Practice News
2-19-21 Covid19 update
Now that more people are being immunized, I am getting more questions about what activities may be ok to do again. Patients are wondering if going to the gym or eating out can now be done without risk of infection. To answer that question, I need to elaborate on what is going on this week.
In Houston Texas, a small group of people were found with extremely high viral loads and relatively mild disease. This group subsequently infected many individuals supporting a current theory known as the 20/80 rule. It is believed that 20% (or less) of the population causes most infections, and consequently the continuation of the pandemic.
In this Houston group the current predominant strain (D614G) was isolated, yet it is believed that by the end of March or early April this strain will be surpassed by the UK/British variant strain B.1.1.7. Thankfully, the British variant remains sensitive to the Pfizer and Moderna vaccines.
However, there are additional variants which are not. The South African strain (B.1.351) is the most concerning, as that is spreading rapidly through the world and is less responsive to the Pfizer and Moderna vaccines (although they do offer some protection).
With more genomic sequencing of the virus, additional mutant strains are now being identified, and so far, seven additional variants unique to the US have been found. At this time, it is unclear how significant these US variants are, although one (from Southern California) has been isolated here in Arizona in addition to the British variant. So far, no cases caused by the South African variant have been identified in Arizona.
One hypothesized worry about vaccines is that someone immunized can still be an asymptomatic carrier of the virus and pass it on to someone else (remember the 20/80 rule). Variant strains not as well covered by the current vaccines could make this transmission more likely. Indeed, it is theoretically possible that an immunized individual could infect another immunized individual with a resistant strain.
So, even though someone may be immunized, they are not necessarily completely protected. Hence, the continuing advice of staying socially distanced and wearing masks when around others. Eventually, when over 70% of the population is either immunized or has natural immunity, these concerns will most likely ease, yet it will be at least another 3-4 months before that occurs.
Therefore, it is ok to go to a gym if you continue to wear a mask when there with others. Eating in a restaurant is a bit trickier, since obviously you need to remain unmasked, yet if done in a larger room with few people this is probably ok. Eating outdoors or a similar open-air environment would be preferable. Getting together with family who have all been immunized or have recovered from an infection is also probably ok yet remember that most of the spread of the last few months occurred in small family get togethers.
The most frustrating aspect of Covid is the unknown. We continue to understand the virus better as time goes on, so it is likely that some of what we believe today may be disproven in the future. Nonetheless, we are limited by what we know and need to advise accordingly in order to bring this pandemic to a quicker end.
I will be back next week with another update. Take care.
Covid19 update Feb 5, 2021
The number of confirmed COVID-19 cases continues to fall here in Arizona. A few weeks ago, Arizona led the nation in the per capita rate of infection. Currently, we are now fourth in the nation with our seven-day average of new cases at 4,080 per day and the number of deaths averaging 133 a day.
While this is encouraging news, these numbers remain extremely high, and some experts maintain that the actual number of cases is much higher since many people still do not get tested if they feel ill or may not feel ill at all. Regardless, the virus is still a very real and present danger. Staying at home as much as possible, wearing a KN95 or N95 mask when going out, and staying 6 feet apart from others while out are still the best way to prevent an infection even if you have received a vaccination.
Mutations or variants of the COVID-19 vaccine continue to be identified and remain worrisome. As noted in my last presentation, the British/UK variant is much more infectious and has been identified here in Arizona as well as other states. Thankfully, this variant does appear sensitive to the vaccines currently in use worldwide. However, the current vaccines may not protect as well against variants from South Africa and Brazil, so the race is on to immunize as many people as possible before these variants become more prevalent.
Unfortunately, vaccine supply continues to be limited both here in Arizona and nationwide. Some of this shortage is due to logistics and distribution of the vaccines from the manufacturers yet most of the problem remains not having enough vaccine for everyone at this time.
A good milestone was achieved this week worldwide, with the number of people receiving at least one dose of vaccine (approx. 104.9 million) now higher than the number of people with confirmed cases of COVID-19 (104.1 million). According to the CDC, in the US, 35 million people have been vaccinated versus 26.4 million confirmed cases, and in Arizona almost 574,000 people have received one dose of the vaccine which means to date, just under 8,000 people per 100,000 have gotten a vaccine dose.
Sadly, getting registered for a vaccine here in Arizona remains a major challenge. Even as pharmacies start to become sites for getting a COVID-19 vaccine, they, like the mass administration sites at Banner, TMC, Kino Sports Complex, and the Tucson Convention Center do not have any appointments available for the next several weeks. Similarly, the 24-hour sites in Phoenix are also booked up. Nevertheless, I encourage those of you with computer access to keep trying. Pima County has now opened registration to those aged 70 and up, and in Phoenix and other parts of the state, vaccines are being given to those 65 and older.
For those of you who do not have computer access and have difficulty getting thru on the phone lines, please contact the office to have my staff try to assist you. We have no special influence so be aware we may not be able to accomplish much at this time, yet at least we can try to help those who are not on the internet.
Finally, there are two to three additional vaccines moving closer to availability with the Johnson and Johnson one up for approval this month. If that occurs, then there is a fair chance that by the end of June about two-thirds of the country could be immunized against COVID-19.
Take Care,
Jeff Mayer, MD
Links for FDA Authorized KN95 masks
Here are two companies that are reputable mask sellers. The two options are the KN95 masks from China (which are FDA authorized) and the KF94 masks from South Korea. The FDA certification is important to assure these masks are protective. While FDA authorized masks may be available on Amazon or eBay, there are a lot of fake masks around so it can be unclear if you are truly getting a certified mask. Be aware there is a KF80 mask as well yet this is not as protective as the KF94 mask. I’ve also included a link to the FDA website regarding masks. Be aware the term respirators refers to these masks.
www.bonafidemasks.com
FDA Authorized KN95 masks
www.behealthyusa.net
KF94 (Korean) masks
FDA FAQ regarding masks
FDA Fact sheet on masks. A little technical
Covid19 update Jan 25, 2021
Vaccines for Covid19 remain the major focus of our approach to ending this pandemic, yet vaccines will not have a noticeable effect for a few months. As we approach our eleventh month of dealing with Covid19 the guidance given to wear masks and, more importantly, to keep at least 6 feet apart from others when around people you do not live with, continues to be the most valuable way to reduce the spread of this infection.
With regards to masks, when out and about it would be best to wear a Niosh N95, KN95 or K94 mask. These masks can protect the person wearing it as well as anyone around them. They are generally superior to cloth masks yet are tighter fitting and thus can be more uncomfortable. The KN95 is perhaps better tolerated yet needs to be FDA approved as there are many KN95 masks sold which are not protective. On my website I will place links to 2 companies that sell certified masks at a reasonable price.
From my perspective as a physician, Covid19 is both fascinating and frustrating. Intellectually, all the research and knowledge obtained on this virus in just a period of a year is unparalleled in modern medical history. Clinically though, Covid 19 is a nightmare, with great uncertainty on how to treat it, and more concerningly, a tremendous unpredictability.
With many infectious diseases, it can be obvious if someone is going to recover (albeit slowly) or not, yet with Covid19 someone may be doing well and then suddenly decline and die. Age is not an ideal predictor of risk, with newer mutant strains of Covid19 appearing to infect younger people at a higher rate then prior strains. Similarly, people without any obvious underlying conditions may die while others with chronic illnesses get better. To a certain extent, this has always happened, yet not like it does with Covid19.
Mutations of a virus are common, and there are two mutant strains of Covid19 which are concerning. First off, is the UK or British strain which appears to be much more infectious. Over the weekend, there was speculation it may also be more deadly, yet that is not entirely clear yet. Second is the South African strain. This particular mutation is especially worrisome since it alters the spike protein configuration. The spike protein is what helps the virus infect cells and is also the target for the two vaccines currently being used in the US (the Pfizer and the Moderna vaccines).
The worry is that these mutations may make vaccination less effective or not effective at all. So far with regards to the British variant that does not appear to be the case, yet concern is high enough with the South African variant that Moderna has started working on a modified version of the vaccine currently being used.
Another fear is that if immunizations are not completed rapidly enough, vaccines may select out for an even more resistant strain of the virus then those we know of today. This point has been speculated upon in countries like Israel where up to 25% of the population has already been immunized with the Pfizer vaccine. There is NO proof this will happen, and it is not a reason to not get vaccinated.
Because the vaccines are new, there is great scrutiny on any bad events which occur after getting them. Unfortunately, with any vaccine there is always a small number of individuals who have a severe or even life altering reaction, yet the number of people this happens to is extremely low, usually in the range of one out of a hundred thousand people or less.
The most likely reaction from a Covid vaccine is going to be a sore arm. Some people also experience headache, fatigue, and fever. Interestingly, in the approval studies for the Pfizer vaccine, those under age 55 were more likely to have a reaction.
Finally, I was hoping to discuss how best to get a vaccine yet unfortunately there is no easy way to achieve that. Arizona would like to get 400,000 vaccine doses a week yet currently is only receiving 169,000. This discrepancy is limiting the availability of appointment slots for vaccines. However, in the next few weeks this situation will probably improve dramatically, with vaccines becoming available in pharmacies as well. I will keep you updated. Take care and have a wonderful week.
Covid 19 Holiday message 12-21-20
A HOLIDAY MESSAGE
2020 has been a most unusual year and tonight in the sky there will be another once in a centuries event when the planets Jupiter and Saturn will appear at their closest separation in the sky since 1623. The best time to see this conjunction will be between 5 and 7 PM tonight so I strongly recommend trying to view it immediately after hearing this message. You should look to the Southwest. Jupiter will be very bright and slightly above and to the left of Saturn. No telescope is needed yet binoculars will help. You may also see it online if you are on the internet.
Similarly, we are now witnessing one of the most rapid developments of a therapy for an infectious disease in human history. The deployment of a vaccine for Covid19 just one year after the virus was first identified is borderline miraculous, yet the groundwork needed for this event to occur started a decade ago when the mRNA idea began to be studied for other diseases.
This fortuitous conjunction of events is now giving hope that the end of the Pandemic may be in sight. If enough people can be immunized then the spread of the virus will be diminished and, if lucky, stopped almost completely. Life as we like to experience it could resume, and we would once again be able to enjoy events such as eating in a restaurant, going to a concert, or attending a game without worry.
Unfortunately, the unpredictability which has characterized 2020 will not just disappear in 2021. Mutations in viruses are common events, and there is now a new variant of Covid19 in the United Kingdom and South Africa which appears to be much more infectious than other strains. Scientists do not yet know whether this new strain will spread to other countries, yet they do believe the emergence of this strain is due to people not staying masked and/or socially distanced from each other. Resistance of this or other mutations to the Covid19 vaccines does not appear evident yet further study is ongoing.
I again implore everyone to continue wearing a face mask while out in public. Even with vaccines, the need for face masks will not go away for many months. Also, if you are having family or other gatherings for the holidays this year (which I again do not recommend), you should stay masked around family and should either eat outside or in separate rooms. As I mentioned before many new cases are developing from these types of small get togethers. A better way to celebrate would be a Zoom or similar type of virtual get together.
I am giving the office staff two paid four-day weekends so the office will be closed on Christmas Eve and Christmas Day and New Years Eve and New Years Day. If you should need anything, please contact me on my cell phone or through the answering service.
Finally, I read an uplifting article over the weekend from a Naturopathic doctor who advised focusing on what you CAN do during these trying times rather than what you CAN’T do. I think this is a wonderful message and I encourage everyone to find the “Silver Lining in this disaster” as the African proverb goes. Take care and have a peaceful holiday season, and I will be back with another message next year.
Covid update 12-11-20
THIS MESSAGE IS FROM DEC 11, 2020
In last week’s message I discussed vaccines and now with the approval of the Pfizer vaccine almost completed people are wondering when they can get it. Unfortunately, due to short supply, a vaccine will not be available for most individuals until many months from now.
When the search for a vaccine began in earnest earlier this year, six products emerged as the most promising. Of those six, two (the Pfizer and the Moderna product) are about to become available as early as next week. However, vaccine development and production are notoriously difficult, and in the beginning, it was impossible to know for certain which one of the six would become available first. Hence the government could not completely commit to buying all the doses needed for the whole country from just one company least that vaccine turned out not to be useful.
Ultimately, about 200 million doses will become available by March 2021 from both Pfizer and Moderna. That means 100 million people will be immunized, which is approximately 30 percent of the population in the United States.
For the moment though, nowhere near those number of vaccines will be available, and here in Arizona it is projected we will only be able to immunize about 190,000 individuals initially. Due to the demanding storage requirements of the Pfizer vaccine, distribution in Arizona is only going to occur in Phoenix and Tucson to start. Hospital employees and other health care workers along with nursing home residents are first in line to be immunized due to their high exposure to the virus.
We will not be administering the vaccines in our clinic since we are not capable of adequately storing them. We will notify everyone where they can get one once they become available on a more widescale basis. It has not yet been officially announced who will be in the second group of people to be immunized.
Once again, I need to strongly encourage everyone to please stay at home. Arizona is now leading the nation in Covid 19 spread. Back in March and April we spoke of “flattening the curve” and we need to return to thinking like that in order to prevent both a complete collapse of our hospitals and an astronomical death rate. Please be safe.
Dec 4, 2020 Covid 19 update
As we enter the holiday season, an unwelcome happening is the widespread increase in Covid 19 cases and deaths. Nationwide we are establishing new records daily and Arizona is unfortunately no different. Our 7-day average for new cases is now 4,585 which is the highest it has ever been. The number of tests positive (also known as the positivity rate) is 18% which is just one percent lower than the peak back in the summer. Over 350,000 people in Arizona have been infected with Covid 19 and almost 7,000 of them have died. Even with these high numbers, we are nowhere close to having immunity within the state, as we would probably need at least 70% of the population to be either infected or immunized against the virus, and we barely have 5% based on the available data.
On the bright side, vaccines are coming, and it is anticipated that the Pfizer vaccine will become available by the middle of the month here in Tucson. Initially, the first group of people to be vaccinated will be hospital and other health care workers and the two distribution centers will be TMC and Banner UMC. Complete vaccination consists of two shots 3 weeks apart.
The decision on whom to immunize first is a difficult one since initially there will not be enough doses for everyone. The Advisory Committee on Immunization Practices (ACIP) the committee of the CDC that guides all vaccination advisories and policies has recommended health care workers and nursing home residents as being the highest priority. However, state governors are free to modify this recommendation and indeed Governor Ducey has indicated he would like schoolteachers in the first group.
Many are concerned about the safety of the vaccine and consequently are reluctant to take it. Based on what I know thus far, I am comfortable with the vaccine’s safety and will be vaccinated when it is offered to me. It has not yet been established how the rest of the population in Tucson will be vaccinated once enough doses become available, although the state health department is discussing having mass vaccination sites similar to the drive-in sites currently being used for testing.
Just because a vaccine is available does not mean the danger is over. In fact, we are entering what is going to be one of the worst periods ever in this country in terms of public health and infectious disease. It remains imperative that everyone continue to wear a mask while out in public. It would also be wise to limit trips outside your home and to avoid public places. Take care and have a good week.
Nov 13, 2020 Covid19 vaccine update
November 13, 2020
There is hopeful news this week regarding a vaccine for Covid 19. The Pfizer/BioNTech vaccine has been shown to be 90% effective in preventing Covid 19 infections. This vaccine, like the Moderna vaccine undergoing clinical trials here in Tucson, utilizes a new technology involving messenger RNA.
In brief, cells use DNA as the template to make messenger RNA. Messenger RNA is then translated into proteins which are utilized to perform the essential functions of life.
An RNA vaccine introduces a messenger RNA strand which codes for a specific disease antigen. Antigens are what the immune system react to when mounting an immune response. In this instance, the RNA strand from the vaccine causes cells inside the body to make Covid 19 antigen. This antigen is then displayed on the cell surface, causing the immune system to form antibodies against the virus.
RNA vaccines are a new technology which have some major advantages over the conventional immunization development process. First off, they are much easier and less expensive to make since they can normally be synthesized in a lab. Consequently, they are quicker to produce then conventional vaccines which may need to be grown or cultured in other cells. Additionally, they are generally noninfectious and unlikely to cause an infection.
Like any new technology, there are challenges. First and most concerning is an unintended immune reaction different from the desired one. This though has not been an issue so far with the Covid 19 vaccines.
Secondly, storage for these RNA vaccines is a challenge since currently they require extremely cold temperatures to maintain effectiveness. Administering these vaccines can also be an issue as the RNA can be quickly broken down by the body before it has a chance to work.
RNA vaccines have been in development for a few years, yet up to this point none have been available for patients. The technique is fascinating and is being investigated as a possible therapy for certain cancers as well as for allergies.
It is unclear when actual doses of the vaccine will become available. It is widely expected that the Moderna vaccine will show similar success as the Pfizer product, yet since Moderna has about 10,000 fewer patients in their study it is taking them longer to get to the number of Covid 19 cases needed to show success.
Finally, the number of new cases, hospitalizations and deaths continues to double about every 2 weeks here in Arizona. While our absolute numbers are lower than at our peak back in June and July, the rate of increase is similar. It is imperative that everyone continue to wear a mask while out in public. Likewise, I strongly recommend not to have any family gatherings for Thanksgiving this year, as many of the new cases are developing from these types of small get togethers. Take care and have a good week.
Oct 30, 2020 Covid Update
Like the rest of the nation, Arizona is experiencing a dramatic increase in the number of Covid 19 cases. Our 7-day average for new cases is now up to 1082 which is up from 879 last week and more then double the average of 480 new cases back on October 1. Likewise, the statewide 7-day average for intensive care unit patients is increased from 172 last week to 188 yesterday. It was 125 at the beginning of the month.
Encouragingly the death rate remains low, especially considering the large increase in number of cases. The 7-day average for deaths in Arizona is 8 which is lower than it was a week ago and half of the 16 deaths a day occurring back on October 1. No one completely understands why this rate is remaining lower, yet one possibility is that the predominant strain of the virus is now more contagious yet less deadly then strains from a few months ago. Also contributing to this lower death rate may be our better understanding of how to treat more seriously ill patients.
In past messages I have singled out South Korea as a model for how I felt we should have responded to Covid 19. However, Taiwan just reported 200 days without a new Covid 19 case, and their approach deserves mention. Due to their experience with SARS (which is a similar virus) in 2003, they had an emergency central government agency which was activated to coordinate testing, PPE production and cooperation amongst various government ministries. They also began aggressive contact tracing and speedy isolation of close contacts of infected individuals. As an island nation, they did have an advantage of more easily restricting travel, yet they were very early in recognizing the threat, and began screening travelers from China in December 2019 and shut down travel into Taiwan in late Jan 2020. They did not do a country wide shut down. While concerns about privacy make similar contact tracing harder in the United States, we need to learn from other countries successes and emulate them.
I would like to update everyone on what we are doing in the clinic. Like most, we struggled in the early months with Covid 19, trying to figure out the right balance of keeping people at home while still seeing those who needed to be seen. We resumed doing Wellness Exams and routine visits on a reduced schedule in the summer, just as our cases in Arizona skyrocketed forcing another slowdown. In addition, our employee count reduced to just 1 full time and 1 part time assistant which greatly impacted our ability to be proactive. Since the end of the summer however we have hired 2 new medical assistants and now have 3 full time and 1 part time staff members. This increase will allow us to be in better contact with patients. However, while we are working hard to schedule as many Wellness Exams as possible, we are still only running at 75% capacity due to social distancing demands. Our hope is to catch up in early 2021.
Finally, I would like to remind everyone of two long standing clinic policies. First, we ask for 72 hours for refill requests. While we can usually do them much more quickly, this timeline helps assure you will not run out of medication. Secondly, if you have not heard back in 5 days on a lab or imaging result, you should call the office for the results unless you have an appointment to review them later then that. Thank you for allowing us to care for you and I wish everyone a peaceful week.
Covid 19 update Oct 23, 2020
Unfortunately, the number of new Covid 19 cases nationwide is increasing dramatically. While not as severe yet, Arizona is also worsening. The seven-day average of new cases per day has risen from 480 at the beginning of October to 879 yesterday. Likewise, the number of patients in the intensive care unit from Covid 19 has gone up from 125 on Oct 1 to 172 yesterday. However, this is still well below the peak of 970 ICU patients on July 13, and thankfully, despite more cases, the seven-day death average has declined from 16 a day on Oct 1, to 10 a day now.
There is a great fear we are witnessing the beginning of a third surge of Covid 19. Many hospitals are at or near full capacity in the Midwest and parts of the West. Tent hospitals have been opened in Milwaukee county (in Wisconsin) and in Utah amongst other places.
In addition, since this outbreak is now more widespread there are not as many nurses and doctors available to travel to the areas most affected, unlike earlier in the year in New York City. One bright spot is we have more experience and better knowledge of how to treat Covid 19 patients, which is leading to fewer deaths.
Pandemic fatigue in the population is most likely contributing to some of this outbreak. People believe they are safe and stop wearing masks. This unfortunately is especially true with small groups of family members or friends who think they are disease free yet aren’t. Larger gatherings of people are also a great risk for spreading the virus.
In person school, whether at the college or high school level also contributes significantly to new cases in some parts of the country. These cases are often arising from students not wearing masks or practicing social distancing when they are away from school and then spreading the virus on campus.
While many make a complete recovery from Covid 19 in 2 weeks, a significant percentage have persistent issues for weeks to months. While good data is not yet available, smaller studies have shown 20% or more will experience fatigue, difficulty concentrating, “foggy brain”, shortness of breath and reduced exercise tolerance amongst other symptoms. Some may also have gastrointestinal or skin issues. More seriously, a few may develop inflammation of the heart known as myocarditis which can lead to heart failure. Long Covid Syndrome is the term used to describe this post active infection state, although it is theorized there may be at least four different syndromes rather than one. This syndrome can occur at any age. An ongoing challenge is recognizing and supporting these individuals.
I will continue to update you next week. Please be cautious and have a good week.
