Theater Is a Huge Waste of Time (The Atlantic, July 27)

More

Influenza Vaccination Frequently Unasked Questions

A woman receives a vaccine
Photo credit: Flickr / SELF Magazine, Creative Commons Attribution 2.0 Generic license

Tuesday, September 8, 2020

With fall almost upon us, patients are abuzz with questions about this season’s flu shot. Below I try to answer the questions they should be asking.

I hear the flu shot is especially important this year because of the coronavirus pandemic.

That’s not a question. I thought I was going to be answering questions. Is this a rambling stream of consciousness post, or a question and answer post?

Wow. You really need more coffee. OK. How about this? Will the flu shot protect me from the novel coronavirus?

No. It will protect you from influenza.

I see. But if I get COVID, will the flu shot make it a milder illness?

No. If you get influenza the flu shot will make it a milder illness. The vaccine protects from influenza. The influenza virus and the coronavirus are in totally different families of viruses.

Then why is everyone making such a big deal about making sure I get my flu shot this year?

Well, it’s less about individual patients than about the healthcare system in general. We really don’t want to be juggling two serious respiratory illness outbreaks at the same time. It’s not that one illness interacts with the other, it’s that if we’re seeing lots of flu patients and lots of COVID patients the same week our ER and hospital beds will fill up. So we’d love to see as little flu this season as possible.

Aren’t COVID and flu treated the same?

No. For influenza we have oseltamivir (Tamiflu) and baloxavir (Xofluza) which can shorten the illness duration and prevent complications in high-risk patients. For COVID-19 we have no proven therapy for outpatients, but solumedrol and remdesivir have been shown to help hospitalized patients. That’s part of the logistical problem. If an ER doctor sees a patient with a fever and a cough today, she can assume the patient has COVID-19 and do testing just for confirmation. But in December, she’ll have to test both for flu and COVID. Given that the best test for COVID has a false-negative rate of about 20%, that will lead to a lot of uncertainly about diagnosis and treatment. So we’d love to see as little flu this season as possible.

Who should get the flu shot?

The flu shot is recommended for everyone over 6 months who doesn’t have a specific contraindication, like an allergic reaction to a previous flu shot. I usually urge patients at highest risk to get it – people over 65, people with lung and heart disease, pregnant women, and people who live or care for folks in the previous groups. But this year I’m asking everyone to get it, because we’d love to see as little…

See as little flu this season as possible. Yeah, I get it. Any special consideration for older patients?

Yes. There are two important points for patients 65 and over. The first is that there is a special high-dose influenza vaccine that is approved especially for people 65 and over. Older people sometimes produce inadequate quantities of antibodies in response to the standard vaccine, so the higher dose helps generate the amount of antibodies required for immunity. Older patients can receive either vaccine, but this year I’m making a point to remind older patients to get the high-dose vaccine. Of course, getting the standard vaccine is better than no vaccine at all.

And the second point?

Huh? Oh, right. The second important point for folks 65 and over is the timing of the vaccine. Younger patients can get the flu shot immediately, because they usually mount a longer-lasting antibody response. (And our office has the standard dose flu shot, so please come and get it, younger patients.) But older patients’ immune response frequently fades after a several months, so it’s recommended that they receive the vaccine in October so that they are still protected in January and February. (I’ll email our older patients when we receive the high-dose vaccine.) Again, getting it too early or too late is much better than not getting it.

Do you have any seasonal thoughts about contrasts between the Gregorian and Hebrew calendars?

Yes, actually. Rosh Hashana, the Jewish New Year, is next week, and I must say that starting a new year in autumn feels much more natural than in January. The Hebrew calendar is obviously tied to agriculture, but you don’t have to be a farmer to feel the sense of a new year starting now. The school year starts in the fall; the fiscal year starts in the fall. In fall Nature declares “You have finished a loop around the Sun. A new loop is starting now. Take note.” Nothing that lasts a year starts in January. Why are we talking about this?

I just thought you might want to offer readers good wishes for the coming year.

Oh, that’s so thoughtful. And, listen, I’m sorry for snapping at you at the beginning of the post.

Don’t worry about it. We’ve all been under a lot of pressure.

Thanks. So, whether you’re celebrating or not, please accept my wishes for a year of good health, prosperity, and peace. And please get a flu shot.

Learn more:
Pandemic Guidance – Vaccination Guidance During a Pandemic (Centers for Disease Control and Prevention)
Pandemic makes flu shots vital this season. Health officials aim for easier, safer ways for you to get the vaccine. (Washington Post)
Can You Get a Flu Shot Now? Yes, and Doctors Say You Should (New York Times)

More

Our Quandary and Your Queries

7-day average COVID-19 cases and deaths calculated on Sundays
7-day average COVID-19 cases and deaths calculated on Sundays
7-day average COVID-19 cases and deaths calculated on Sundays

Wednesday, July 22, 2020

In my last post three weeks ago I observed the trend that the number of new daily COVID-19 cases had been increasing for two months in LA County while deaths from COVID had been decreasing. That post generated many questions and responses. (Thanks!) Today I’d like to update us on the situation in LA and answer some of the questions you posed.

About two weeks ago death rates reversed their previous declines and rose to a seven-day average in the mid-40s, which is where they were back in April. (See the graphs above.) Forty-something deaths per day in a county of ten million people might not seem like a lot, but the usual annual mortality in LA County is 60,000. Forty deaths a day amounts to a quarter of that total and is about the same as the number of deaths from the greatest killer in LA County – heart disease. So a sustained rate of 40 deaths daily would be awful.

In the last two weeks hospitalizations for COVID have climbed and have reached new highs. I should make it clear that we are not in immediate danger of running out of hospital beds, but the trend is clearly in the wrong direction. And of course the number of new daily COVID cases continue their rise, now tallying more than 3,000 new cases per day.

So my hypothesis in my last post that low risk individuals were increasingly exposed to COVID while high risk individuals were effectively protecting themselves clearly failed. Apparently as the number of new infections continued to grow, they were not limited to those who would easily recover. In that post I suggested that we shift our focus from figuring out the sorts of establishments that can reopen to instead figuring out the sorts of people who can safely go to any establishment. But that suggestion depends on death rates declining, so it’s moot for now. And, in fact, last week the Governor ordered many businesses that had reopened, like gyms, hair salons and malls, to reclose.

Let me turn now to some of your questions.

Shouldn’t even people at low-risk continue to wear face coverings and practice physical distancing?

Absolutely, and I should have said so explicitly in my last post. Now that death rates are climbing, we should all stay home when possible. When we venture outside, we should maintain distance from others and wear face coverings. And everyone should wash their hands frequently.

There are some suggestions that COVID infection has long-term consequences. Isn’t that a reason that even people at low risk take strict precautions?

To be clear, now that death rates are high, everyone should take strict precautions. Whether low-risk people can be more lax is a question to take up when death rates are low again. There is some evidence that some patients have protracted injuries to their lungs, brains, and hearts months after COVID infection. The frequency and magnitude of these complications are unclear, however. Recall that many people with COVID have no symptoms (and presumably no organ injury) at all. Whether these injuries resolve or persist in the long term won’t be known until the long term. But the unclear possibility of harm in the distant future does not seem like the sort of risk that would generate consensus about closing businesses. We don’t close bars even though we understand the long-term risks of drinking alcohol. We closed businesses to keep our hospitals from being immediately flooded with patients, not to prevent health consequences years from now.

High-risk patients don’t live in a cocoon. By necessity they interact with others even if only to pursue essentials, like medications and groceries. Since those others might be at low risk, doesn’t that mean that all of us must act as if we’re at high-risk to protect those who are?

Maybe. And if so, then my suggestion last time is unworkable. If low-risk people can’t segregate with only other low-risk people, then high-risk people will necessarily be harmed as case counts rise. And this may be exactly what happened two weeks ago. If at some prevalence of disease the infection will always “leak” out of the low-risk silo and into the high-risk silo, then we can’t afford to let the case counts rise. It would be nice if that wasn’t the case. It would be nice to let low-risk people get on with their lives, generate income, and reform frayed social ties if they could do so without consequence to their health or to others’ health. That would result in case counts continuing to rise while death counts remained stable or declined.

But that isn’t what’s happening. So until things improve, each of us has to stay away from others, wear a face covering, and wash our hands, as if we’re the only one keeping our neighbor, our relative, our grocer, or our pharmacist out of the hospital. Because we might be.

Learn more:
Newsom orders statewide reclosures (LA Times, July 13)

As 13 New Deaths and 2,593 New Cases of COVID-19 are Confirmed, Revised Health Officer Order Requires Closure of Additional Indoor Operations and Sectors: Actions come as Public Health releases new K-12 protocol to provide “roadmap” to help schools plan for reopening (News Release July 13, LA County Dept of Public Health)

Majority of Newly Reported COVID-19 Cases are in People Under 41 Years Old, New High of COVID-19 Hospitalizations – 11 New Deaths and 2,848 New Cases of Confirmed COVID-19 in Los Angeles County (News Release July 19, LA County Dept of Public Health)

COVID-19 page (LA County Dept of Public Health)

My previous posts about the pandemic:
Summary, Speculation, Suggestion (July 3)
Think Local, Act Local (April 27)
Testing, Testing Part 2 (April 17)
Of Masks And Meaningful Measures (April 5)
Updates From The Socially Distant (March 30)
Testing, Testing (March 26)
Novel Coronavirus FAQ Part 2 – Pandemic Hullabaloo (March 20)
Coronavirus Frequently Asked Questions (March 13)
Community Transmission Of Novel Coronavirus In LA County (March 11)
What You Need To Know About The Novel Coronavirus (March 1)

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Summary, Speculation, Suggestion

7-day average COVID-19 cases and deaths

Friday, July 3, 2020

I haven’t written for about two months. One reason is that I’ve been busy taking care of my patients. Only three of my patients have contracted COVID, as far as I know. All have recovered. Many others may have had asymptomatic infections. But almost all of my patients have had important COVID-related questions and concerns. Another reason for the blogging pause is that for the last two months I haven’t known what to write, because I didn’t understand what was happening. I still don’t understand what’s happening, but it’s increasingly clear that neither does anyone else, so I thought it was a good time to post an update and propose a shift in strategy.

Since the middle of May the number of new daily COVID cases in LA County has been steadily climbing, from 900 new cases daily to just over 2,000 cases daily at the end of June. (COVID statistics are from the Los Angeles County Dept of Public Health. I applied a seven-day average calculated on Sundays.)

I should clarify what a “case” is. A case is a person who tests positive for the novel coronavirus and is reported to the LACDPH. So cases are definitely an undercount of all the COVID infections because they exclude the asymptomatic infections that weren’t tested and they exclude the sick people who recovered at home and weren’t tested. (The number of asymptomatic infections at any given time is an important factor in how quickly COVID can spread and in the risk of being infected in a public place. We don’t have a good estimate of this number.)

During the same time period COVID deaths in LA steadily dropped from an average of 45 daily deaths to about 26 daily deaths. So in about 7 weeks the number of daily cases doubled while the number of daily deaths halved. What’s going on? Is the disease one quarter as deadly as it was 7 weeks ago?

The short answer is that no one knows. Several possible explanations have been explained, and I’ll briefly analyze each.

Deaths lag behind cases by a few weeks. One explanation offered by public health officials is that deaths are a lagging indicator. It takes a few weeks for those who are going to die to die, so case numbers usually rise prior to deaths. That’s true, but deaths don’t lag by seven weeks. If the cases diagnosed in May were going to die at the same rate as those in April, we would have seen an increase in deaths by now.

Increasing case counts are an artifact of increased testing. This theory posits that since more testing is happening, we’re detecting more disease even though the number of actual infections is stable. There is good evidence that this is false. The best evidence against this theory is that the percentage of the tests done that are positive is increasing, suggesting that the number of infected people in the population is going up. The rate of new infections is really increasing.

Hospital care has improved. This is certainly at least part of the story. Recent studies demonstrating the effectiveness of remdesivir and dexamethasone in patients with severe COVID have informed current hospital care. Other best practices like placing patients in the prone position (on their stomachs) have spread, and hospitalists have gotten better at protecting themselves while caring for patients. There’s every reason to believe that this has led to more patients surviving their hospitalization.

The virus has mutated. There isn’t a shred of evidence for this theory, but it deserves some thought. All pathogens (like everything with genes) occasionally mutate. Most mutations are detrimental to the pathogen, but occasionally a random mutation causes a change that helps the pathogen infect more hosts. In general, milder strains of germs spread to more hosts, since a dead host is ineffective at spreading the infection. So over time, evolution tends to favor germs that cause milder disease. There’s no specific reason to believe that the novel coronavirus mutated to a milder strain in May, but one can dream.

The disease is shifting to people who are less vulnerable. Many regions have reported that patients who have been infected recently are younger, on average, and healthier than those infected a few months ago. This trend may simply be due to different isolation behaviors by those at high risk and those at low risk. If high-risk individuals have become ever stricter about social isolation, while those at lower risk have participated in the economic reopening, that would lead to more low-risk individuals being infected and simultaneously to fewer deaths. This is the most intriguing possibility, since it suggests that (again, on average) individuals are making rational decisions balancing their risk of infection and their benefits of social and economic interactions. It suggests that those who have least to lose have returned to work and to play and are being infected without terrible consequences. (The COVID hospitalization census at Cedars-Sinai has been declining or flat until about two weeks ago. There has been a small increase since then.) And those who have most to lose have remained isolated and stayed healthy.

Public health officials in many regions are sounding the alarm about the increasing case counts. In some states businesses that had been opening are reclosing. LA County has resuspended in-restaurant dining, which had only been opened a few weeks ago. Perhaps this is wise. But perhaps a focus on case counts misses the mark. LA County hospital utilization, while increasing, is nowhere near full. We should recall that the point of flattening the curve was to maintain availability of hospital beds, ICU beds, and ventilators. We have done that. Regions like Arizona that are in danger of swamping their bed supply might need to return to stay-at-home orders to keep hospitals open, but while LA County hospitals continue to have open beds, I would like to propose a different pandemic mitigation strategy.

Rather than issue guidance and regulations focused on different establishments (restaurants, retails stores, gyms, etc.), I suggest it would be more effective to issue guidance focused on people of different risk levels. Those at highest risk (people over 65, people with chronic health problems, people who are immunosuppressed) should continue to socially isolate until case counts are negligible or an effective vaccine is available. Those at lowest risk (young healthy people who do not live with high-risk people) should get back to their lives. Yes, their risk isn’t zero. Yes, some of them may end up hospitalized, and even though they would survive, their stay in the ICU might be miserable. But for every one of them in the ICU, hundreds would have very mild disease, and thousands would be able to return to work, to exercise with friends, and to pray with their congregation.

Instead of advice about where we can go, we need advice about who can safely go anywhere and who should stay home. We need public education about which chronic medical problems increase risk so that individuals can make effective decisions for themselves. If death rates stay low and healthcare resources remain available, rising case counts should be seen as evidence of people getting on with their lives, and herd immunity getting closer. This should be met with optimism and with gratitude to the hospitalists whose improving care is making it possible. It is not a reason to retreat to our policies from March.

As we prepare to celebrate our nation’s 244th birthday, I’m disheartened by the many failures we’ve had in managing the pandemic at the federal, state, and local levels. (Why do we still not have enough tests?) Perhaps the diverging case and death counts suggest that a strategy that stratifies patients rather than businesses should be attempted.

Happy Independence Day! Stay well.

Learn more:
COVID-19 page (Los Angeles County Dept of Public Health)
Osterholm update (a weekly podcast about COVID-19 by Dr. Michael Osterholm, epidemiologist and infectious disease specialist)

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Think Local, Act Local

Calvin and Hobbes go for a walk

Monday, April 27, 2020

“Example is the school of mankind, and they will learn at no other.”
— Edmund Burke

If you’re reading this, I assume you’ve already been recruited into one of the several armed motorcycle gangs that scours the city’s ruins for canned food. I know finding a generator to recharge your laptop isn’t easy so I’ll keep this short.

Oh, wait. That’s the first paragraph of the post I’m writing for June. Where’s my end of April post? Oh, here. Let’s start over.

In Los Angeles we seem to have achieved a stalemate with the virus. The number of new daily cases and the number of new daily deaths aren’t going up exponentially, but they’re not going down exponentially either. Both graphs are bouncing around in the same range. Hospital censuses are also neither exploding nor decaying like any well-behaved exponential function should. Hospital beds, ICU beds and ventilators remain available to those who need them. That, in itself, is a major achievement. The curve is flattened, which after all was the first goal of our response.

Now our collective minds are obsessed with two questions. What’s the next step? And how does this nightmare eventually end?

Let’s consider the second question first. What does the final goal look like? We’re currently pinning our hopes on the development of a vaccine or on acquiring herd immunity.

There will certainly be lots of resources, brains, and time devoted to finding a vaccine for the novel coronavirus. But vaccines for coronaviruses are notoriously difficult to develop. The SARS outbreak of 2002 was caused by a coronavirus and led to a search for a vaccine. There still isn’t one. But that outbreak was tiny compared to the current pandemic. Surely, the global search for an effective vaccine will be successful this time. Well, I hope so. But if you need an example of a virus for which a search for a vaccine consumed many dollars and many minds for many years and remains unsuccessful, look no further than HIV.

And what about herd immunity? Herd immunity is the mechanism by which many immune individuals (the herd) protect the other vulnerable individuals from infection. They do so by simply providing the virus fewer vulnerable hosts. If a high enough fraction of the population is immune so that, on average, each infected person infects fewer than one vulnerable person, then the epidemic fizzles out. The goal is similar to the goal of social distancing – put fewer vulnerable people next to infected people – but instead of distance we use immune people as the barrier.

No one is sure how many of us need to be immune for that to happen. 30% is the lowest estimate. Other experts say 50 to 60%. Are we close to that? A study by USC and the LA County Dept of Public Health tested a random sample of LA County residents for antibodies to the novel coronavirus. It found that about 4% of us have the antibody. This was touted as good news since it’s 20 times greater than the number of cases diagnosed through the viral swabs. That implies that the fatality rate of the virus is 20 times lower than we thought, and it underscores that many cases have such mild symptoms they never seek medical attention. A similar study in Santa Clara County found an antibody prevalence of about 3%. Neither of these studies has been peer-reviewed, so there may be flaws in their methodologies or calculations that have yet to come to light. But as far as we can tell now, with the possible exception of New York, there is no reason to believe that any US city is close to achieving herd immunity.

Our office now offers a Covid-19 antibody test (performed by Quest Diagnostic Labs). I will offer it to my patients, but as I explained in my last post, the test will be more useful as a broad measure of community antibody prevalence than to help any individual patient make any decision.

So the novel coronavirus might end up being contained through social distancing and herd immunity and other traditional public health measures, as SARS was contained in 2003. Or it might be eradicated through a massive vaccination program as smallpox was. But these outcomes will not happen soon, certainly not in the next year. Or, like common colds, the novel coronavirus may mutate and continue to circulate globally and evade our grasp.

This tremendous uncertainty about the final goal must inform how we approach the first question. What next?

The LA County “safer-at-home” order has been extended until May 15. Different localities, faced with different numbers of cases, different economic pressures, and different healthcare capacities are making different decisions about when and how to allow people to reopen businesses. The debate about whether to “reopen the economy” has generated much heat but little light. The debate presupposes that it was the government that shut down the economy. It wasn’t. It was the customers. Customers stopped going to restaurants before the stay-at-home orders were given in most states. And they will likely stay away long after the restrictions are lifted. There is no valve labeled “Economy” that someone in Sacramento or Washington can turn to get everyone back to work.

Economies will restart in fits and starts from the bottom up, with every state, city, and family making decisions and balancing risks in a way that fits their particular circumstances. Some states are lifting restrictions now, and some are not. Some colleges have pledged to return to on-campus instruction in the fall, and some will continue online instruction in the fall. And that’s as it should be. There is no reason to expect, say, an older successful urban couple to make the same decision as a twenty-something poor rural couple. The first couple has much to lose by being exposed to coronavirus and little to lose by isolating at home. The second couple might have no alternative but to return to work. And the probability of infection and the consequences of infection would be much lower for them.

This embrace of radical localism will require all of us to reject the extreme arguments on both sides of the debate. On one extreme are those who assert that economic matters are irrelevant and that the shutdown should last until a vaccine or some effective treatment is found. They assert that when lives are at stake, no economic toll is too great. The biggest flaw with this position (and there are many others) is that making everyone poorer will make more people die of other things. Poor people die of chronic illnesses at a much higher rate than rich people. That’s because patients with chronic illnesses frequently benefit from expensive new medications, lifestyle modifications, and logistical support that consume a lot of resources. So if we make everyone poorer by keeping businesses shuttered we’re not simply trading dollars for lives. At some point we’re trading future lives lost to diabetes, heart disease, stroke, and depression for lives saved now from coronavirus.

Those on the opposite extreme assert that the novel coronavirus is no worse than a bad flu, that our reaction to it is exaggerated, and that any further economic toll is unjustified given the tiny death rates in the majority of the country. The biggest flaw with this position (and there are many others) is that the economic toll has been largely dealt by customers, not governments. In a city in which cases and deaths are climbing and hospitals are overwhelmed, very few people will go to movie theaters regardless of whether the economy is officially “reopened”. What may persuade them to go to movie theaters is declining case counts and available ventilators. So managing the pandemic is a prerequisite of, not a competing priority to, reopening the economy.

Given that our understanding of the novel coronavirus is in its infancy, and given that our projections of the consequences of various actions are based entirely on mathematical models that may be entirely unreliable, we should approach local experimentation with some humility. Rather than heap scorn on localities that try a different approach, let’s study their data and learn from their experience. No one knows how to keep the ICUs from filling up while letting people try to make a living. So let’s stop pretending we know.

The best we can hope for is to muddle through, learn from each other, keep a close eye on the local daily case counts, and apparently hoard toilet paper and canned food. Which reminds me. If an armed motorcycle gang comes to your door to recruit you, don’t try to impress them with your unicorn henna tattoo.

Learn more:
More L.A. County Residents Likely Infected With Coronavirus Than Thought, Study Finds (Wall Street Journal)
USC-LA County Study: Early Results of Antibody Testing Suggest Number of COVID-19 Infections Far Exceeds Number of Confirmed Cases in Los Angeles County (LA County Dept of Public Health)
COVID-19 Antibody Seroprevalence in Santa Clara County, California (medRxiv)
Reopening Has Begun. No One Is Sure What Happens Next. (New York Times)
Do Lockdowns Save Many Lives? In Most Places, the Data Say No (Wall Street Journal opinion)
Governor Newsom Outlines Six Critical Indicators the State will Consider Before Modifying the Stay-at-Home Order and Other COVID-19 Interventions (Office of Governor)

My previous posts about the novel coronavirus:
Testing, Testing Part 2
Of Masks And Meaningful Measures
Updates From The Socially Distant
Testing, Testing
Novel Coronavirus FAQ Part 2 – Pandemic Hullabaloo
Coronavirus Frequently Asked Questions
Community Transmission Of Novel Coronavirus In LA County
What You Need To Know About The Novel Coronavirus

 

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Testing, Testing Part 2

Hobbes, our cat

Can you feel it, now that spring has come?
That it’s time to live in the scattered sun.

Waiting for the sun. Waiting for the sun.
Waiting for the sun. Waiting for the sun.

This is the strangest life I’ve ever known.
— Waiting for the Sun, The Doors

[I’m writing this on Friday, April 17. Everything in this post might be false in a few days, and conditions might be different in places other than Los Angeles. Keep up to date by checking your local health department website.]

So far, Los Angeles has been fortunate. Hospital censuses are stable. Hospital beds and ventilators continue to be available to those who need them. We have not (yet) seen the numbers of deaths and levels of suffering endured in New York. In a county of 10 million, we have counted just over 11,000 cases and just under 500 deaths. The number of new daily cases hasn’t been increasing. We’ve flattened the curve. Today, for the first time, the number of deaths is less than the day before. Things might be on the verge of improving, so we habituate to the danger and grow restless. Our kids (especially the extroverts) complain that they want to visit friends. Parents stare at the calendar and wonder if they can make tentative summer vacation plans. All of us have become children in the back seat on an interminable road trip. “Are we there yet?”

As a possible roadmap out of eternal isolation our nation turns its lonely eyes to testing. In this post I summarize the current status of testing for Covid-19 and what we can expected in the short-term.

Testing for virus

Tests for the novel coronavirus have become more widely available. In LA County over 67,000 individuals have been tested. This test checks for the actual presence of viral particles on a swab, which is collected from the patient’s nose or mouth. This is used to determine if the patient is currently infected with the virus that causes Covid-19.

The City of Los Angeles is offering free drive-through testing to anyone with any symptoms consistent with Covid-19. The tests are performed only by appointment, which can be scheduled on the website. Doctor’s offices, including ours, also have tests. So if you don’t feel well, call your doctor or make an appointment for drive-through testing through LA City.

The main drawback of these tests remains their sensitivity of about 70%, which I discussed in my last post about testing. It means that 3 out of 10 patients with Covid will test negative. So, while positive results are very reliable, negative results are not.

Antibody testing

Antibody tests (also called serology tests) are blood tests which detect antibodies produced by the patient’s immune system in response to infection. It’s important to note that an antibody test can not be used to diagnose or exclude a current Covid infection. That’s because antibodies can take several days to appear after the onset of illness. A negative test may simply mean that the patient has Covid but hasn’t made antibodies yet. A positive test may mean that she had Covid weeks ago and has recovered.

We have tests for antibodies to lots of other viruses, like HIV and herpes and measles. Unfortunately, antibody tests for the novel coronavirus are not yet ready for prime time. A few private labs have marketed tests to patients that have very poor validation. The problem with these tests is high false positive rates. That means that the test may give a positive result if the patient has antibodies to some old coronavirus strain that she contracted years ago when she had a mild cold. More reliable tests are being developed but are not yet available. Cedars-Sinai is one of the many medical centers working on a serology test, and we will offer it in our office as soon as we can. But that’s still at least a few weeks away.

So the anticipation for a reliable antibody test runs high, for several reasons. First, we know that many cases of Covid-19 are very mild and those patients don’t seek medical attention. This has led many to speculate that there may be a huge population of people who’ve already had the disease, recovered, and are now immune. They could conceivably get back to work, take the lead in patient care, and stop social distancing. They could also provide the frequently mentioned but infrequently understood herd immunity, by which the vulnerable are protected by being surrounded by people who are immune.

The second reason people are looking forward to an antibody test is that a lot of us (including yours truly) went through a miserable flu-like illness in January or February. It’s very tempting to hope that we had Covid-19. After all, even though cases of Covid weren’t officially discovered in Los Angeles until later, given the amount of travel between LA and China, and given what we know about asymptomatic spread of Covid, couldn’t community transmission have been happening in LA much earlier? If some of us have already recovered from Covid, then presumably we are immune, with all the potential resultant benefits I already listed above.

The problem with these lines of thinking is the problem with all wishful thinking. We tend to overestimate the likelihood of positive outcomes and we tend to underestimate the outcomes we’d rather not have to consider. It would be great if half the population was already immune and it would be great if I already paid my dues when I was sick in January. But that doesn’t make it so.

We have very few ways to estimate the prevalence of mild Covid in the population so far. A letter to the New England Journal of Medicine published the results of Covid testing for every woman admitted to the labor and delivery ward of a New York City hospital from March 22 to April 4. 15% of the women tested positive, even though only 2% had symptoms. That means in the US city with the greatest concentration of Covid cases, about 15% were actively infected as of two weeks ago. Mathematical models suggest that 29 to 74% of us would have to be immune to confer herd immunity on the rest of the population, that is to give the virus so few available vulnerable hosts that the epidemic fizzles out. That suggests that in all but the hardest hit cities, herd immunity will remain out of reach. The whole point of flattening the curve has been to minimize new cases and keep the numbers as low as possible. Success has meant keeping the demand for beds and ventilators less than the supply. But it has also meant that there are very few of us who are immune.

There are lots and lots of other viruses that I might have had when I was sick in January, including adenovirus, parainfluenza, respiratory syncytial virus, and metapneumovirus (which is the most fun to say). Even though I had the flu shot, I could have also had influenza. I don’t want to have had those other viruses. I desperately want to have had Covid so I could be bulletproof now, but that doesn’t make it so.

I will certainly encourage all my patients to have the antibody test when it’s available, and I’ll definitely have it myself. But we should understand what to expect (and what not to expect) from it. A negative result will definitively exclude a prior infection, but will not exclude a current infection. A positive result will diagnose a past infection with a certainty that depends on the specificity of the test and the prevalence of past infection in the population. (The specificity of any test is the fraction of people who don’t have the disease who test negative.)

Imagine if 1% of the people in LA County have had Covid and are immune. That’s 100,000 people, which is about 9 times the number of people who have had a positive virus test so far. Say a test with 99% specificity is developed. That means for every 100 people who don’t have antibodies who are tested, only one false positive results. So for every 100 people tested you would have 1 true positive (the person who actually had it), 1 false positive, and 98 true negatives. That means that half of the positive results would be false. That would make a positive result not very useful. The only way to decrease the fraction of positive results that are false would be to use it in a community with higher disease prevalence or to have an even more accurate test.

So a positive test might mean you’ve had Covid before, or maybe not. That wouldn’t give you the certainty you need to stop social distancing and potentially expose yourself to the virus.

The serology test attempts to answer a different question for individual patients and for entire populations. An individual patient is asking “Am I immune now? When I was sick last month, was that Covid?” To those questions the test might give a definitive no or a maybe. It’s unlikely that we’ll have a test reliable enough to get a trustworthy yes. But populations ask “What fraction of us have already recovered from Covid?” And if lots of people get tested, that’s a question that we might be able to answer.

But that answer might be disappointing. We might find out that we’re not there yet. We might find out that our herd is not immune. We might find out that this horrible trip doesn’t end until we have a vaccine. Until then, stay inside and stay healthy.

At the beginning of a pestilence and when it ends, there’s always a propensity for rhetoric. In the first case, habits have not yet been lost; in the second, they’re returning. It is in the thick of a calamity that one gets hardened to the truth–in other words, to silence. So let’s wait.
The Plague, Albert Camus

Learn more:
COVID-19: The Worst Days of Our Careers (Annals of Internal Medicine)
Schedule a COVID-19 Test (City of Los Angeles)
Antibody Tests For Coronavirus Can Miss The Mark (NPR Shots)
Health Authorities Roll Out New Coronavirus Tests to Gauge Infection’s Spread (Wall Street Journal)
Prominent scientists have bad news for the White House about coronavirus antibody tests (CNN health)
Coronavirus ‘Immunity Passport’ Stumbles in U.K. (Wall Street Journal)
Universal Screening for SARS-CoV-2 in Women Admitted for Delivery (New England Journal of Medicine)

My previous posts about the novel coronavirus:
Of Masks And Meaningful Measures
Updates From The Socially Distant
Testing, Testing
Novel Coronavirus FAQ Part 2 – Pandemic Hullabaloo
Coronavirus Frequently Asked Questions
Community Transmission Of Novel Coronavirus In LA County
What You Need To Know About The Novel Coronavirus

More

Of Masks and Meaningful Measures

Clayton Moore playing the Lone Ranger in 1955. The mask he is wearing is entirely unlike those discussed in this post.
Photo credit: Wikimedia Commons, public domain

[I’m writing this on Sunday, April 5. Everything in this post might be false in a few days, and conditions might be different in places other than Los Angeles. Keep up to date by checking your local health department website.]

“All I maintain is that on this earth there are pestilences and there are victims, and it’s up to us, so far as possible, not to join forces with the pestilences.”
The Plague, Albert Camus

It the last several days the City of Los Angeles, the California Department of Public Health, and the Centers for Disease Control all issued suggestions that all of us wear cloth masks covering the nose and mouth when in public. I have just spent two weeks educating my patients about the previous recommendations that masks don’t prevent healthy people from getting infected, and that there’s no reason for asymptomatic people to wear them. What gives?

Back when I trained, I was taught that surgical masks slowly absorb moisture from the breath and within about 15 minutes they stop acting as a filter since all the pores are closed with water droplets. After that point the mask is simply a barrier that one breathes around, not through, which means that after that point it doesn’t prevent inhaling germs. The surgeon wears the mask so as not to inadvertently cough or spray saliva onto the sterile surgical field, not to protect herself from exhaled germs from the patient. This led me to think that citizens in Asian countries in which mask wearing is common were superstitious germophobes. They clearly didn’t know that the masks were not protecting them and were wearing them as magical amulets to ward off disease.

Many years later colleagues explained to me that pedestrians in Asia are wearing masks to protect other people, not themselves. They use a mask if they must go to work with a cold and wish to avoid infecting their coworkers. They’re using the mask as a barrier, not a filter.

That’s the logic behind the current recommendations. And, it must be said, the science behind them is scant. We know from lots of other respiratory infections that social distancing works. We have known since Dr. Ignaz Semmelweis that hand washing is critical in preventing the spread of infections. The evidence for masks in preventing infection from asymptomatic people is much flimsier, but I’ll lay out the case.

We know that the novel coronavirus can be spread by infected people before they know they’re sick. We know that some people infected with the novel coronavirus never get symptoms, and even those who get symptoms are infectious for a few days before symptom onset. So social distancing is a mechanism predicated on the assumption that we all might have it and intended to prevent us from infecting one another.

We also know that the amount of virus that a person is infected with makes a big difference to the severity of their disease. Meaning, if you inhale a tiny amount of virus your immune system might clear the virus without any symptoms, but if you inhale a high number of virus particles, the virus will have a head start, and will have a chance to replicate and cause illness before your immune system can catch up.

So masks are a tiny intervention for a very specific situation. They are just a way to reduce the number of virus particles that someone who is infected and doesn’t know it exhales on other people. This should only be relevant in the few instances when social distancing breaks down – a customer at a grocery store approaching the cashier, pedestrians on a sidewalk failing to avoid each other, neighbors in an apartment building passing in a stairwell or taking the same elevator. Masks are just a way to make those encounters a tiny bit less risky for the other guy, not for the mask wearer.

And masks have the additional benefit of reminding us not to touch our face, which might result in a germy respiratory droplet being transferred to our hand, and then to that doorknob, and then to someone else’s hand.

Of course, surgical masks are in short supply and should be preferentially saved for healthcare workers, so cloth masks (or scarves or bandanas) are recommended.

The critical caveat is that wearing a mask should be done in addition to, not instead of, frequent hand washing and social distancing. Public health officials are stressing that hand washing and social distancing are proven effective measures, and that mask wearing would yield a net harm if people thought that masks made the other measures unnecessary.

I was left with the impression that recommending masks was a minor intervention backed by weak studies which at best would have modest effects. Why bother?

Well, Californians have been told to socially distance for just over two weeks. That’s long enough that if new infections were stopped by these measures, we would have seen it reflected in a decrease in the number of new cases. Instead, on Saturday Los Angeles County reported the largest number of new cases so far, 711. That doesn’t mean that social distancing isn’t working. The number of new cases would be far worse without it. It simply means that, like any activity attempted by 10 million people, we’re not doing it perfectly. There are clearly still enough interactions between people that are allowing this incredibly infectious pathogen to find new hosts.

So, it’s time for all of us to improve our performance of social distancing and hand washing. And there’s never been a better time to add on a minor intervention backed by weak studies which at best would have modest effects. If ten million of us do it, as feeble as it is, we might protect the next 711 people who would have been infected tomorrow. We need that number, day by day, to get closer to zero.

It is frightening to find ourselves in a time of plagues. And this horrible pox has not yet dealt us its worst. But we are also in a time of masked heroes whose superpowers are hand washing and social distancing. And they also put on a mask, mostly to let us know they will not join forces with the virus.

Stay inside and stay healthy.

Learn more:
U.S. Expected to Recommend Cloth Face Masks for Americans in Coronavirus Hot Spots (Wall Street Journal)
These Coronavirus Exposures Might Be the Most Dangerous (New York Times)
What Are the Benefits of Wearing a Face Mask? (Wall Street Journal)
Face Coverings Guidance (California Department of Public Health)
Guidance on wearing face coverings in public (City of Los Angeles)
Guidance for Cloth Face Coverings (Los Angeles County Dept of Public Health)
Use of Cloth Face Coverings to Help Slow the Spread of COVID-19 (Centers for Disease Control and Prevention)

My previous posts about the novel coronavirus:
Updates From The Socially Distant
Testing, Testing
Novel Coronavirus FAQ Part 2 – Pandemic Hullabaloo
Coronavirus Frequently Asked Questions
Community Transmission Of Novel Coronavirus In LA County
What You Need To Know About The Novel Coronavirus

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