The Latest on COVID-19

There were 6000 cases in the world, 200 deaths and 5 cases in the US.  Today the story is very different.  Here are today’s data (likely a large underestimate):

CO has reported 5,172 total cases, 150 deaths, 39 confirmed cases in Pitkin County.

FLATTENING THE CURVE: 

Most governments have ordered strict restrictive policies, shutting down all non-essential business, forbidding travel between and within countries, and issuing shelter at home orders.   China has seemed to contain and stop viral spread using these methods, South Korea has done the same using a containment strategy of intensive testing then tracking contacts and isolating them.  Spain and Italy may finally be bending the curve after much devastation.  Germany has also rolled out much testing and containment of cases, so their cases and deaths have not been as severe as other European countries.   Finally, the US may be in the very early stages of bending the curve.

How well is the US flattening the curve? 
Deaths could peak in mid April

TESTING (The hottest topic in COVID-19 today) WILL HELP BEND THE CURVE MUCH FASTER:

There are two types of tests- 

1.  Testing for the acute presence of SARs-CoV-2.  Making and distributing an adequate number of these tests with quick turnaround time has pretty much been a disaster in the US due to regulatory issues, lack of supply chain for reagents, the CDC test being faulty for too long, and lack of manpower to perform specimen collection as well as logistical bottlenecks in performing the tests in labs.  However, now dozens of these types of tests have very recently received emergency use approval by the FDA.  

Current testing is generally sent to a central lab for processing with a turnaround time of days, a few newer ones enable Point of Care (POC) testing which can give either a positive or negative result in as little as under an hour.  However, the sensitivity of many of these tests is only 65-70%, meaning lots of false negatives.  Variables such as the method of collection, timing of the appearance and clearance of the virus in the human respiratory tract, and the performance characteristics of the tests themselves are responsible for the low sensitivity.  Therefore, we cannot be over reliant on these tests to confirm COVID-19 or not.

2.  The second type of testing getting much press lately are the antibody tests (serologic).  Animals make immune responses to pathogens such as viruses and these responses are generally measured by looking at levels of antibodies (Immunoglobulins-Ig) in the blood.  IgM is generally indicative of a rapid or acute response, usually seen within 2-6 weeks after an infection, they diminish; IgG levels rise later and can stay high for some time, even a lifetime.

These tests are going to be crucial to determine who in a population has been exposed, infected, and is (hopefully) immune.   But we don’t quite know yet which antibodies, if any, will indicate short- or long-term immunity.  There is a huge worldwide race on to figure this out and validate findings.  Based upon SARS1 and MERS antibody data immunity to COVID-19 is expected to last 2-3 years. 

TESTING IN THE ROARING FORK VALLEY:  AVH has adopted a policy of testing only very severely ill people that need hospital admission with the acute test.  To fill the gap, several providers in the Roaring Fork Valley are offering these tests.  I offer testing through LabCorp.  Another provider can do large numbers of tests though tests are being reserved for patients with symptoms or health care providers.  So please, give me a call if you are sick and interested in this. I will also shortly have the antibody testing available through LabCorp.

TAKE HOME MESSAGES:

• Symptoms are commonly fever, cough, shortness of breath but can be just minor cold-like, diarrhea, headache, and achiness, as well as loss of taste and smell.

• Most cases are likely to be mild and self-limited (80%+); children especially tend to have milder illness.

• At present the mortality from 2019-nCoV appears to be 1-2% in the US.

• The median age of cases is 47-59 years; about 57% of infections are in men. The elderly and people with underlying health conditions are at highest risk for dying:  15% in those over 80; but this can be a very dangerous disease at ANY age.  Many young healthcare workers and first responders without health issues have died from COVID-19.   

• We are still not sure why some people get sick and die and others seem so resistant, i.e., why is the death rate in Italy so high?  It’s not just age.  Scientists are researching possible

• the “R0” or spread rate appears to be about 2.5; that is, without physical distancing, for each case an average of 2.5 additional people will get COVID-19.

• Time from being exposed to getting signs are median of 5.1 days, can be 2-14 days.  We now know people can be transmitting the virus while they are asymptomatic and in fact may be most contagious during that time!

• Research shows that SARS2-CoVID2 viral RNA is detectable in the air for up to two hours and on some surfaces for up to three days after shedding occurs.  The virus is shed in stool for a month or more.  Whether any of this is live virus able to infect again is unknown at this point.

• Handwashing continues to be a hallmark of reducing spread.  The CDC now recommends use of masks by everyone all the time when in public.

• Treatment is largely supportive but some old meds like HYDROXYCHLOROQUINE and Remdesivir appear promising.  The WHO is launching a huge randomized trial (Solidarity) of the four most promising treatments.  In the meantime, hospitals in the US are treating sick people with hydroxychloroquine and Remdesivir, among others, when available.   Using serum from people who have recovered from COVID-19 anecdotally works.

• The first US vaccine trial started several weeks ago in SEATTLE.  Other trials have also recently started.  Bill Gates announced that he will be setting up funding for 7 laboratories testing the 7 most promising vaccines, developing and testing in parallel.  This is costing billions of dollars.

• Because SARs-CoV-2 attaches to human respiratory cells through the ACE2 (angiotensin converting enzyme 2) receptor, there is speculation that use of ACE-inhibitors and ARBs (angiotensin receptor blockers), which can upregulate the ACE2 receptors, could be harmful—though there is no data on this yet.  Other scientists feel those medications may be helpful.  Stay on all your prescribed meds including ACE=inhibitors (i.e., lisinopril—the “prils”) and Angiotensin Receptor blockers (the ARBS—like losartan) until you check with your physician.  There is no evidence that these should be stopped to prevent or treat COVID-19.  

• Ibuprofen has NOT been shown to be unsafe in COVID-19 per se, however, some people will have contraindications to using NSAIDs (i.e., kidney disease, clotting issues, liver problems) and some people prefer not to take the risk.  That’s fine:  use acetaminophen instead for fever and aches.  

Call us if you develop signs of COVID-19 or

have questions about getting tested!

THE MEASLES: Should you worry and how can you protect yourself?

Many people are concerned about the news regarding measles outbreaks across the US.  Measles outbreaks continue to pop up across the United States, with the number of confirmed cases of the once-eradicated disease now exceeding 700 in 22 states — but so far, only one person in Colorado has become ill with the highly contagious virus.  It’s the only confirmed case of measles in Colorado this year, but health experts said the state’s notoriously low vaccination rate makes communities here vulnerable to a possible outbreak.

In 2000, measles was declared eliminated from the United States. However, measles cases and outbreaks still occur every year in the United States because measles is still commonly transmitted in many parts of the world, including countries in Europe, Asia, the Pacific, and Africa. Worldwide, 19 cases of measles per 1 million persons are reported each year; an estimated 89,780 die each year.

Measles is a virus with symptoms that include high fever, cough, runny nose, watery red eyes and a rash (cough, coryza and conjunctivitis). Up to 90 percent of the individuals close to a person with the virus can become infected if they aren’t immune, according to the CDC.

In uncomplicated cases, people who get measles start to recover as soon as the rash appears and feel back to normal in about two to three weeks.  But up to 40 percent of patients have complications from the virus.

People at high risk for severe illness and complications from measles include:

• Infants and children aged <5 years

• Adults aged >20 years

• Pregnant women

• People with compromised immune systems, such as from leukemia and HIV infection

Common complications from measles include otitis media, severe bronchitis and pneumonia, encephalitis, and subacute sclerosing panencephalitis (SSPE).

Should you be vaccinated… (again)?

You should receive a measles vaccine unless you have evidence of immunity!     

Acceptable evidence of immunity against measles includes at least one of the following:

• written documentation of adequate vaccination:

  • one or more doses of a live measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk

  • two doses of the live measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers

• laboratory evidence of immunity (a blood test showing adequate titers of imunity)

• laboratory confirmation of measles infection in the past

• birth before 1957

Considerations . . .

For people with compromised immune systems, all family and other close contacts who are 12 months of age or older should receive two doses of the live MMR vaccine unless they have other evidence of measles immunity.

People who were vaccinated prior to 1968 with either activated (killed) measles vaccine or measles vaccine of unknown type should be revaccinated with at least one dose of live, attenuated measles vaccine (MMR).

A killed measles vaccine, which was available in 1963-1967 was not as effective.

People born before 1957 are likely to have been infected naturally and therefore are presumed to be protected against measles, mumps, and rubella.

However, if someone born before 1957 belongs to certain high-risk groups, they may need MMR vaccine or other proof of immunity.

Childbearing women who received adequate prenatal care within the last 25 years would have had a TORCH titer done which would have tested for measles mumps and rubella immunity.  

If you have further questions, gather what documentation you can and schedule a consultation if you feel you may need to be vaccinated.

Don't Let Mountain Sickness Ruin Your Vacation

More than 25% of people traveling to a mountain town will get at least mild mountain sickness.

You can take action to avoid or adapt to the immediate effects of being at high altitude!

What makes high altitude different from other environments?

• Less oxygen in the air

• Lower temperature and humidity

• Air quality can be better or worse

• Fewer allergens in the air

These changes can cause no trouble at all for some people; others may get Acute Mountain Sickness (AMS).  AMS occurs in susceptible individuals when ascent to high altitude outpaces the ability to acclimatize.

Symptoms of mountain sickness include:

• Headache

• Nausea

• Shortness of breath

• Malaise

• Trouble sleeping

• Fatigue/weakness
  

You can do things to prevent mountain sickness—before and after arrival:

• If coming from sea level, talk to your doctor about Diamox (Acetazolamide) and Decadron (dexamethasone) which can be started a few days ahead of time or once you get here

• Come to the Roaring Fork Valley gradually:  i.e., spend the night in Denver. Aspen is 9000, Basalt 7000, Carbondale 6000 feet high

• Hydrate- at least 4 liters of water a day-unless your physician has advised fluid restriction

• Avoid immediate strenuous activity:

Being in good shape is not a guarantee for prevention

• Avoid depressants-drugs, alcohol and sleep aids depress the respiratory drive

If you do begin feeling the symptoms of mountain sickness, you don’t have to go home!

Visit a local physician to talk about:

• Starting Diamox and Decadron

• Short term oxygen use

• Other treatment options

CAUTION!  High Altitude Pulmonary Edema (HAPE) and High Altitude Cerebral Edema (HACE) are very dangerous conditions that may result in death.

HACE:  symptoms of mountain sickness may exist but with:

• Altered mental status (delusions, altered sense of reality, delirium)

• Drowsiness

• Stupor/decreased consciousness

• Lack of coordination

HAPE:  symptoms of mountain sickness may exist but with:

• Loss of stamina

• Extreme shortness of breath

• Dry cough progressing to wet maybe pink cough

• Blue lips and fingertips
  

BOTH THESE CONDITIONS REQUIRE EMERGENCY EVALUATION:  GO THE EMERGENCY DEPARTMENT OR CALL 911

(**Please note:  This material was prepared by Josh Ferreri, MSIII, from the University of Colorado School of Medicine and presented at the Pitkin County Library in June, 2018. Edited and used with his permission.)

Simple Rules for Healthy Eating

The statistics are shocking:  80% of Americans are overweight and recently, 60% have been declared obese.  People are confused about what to eat and what not to eat and the internet is overflowing with information about nutritional wellness.   The human body is very adaptable (out of necessity in many cases): native Americans subsisted on beans and maize with animal protein when they could get it, the Masai , cattle blood, meat and milk, and the Inuit of Greenland, whale blubber and lichen.   

Snowballing rates of obesity, diabetes, cancer, and heart disease in the U.S., however, have been linked to our Western diet.  So, how do we change?

There are many diets out there-- some work, some don’t, and most are not sustainable or healthy long term.  

Having studied food and nutrition long and hard my entire life, I agree with Michael Pollen, who in addressing an overflow crowd Center for Disease Control (CDC) Scientists in March 2009, summed up healthy eating in 7 words:  

EAT FOOD, NOT TOO MUCH, MOSTLY PLANTS

EAT FOOD means real food—vegetables, fruits, whole grains, and fish and meat if you choose.  Avoid edible “food-like” substances.

Here are seven simple rules to clarify the 7 words:

1. Don’t eat anything your grandmother wouldn’t recognize as food. Don’t eat anything with more than five ingredients, unless you put them in yourself.  Don’t eat anything with an ingredient in it that you cannot pronounce or agree the food requires. For instance, why eat anything containing a “preservative”?

2. Stay out of the middle of the supermarket, shop the perimeter where the produce and meat, dairy sections are.  Don’t eat anything that won’t eventually rot—with exception of things like honey.

3. Always leave the table a little hungry.  Adopt a saying: “eat until you are four fifths full” or “tie off the sack before it is full”, for instance.  Don’t let your eyes be bigger than your stomach.

4. Enjoy meals with people you love, take your time.  Don’t buy food where you buy your gasoline. There is not much real food there and 20% of food is eaten in cars!

5. Move to a mostly (or completely) plant-based diet.  Plants contain virtually all the nutrients that human beings require to flourish and prevent disease.  

6. Balance your diet.  Don’t eat too much of any one good thing-- for example, many plants contain oxalate --too much oxalate in the diet can cause kidney stones.  Eat a variety of foods in moderate amounts. Do not take too much of any one supplement, if you take supplements at all.

7. Create a sustainable healthy diet that works for you, following the rules above.  There is not right or wrong answer (see the adaptability comment above) but there is an answer for you!

Important note:  People with diseases and conditions such as diabetes, heart disease, and others may require modification of these rules.  Consultation with a physician and nutritionist is strongly advised. We have a nutritional support team at Kadison Medical Group, are closely connected with diabetes educators and Dr. Kadison is available to provide guidance in developing a personalized nutrition plan for you.