Updated: Feb 14, 2021
Understanding all the facets of COVID-19 is still very much in its infancy. I've shared a little bit about COVID-19 developments from the perspective of a primary care provider previously, and written a little about the developing vaccine and testing for antibodies. Today, it seems the distribution and impact of the COVID-19 vaccine are at the forefront of everyone's thoughts, as well as the long term impacts on those who have become infected COVID-19, as well as our evolving response to the pandemic within the community. Until we have larger, prospective, and multicenter studies, we are really just offering our best guesses on each of these matters. You may find it interesting though that Europe's oldest person, a 117-year-old French Nun, survives COVID-19 and never even presented symptoms.
It is now recognized however, that symptoms do persist for many following COVID-19 infection and those symptoms can be quite significant. What was once thought of as a fairly exclusive respiratory infection is now recognized as a multi-organ syndrome. These individuals will see their symptoms persist for more than four weeks with many suffering two to six months or longer.
Fatigue seems to be the most common lingering symptom, followed by dyspnea and other pulmonary complications. Neurologic symptoms such as brain fog and numbness or tingling throughout the body, as well as mental health challenges such as post-traumatic stress disorder have also been reported anecdotally. Symptoms of post-COVID-19 syndrome can also be somewhat similar to those experienced during the acute infection, although those who were asymptomatic with SARS-CoV-2 infection rarely seem to progress to persistent post-COVID syndrome. What is being more recognized however, is those who were not managed within the hospital but rather stayed at home and are now struggling more significantly with these lingering post-COVID-19 sequelae.
Certainly those who suffered in-hospital stays from COVID-19 may have more commonly understood morbidity associated with these types of infection such as peripheral neuropathy from lying prone for a longer duration, particularly if these individuals are diabetic. Furthermore, a long-term hospital stay can trigger adverse mental health outcomes, including anxiety and depression. These adverse effects are not unique to COVID-19 but are also reported in other people who spend weeks or months in critical care.
The Centers for Disease Control and Prevention is currently working on guidelines for diagnosis and management of people with post-COVID syndrome. The National Institutes of Health is also interested in developing protocols. Recovery clinics are even emerging integrating care from multi-disciplinary teams, such as pulmonologists, cardiologists, and psychiatrists, as well as rehabilitation specialists, to address specific symptoms.
It is unknown what proportion of people with COVID-19 will progress to post-COVID syndrome, but experts estimate approximately 10 to 15 percent will suffer weeks or months post-acute infection. Men do seem to suffer more significantly long term from COVID-19 and demise from the infection. It is unclear how the vaccine may play a role in this post-COVID-19 syndrome.
The neurological concerns are those which my clients have more often suffered, along with fatigue. Newer reports are finding those with long-term neurologic symptoms, such as "brain fog," are suffering larger megakaryocyte cell occlusion in their brain capillaries. Five separate post-mortem cases have demonstrated these findings in cortical capillaries with immunohistochemistry confirming these findings. The really peculiar point is that megakaryoctes haven't been found in the brain before.
Other viruses can cause changes in the brain, such as encephalopathy, but viral encephalitis hasn't been apparent in post-mortem COVID-19 cases although these unusually large cells were found in the brain capillaries. Experts aren't finding any other known cases of having found these cells, from the bone marrow, in the brain either. The cells are so large and out of their element, so to speak, that these vessels aren't built for their passage so their presence alone is causing occlusion and this creates the atypical form of neurologic impairment. Pressure is distributed to other vessels, potentially causing ischemic alteration or even increasing the risk of stroke, although this hasn't represented just yet in the cases identified. Outside of these megakaryoctyes, the brains of these COVID-19 victims appeared normal.
As discussed in a previous blog post, the current COVID-19 vaccine has demonstrated protection for only four months. I have been awaiting recommendations for re-inoculation to address this shortage in so-called-protection. This past week, the CEO of Johnson & Johnson announced that people may need to get vaccinated against COVID-19 annually over the next several years, along with the flu vaccine. Part of the concern is the viral mutations which occur over time, so newer vaccines would work to address these variants.
Johnson & Johnson anticipates having its two-part vaccine available towards the second half of the year and is "extremely confident" that they will meet the target of delivering more than 100 million doses of their one-dose vaccine throughout the United States by the end of June.
Another interesting theory on the vaccine currently circling is that vaccines generate blood-borne immunoglobulins like IgM but not mucosal ones like IgA, and so maybe the vaccines protect against big systemic infections but the virus can still set up show in the nasal passages. Ultimately this means that symptoms may be reduced, but infections are not. Those who may become really sick may subsequently be asymptomatic post-vaccine, but they remain infected with potential to spread disease to those who are unvaccinated. This nightmare scenario though doesn't really hold well, as infections in general do seem to be lowered with vaccinations, symptomatic or otherwise. These studies are ongoing.
Can the vaccinated take off their masks?
Not quite yet as there is clearly risk for asymptomatic infection even after vaccination; it's just not likely as prominent as those who are non-vaccinated. A ubiquitous testing system for identifying asymptomatic cases would help identify this - scientifically speaking. Another option would be to vaccinate everyone at once, but again, this is only scientifically speaking as doing so would violate our human rights, which is paramount in a country founded on individual freedoms. A third option would be to utilize post-vaccination antibody testing, focusing on the spike protein. If they have other antibodies to the SARS-CoV-2, beyond the mRNA or spike protein, then this would indicate they have had the wild-type infection. In the absence of daily nasal swabs, this may be the only other way to identify the risk for asymptomatic spread from vaccinated individuals.
One of the more critical aspects of slowing the spread of coronavirus, as determined by the experts, is contact tracing, although this effort has fallen behind in recent months as cases have soared. President Joe Biden has pledged to change that. His current proposal is to hire 100K people nationwide as part of a new public health job corps to help improve contract tracing and facilitate vaccinations. This is going to be challenged by the more contagious variants of the infection and its accelerated transmission. Screenings are currently at about 2 million per day and the number of infected are understood to be at two to three times the number who are reported through positive test results. This translates to 75 million to 100 million infections in the U.S. or an estimated third of the population of our country.
It could take more than 9 months to vaccinate 70 percent of Americans against the SARS-CoV-2 infection and reach a herd immunity threshold, assuming the current pace of immunization continues and requires either two-dose regimen from either Pfizer/BioNTech or Moderna vaccines. As of last week, more than 44,769,970 doses have been administered according to the CDC COVID Data tracker. Medscape calculated this projection by making the assumption that vaccinations will continue at 1.44 million doses per day, the highest moving 7-day average. Scientists have estimated that 70 to 85 percent coverage would need to be achieved to offer herd immunity, and Medscape's calculation of 9 months was made using the more optimistic 70 percent. Biden's administration's goal of 100 million doses available in 100 days is necessary to achieve this goal.
I can't not share that it concerns me to some degree to hear that Pfizer is attempting to take production from 120 days to less than 30 days, in under a month, for a vaccine that was already granted emergency distribution to the public after a year of development compared to a more average 8 year investment. How do production managers even make this possible? What sort of accomodations have to come together to make this doable and where are we sacrificing? I hate to lean into doubt regarding our administration's ability to make this happen, but if they are capable of pulling this off without massive quality assurance errors, why the hell can't we accomplish other issues with even half the effort - such as our mental health crisis, domestic violence, rape culture, veteran suffering, the opiate crisis, chronic disease, our foster system, systemic racism, educational failures, and the list goes on and on forever and ever.
As coronavirus variants spread, health experts are discussing various options for protecting the public, but did you know healthcare providers are now facing counterfeit N9 masks! I wish I was making this stuff up. Thousands of counterfeit 3M respirators have slipped past U.S. investigators in recent months, entering more than 40 hospitals. Workers noted "odd-smelling 3M masks" and feared knockoffs and have since had their worst nightmares confirmed. These masks were fakes and they were in fact, unprotected.
This new variant however, and those to follow, aren't necessarily more aggressive or hold greater superpowers. However, the variant identified in the UK has reportedly greater ability to stick to the cell receptors so if exposed, infection would be more likely. There are also reports that this particular variant has been more deadly. This affinity for the cell receptors would also mean that less viral load would be required to become infected with the newer variant. This would therefore, impact transmission prevention measures.
Double-masking has hence, become a newer recommendation from the CDC. Admittedly, the moisture created on the mask itself from breathing, as I've previously mentioned, creates a wick and can increase transmission which is why healthcare workers only wear these while in a specific room with a high risk client and then removed and replaced from incident to incident. The public's use of masks, hour upon hour and repeated use of the same mask for prolonged duration and even with various environments is not consistent with recommended use. Wearing a double mask has shown to lower the risk. The idea is to pull the mask closest to one's face taut and allow the outer to lie more lose.
There is a CDC report demonstrating that within states where mask mandates have been implemented, COVID-19 hospitalizations have dropped. I am not confident this equates to science demonstrating that masks are highly effective in reducing risk, but data is finally becoming available for critical review, for which I am grateful. The issue is more about protecting oneself from getting spit on in the face, which certainly does happen, than inhaling or exhaling around the mask or even picking up and spreading the virus via one's clothing or hands, or even from discarded masks as no biohazard disposals have even been suggested.
The double mask also invites increased difficulty with breathing and discomfort, even anxiety and panic for some. One has to consider so many variables, such as simply tugging the mask on and off at the edge, which may transmit the virus from one's hands to the nose or mouth. Maybe they hadn't been "spit upon" so-to-speak, but did pick up the virus on the plethora of items they touched within Walmart and now they've transferred that to their mask and ultimately, their nose or mouth inadvertently because they had to manipulate their mandated mask for removal. Visit the local Chick-fil-A drive through line and you can witness our youth readjusting almost continuously their mask with their hands, which I can't imagine wouldn't significantly increase their risk over not having a mask to fuss with in the first place and just creating some level of muscle memory not to touch their face with their hands at all.
Another variable that all nurses, particularly those who work in the OR are well aware, is wind travel. The virus has been said to be most clever in its transmission efforts by catching a breeze and traveling to its next victim. This is why an OR tech will position themselves in the OR so that they face the door and can watch traffic in and out, monitoring for potential transmissions as the movements and wind traffic is increased within the room. Imagine though, our wearing our masks, being coughed and spit upon and then sinking them down in our pockets, only to return them to our faces after being touched with our hands or even flipped inside out before being replaced on our faces. We aren't following smart procedure in the use of these masks. I suspect any finding in reduction of transmission is a variable associated with masks, such as reduced traffic in general, than to the mask itself. The jury is still out on this one.
The good news is that the fatty membrane of this virus is easily destroyed by soap. Washing between every drive through customer though will invite risk for drying and cracking, which breaks that protective barrier and again increases risk for transmission. At some point we have to consider that our bodies are designed to protect us and some of our interventions actually increase risk. It is vital to think critically. What makes sense to you? My advice as you dig in and think, consider a non-perfume moisturizer and eating exceedingly health, getting in the fresh air, moving frequently, and reduce your stress. Sleep sufficiently every single night.
There is discussion, even at the level of the World Health Organization, that social distancing should be decreased to every three feet. This may help those who carpool. Please open our gyms and reschedule our concerts.
Urgent Care Staffing
Flu season is always a challenge for urgent care centers, increasing visits with symptoms of fever, body aches, and other classic flu symptoms. These clients receive flu screenings, and sometimes antiviral medications such as Tamiflu or Xofluza. This year however, the nation is in the throes of a surging pandemic and urgent care centers were already seeing an increase in patients, but most are less worried about flu and more focused on COVID-19.
During these busier times, urgent care centers often turn to staffing agencies to meet these short-term needs. October through March tend to be the busier seasons for urgent care, but this year certainly hasn't seen the same flu numbers as the 2020-2021 season. In fact, there are clinicians reporting they haven't seen a single case of flu this entire season! January through April do tend to be the worst seasons however.
Fewer flu diagnosis may be due to a greater emphasis on safety precautions such as social distancing, face wearing and handwashing. Whether clients seek care in the urgent care for suspected flu or COVID-19 or screening for either, these will likely soon be locations for receiving COVID-19 vaccines as well. Certainly, if you are a primary care client of mine, connect with me if you feel you have symptoms, and I am more than happy to assist you in making decisions regarding your options.