Practice News
Herd Immunity-Covid19 update 10-16-20
In the last 2 weeks there have been several Covid related stories. One of these stories is the argument that society should seek to get herd immunity by isolating the most vulnerable individuals and letting the rest of the population resume normal activities without restrictions. Specifically, face masks and social distancing would not be encouraged. Hand washing and staying home when ill would be the only recommended actions.
The proponents of this plan like to point to Sweden as a model. Specifically, Sweden did not shut down like the rest of the world back in March, and they assert that Sweden did as well or better than any other country in terms of infections and deaths while not suffering as much economically.
However, the data does not support the Swedish model. As of late September, Sweden had 57 deaths per 100,000 people, while neighboring countries who did take actions to limit activities had far fewer deaths. Denmark only had 11 deaths per 100,000, Finland 6 deaths per 100,000 and Norway 5 deaths per 100,000. Sweden also suffered through an economic downturn. In addition, the percent of Swedes who have antibodies to Covid19 remains low, and nowhere near the numbers needed to assure herd immunity.
It is estimated that up to 22% of New Yorkers have antibodies to Covid19, yet the number needed for herd immunity is most likely 70% or higher. Furthermore, many millions of people would need to get infected in New York City to achieve herd immunity and the death rate would range between 15,000-30,000 additional people. So far New York City has had just under 24,000 deaths.
Another equally distressing factor is the unknown duration of immunity from a Covid19 infection. While thankfully case reports of recurrent infections with Covid 19 are relatively uncommon, no one knows how long someone will remain protected. Only time will tell.
More problematic is figuring out who is truly vulnerable. Older adults are not necessarily more likely to get Covid19, yet they are more susceptible to get seriously ill if they do become infected. In addition, it is estimated that about 45% of the US population has some preexisting health condition that may increase the risk of a serious infection, and this includes people of all ages.
Clearly, shutting everything down is not the answer, yet going to the other extreme and opening everything up without restriction is also not an acceptable solution. Until we have a vaccine, prudent interventions and restrictions in areas with Covid 19 activity make the most sense. These include mask wearing and social distancing and when case numbers go above a certain threshold, selective closures and restrictions to contain the outbreak. We saw this done successfully at the University of Arizona last month
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Finally, not everyone has a full and complete recovery from Covid 19, and residual neurological, pulmonary, and cardiac issues do affect a significant minority of individuals. I will discuss these more in my next message. Take care and have a good week.
Jeff Mayer, MD
Travel Advice in the age of Covid-Oct 9, 2020
Dear Valued Patient,
With Thanksgiving and Christmas coming up, many people are wondering if it is safe to travel, or vice versa have family visit for the holidays. While no one knows for certain, there is concern that travel can be risky. However, as I mentioned in my last message there may be ways to reduce that risk, and I wish to share with you what one Pulmonary Critical Care physician, Dr. Vin Gupta, recommends.
First off, make sure you or your visitors have no COVID like symptoms for at least 2 weeks prior to travel. Right before traveling, you should get tested, and if it is negative you could then travel. Ideally, when you or your visitors arrive you should quarantine at a hotel for at least 48 hours before seeing anyone. I have been recommending 5 days since many times symptoms become visible 5 days after infection, yet I realize that is not always practical.
Driving will be safer then flying, yet if you plan to stay in a hotel you should check with each one how they are trying to reduce the risk of the virus. Many properties are not placing people in rooms next to each other and are also letting rooms sit empty for at least 24 hours before putting someone else in the room.
If you fly, try to fly at less popular times so the airport and plane may be less crowded. Wearing a well-fitting mask is important, and if you can get one, an N95 mask is recommended. (Be aware that N95 masks are more uncomfortable especially when worn for an extended period). Make sure the airline is keeping the middle seat open and take wet wipes to wipe down the back of your seat and tray table. Also, make sure to have hand sanitizer.
When you are gathered with family, try to avoid close contact and talking without a mask, especially if you are around older family members and/or ones with underlying medical conditions.
Dr. Fauci’s own daughters have decided not to visit him and his wife this year for Thanksgiving so as not to put their parents at increased risk, yet Dr. Fauci has advised each family to make its own decision by “look(ing) at the individual situation in your own family and mak(ing) a decision that way.”
I realize COVID-19 has negatively impacted family life. Hopefully, by applying some of this advice some of you may be able to enjoy the upcoming holiday season. I will be back next week with another update.
Take care and have a good week.
Jeffrey Mayer, MD
9-18-20 Covid19 update
This is Dr. Jeff Mayer with a quick COVID 19 update. Today is Friday, September 18, 2020.
The numbers in Arizona are increasing yet this change is due to how new cases are being counted rather than an increase in the number of infections. The state health department has now added positive results from antigen tests to the PCR results, which has caused the number of new cases reported to increase dramatically. The PCR test is still considered the better test, yet the antigen tests have the advantage of getting results back within minutes to hours versus days and are still accurate enough to be included in the total count.
More telling is the number of hospitalized patients with Covid19. Arizona continues to see lower numbers of hospitalizations for Covid, and yesterday was the second lowest count since the numbers began being reported publicly back in April. The death rate average has increased slightly to 19 a day over the last 7 days and this number may go up even more as some older data is introduced into the statistics. Currently though the belief is that the number of deaths remains stable.
Earlier this week, there was a directive to UArizona students to limit activity away from home. As noted in last week’s message, positive cases around universities throughout the country have increased dramatically due to students not heeding social distancing and mask wearing recommendations. Some universities have gone so far as to return completely to remote online courses again. The fear is these students will spread the infection in their surrounding communities leading to a new outbreak. Thankfully, we have not seen this yet.
Some patients are wondering about the safety of flying now. Information available is more speculative then authoritative since good studies have not been done. However, if people on a plane are primarily wearing masks and the middle seat is empty then the risk of getting a Covid infection on the plane is not too high given improved ventilation systems. A larger risk may be present if people are congregated close together when boarding the plane or when waiting near the gate. In those instances, social distancing may not be practiced as diligently as it needs to be, yet once again, mask wearing will help reduce the risk. Unfortunately, no activity around large numbers of people is without risk, so the decision to fly or not depends on an individual’s comfort in accepting that risk.
Finally, I wish everyone a happy and healthy week. Take care.
9-11-20 Covid19 update
The numbers in Arizona continue to improve. Currently, the number of patients hospitalized for Covid 19 is the lowest it has been since April, with 577 people hospitalized throughout the state yesterday. In addition, the number of patients in the ICU was 171, which is the second lowest number since April 8 when the number was 155. Overall, the weekly average of new cases is now below 500 a day. However, it remains above the 300 cases a day we had back in March and April.
Unfortunately, one of the hotspots for new infections has been the universities. UArizona and ASU have seen significant outbreaks due in large part to students not following social distancing recommendations. This problem is nationwide in areas with large college student populations. While young people in general are less likely to get a serious case of Covid19, they are not invincible, and when they end up in the hospital about a third will have life threatening cases.
Recently, Astra Zeneca suspended their vaccine trial due to a participant developing a medical condition which could have been caused by the vaccine. While details are not public, the supposed reaction may be due to the vaccine or may just be a coincidence. That is the challenge with new treatments: determining what is due to the treatment versus something else. Also, side effects which may not appear in a group of thirty thousand patients may occur when the treatment is administered to millions of patients. Therefore, it is important to have good data from the phase 3 trial and likewise to do post release monitoring.
That leads to the question of should someone get a Covid19 vaccine if it were released in the next month or so. At this point in time I advise to wait and see what the data looks like. Especially important will be the side effects of the vaccine. While effectiveness is the goal, safety is the priority.
One concept poorly communicated by public health officials is that vaccines are not necessarily intended to prevent someone from getting the disease. For instance, the main benefit of Flu shots is to keep someone from dying from Influenza pneumonia by getting a less severe case. Clearly, it is nice when the shot prevents the disease completely, yet the main goal is to help someone survive the infection with little or no serious consequences. Likewise, that will be the goal with any Covid19 vaccination.
Finally, if you have not already done so, please take a moment to think of and remember all the people who tragically lost their lives on this day 19 years ago. Take care.
Jeff Mayer, MD
September 11, 2020
Covid19 update Sept 6, 2020
Overall, there continues to be an improvement in the number of COVID cases here in Arizona. For the past 7 days, new cases are averaging under 600 a day and the number of deaths remains about 35 a day. Hospital admissions however are way down, and most significantly the number of patients in the intensive care units is the lowest it has been since early April. Both Pima and Maricopa counties have fulfilled the 3 criteria established to reopen schools, although many will remain closed until at least October. Of note though, we still have double the number of cases as compared to March and April when the initial stay at home order was issued by the governor.
Certain restrictions are being relaxed and several businesses that had been closed (such as movie theaters) are now reopening. There is worry that people will believe the threat is over and will resume the behaviors that led to the huge spike in cases in May and June. It is important to continue wearing a mask while around others in public as well as trying to maintain a distance of at least 6 feet from others. In addition, gatherings of more than 10 people still represent an increased risk.
It is probably ok to get a haircut or see the dentist now, yet you should check with them to see what they are doing to reduce the risk of infection. In general, they should be limiting the number of people in the space at any one time and should have an established routine for how they disinfect chairs and equipment in between visits.
There is a lot of speculation about when a vaccine may be available. So far, I have nothing to add to what I mentioned in my talk last week. I will keep you updated as information becomes available.
Finally, I want to wish everyone a happy and safe Labor Day weekend.
Take care and have a good week.
Jeffrey Mayer, MD
Covid 19 Update Aug 28, 2020
This past 10 days there have been two recommendations which have generated considerable discussion in the medical community. First off, the FDA issued an emergency use authorization for convalescent serum to treat Covid 19 infections. Convalescent serum is made from the antibodies of patients who have recovered from Covid 19. The theory is that by transfusing these antibodies patients will have a better chance of recovery. While the therapy appears safe, the data on its effectiveness is unclear. The therapy has NOT been compared to a placebo, so it is impossible to know if it truly helps, or if people would have recovered without it. Convalescent serum has been available for several months, so the hoopla surrounding the announcement was confusing. The emergency use authorization makes the therapy more available yet may also limit the ability of researchers to study it fully. Mayo Clinic has been leading this research with over 30,000 cases, and Tucson Medical Center is part of a network of hospitals that work with Mayo.
Similarly, the CDC issued a new recommendation to not test people who have been exposed to Covid 19 if they do not have symptoms. This recommendation is controversial as many public health officials believe more testing is the only way to truly know the prevalence of the disease in the population. The concern is that barriers may once again be placed in getting testing.
However, just yesterday a new type of test received emergency use authorization. This test can be done in an office and results are available within 20 minutes. It is like an over the counter pregnancy test with the results being one or two lines on the testing card. It reportedly will be priced around $5 a test. Unfortunately, it has a relatively high false negative rate, meaning the person may still have Covid 19 despite testing negative. This detail will limit its usefulness for screening, yet it may help us confirm if someone does have the infection if they are having symptoms. I am not certain if similar tests which may be more accurate will become available from different manufacturers.
While there are several vaccines being looked at throughout the world, I want to highlight a few which may have more promise. As I have mentioned before, the Moderna vaccine is in phase 3 trials with some testing occurring here in Tucson. In addition, there is the Oxford/Astra Zeneca vaccine which is already in phase 3 trials in Europe and will be starting testing here in the US soon. Pfizer and Johnson and Johnson are also working on vaccines which are far along. In Latin America and the Middle East, a Chinese vaccine is in phase 3 trials. Finally, the Russians have approved Sputnik V vaccine for use in their country, yet they decided to skip phase 3 trials and go straight to approval.
The Sputnik vaccine is a good example of political pressure getting ahead of science. If the lethality rate of Covid 19 was high (say 5% or more) then I believe you could justify making that decision. However, with a lethality rate of 1% or less, I strongly feel you must wait to demonstrate the safety and effectiveness of a vaccine. For instance, back in 1990, there was a study published looking at an experimental Coronavirus vaccine for cats which showed that the cats who got the vaccine died at a higher rate when exposed to the virus then those who did not. (Please note this coronavirus was different then Covid 19). In 1976, the US rushed a Swine flu vaccine which resulted in a significant number of cases of a potentially life-threatening condition called Guillen Barre Syndrome. Hence the reason for caution.
Finally, the number of new Covid19 cases here in Arizona continues to decline. We are now averaging less than 600 new cases a day. Deaths are lower as well, with approximately 35 a day on average over the past 7 days. Likewise, the percentage of tests which are positive has declined down to 5% for the past 2 weeks, which is good news.
Take care and have a good week.
Jeff Mayer, MD
Aug 14, 2020 Covid update
COVID-19 UPDATE
Dear Valued Patient,
The number of new COVID-19 cases here in Arizona continues to decline. For the past 7 days, we averaged just over a thousand new cases a day which is down by about 15% from last week. Deaths are slightly lower as well, with around 54 a day on average over the past 7 days, down from 55 a day last week.
To clarify some questions I have received, I get my data from the Arizona state health department website azdhs.gov. There are some nuances associated with using this site. The state will update the data daily, yet also has a bar graph showing cumulative results. The bar graph is often a week behind the actual reported number for each day. I do not know why that is. In addition, case reports like the numbers I just mentioned often reflect what was going on several days ago due to the time between when a test is done and when it is reported out. Using a 7-day average helps adjust for some of that discrepancy, yet the data is still a little off in terms of timeliness.
On the other hand, the hospital data is up to date, and encouragingly we are seeing steady declines in the number of patients hospitalized for COVID-19. We peaked in hospitalized patients exactly a month ago, yet now we are seeing levels that we were seeing back in June before we saw the massive increase. We are not yet at the lowest levels yet appear to be approaching them. However, there are still 1359 patients hospitalized with COVID-19 statewide as of yesterday.
Flu shots are becoming available and I encourage everyone to get one this year since our nightmare scenario is having a massive influenza outbreak combined with a COVID resurgence. I am aware that several pharmacies around town already have doses available. We too will have doses available in the office later this month. However, I recommend not getting a flu shot until September, since the vaccine only lasts about 5 months, and too early an administration will not necessarily protect you during our usual peak months of February and early March. Unlike my advice in years past, I do not recommend waiting past September to get your flu shot. Those over age 65 should get the high dose shot and regardless of age everyone should get a quadrivalent or four-strain shot. This year marks the first time we have a four-strain shot available in the high dose shot.
We are seeing patients every day of the week now except for Wednesday and weekends, so I kindly request that if you need to reach me during clinic hours of 8:30AM to 4:30 PM please call the office. If you would like us to give you a flu shot call us and we will let you know when to come in to get one since we are still restricting the number of people in the office.
Finally, we welcome Karyssa to our staff as a new medical assistant/front office person. Sue, BJ, Erin, and Cynthia continue with me as well.
Take care and have a good week.
Jeffrey Mayer, MD
COVID19 Update 8-7-20
Some good news this week. The number of new COVID-19 cases here in Arizona is now averaging almost a thousand a day fewer than last week. We are now seeing about 1600 new cases daily, down from approximately 2400 a day last week. Deaths are averaging around 55 a day over the past 7 days.
Unfortunately, 10.8%, or just over 1 out of every 10 people tested for COVID-19 here in Pima County have the virus. This percentage is important since it is being used to determine when students may return to in-class instruction. The recommendation from the state has 3 main criteria, one of which is not to return to in-class instruction until the percentage of positive COVID-19 tests is below 7% for two weeks in a row. Since we are nowhere near that number, the school districts in Pima County have started classes this week with online instruction. My 16-year-old daughter and teacher wife hate it.
You may see some students back on school campuses on August 17, yet this will mainly be for students who are unable to do online instruction at home. There will not be any in-class instruction, and these students will be kept with the same small group all day. It is hoped that keeping the schools closed for now will slow down the spread of new cases.
There are now several options for free COVID-19 testing here in Pima County. The county health department has now established 3 separate permanent testing sites and is also having several one-day testing sites at various locations throughout the county. You do need to make an appointment for a test. The permanent sites are at Kino Event Center, Udall Park, and Ellie Towne Flowing Wells Community Center. The Flowing Wells site is doing a saliva collection, while the other two sites are doing nasal swabs. According to the health department, results are supposed to be available within 2-3 days. Unfortunately, we are unable to do this type of screening in the office since we can not obtain enough personal protective equipment. You may go online at www.pima.gov/covid19testing or call 1-800-369-3584 to make an appointment.
Finally, with regards to treatments, there are no new discoveries or developments to share this week. Vaccine trials continue, and one or two additional vaccines have shown promise.
Take care and have a good week.
Jeffrey Mayer, MD
July 16, 2020 Covid update
There are many different therapies being looked at for Covid19. As I have discussed in past messages, three being utilized here in Tucson are Remdesivir an antiviral medication, Dexamethasone a steroid, and convalescent serum, which is essentially antibodies collected from the blood of people who have recovered from Covid 19.
However, several agents are being investigated nationally and internationally, and I have posted on this website an extensive summary of them along with the available scientific evidence. This list is from the American Society of Health Care Systems Pharmacists, who also have a website http://www.safemedication.com/ which is a good resource for general drug information as well as updates on Covid 19 therapies.
Some common medications in use have been speculated to either help lessen or prevent Covid19. Specifically, Pepcid/Famotidine was suggested as reducing the severity of Covid19 infections when used in high doses in ill patients. To date though, there is no firm evidence supporting this observation, and no proof that it can help prevent an infection. Unfortunately, this has not stopped people from buying this medication to prevent Covid19, and shortages have now developed. Due to the unavailability of alternative agents in this class (specifically Zantac/Ranitidine), patients are sometimes being switched to a less desirable class of medications for their acid reflux. Likewise, hydroxychloroquine went into short supply when that drug was touted as a preventative measure, and my arthritis patients on that medication had increased expense and difficulty getting it.
Supplies continue to remain a major issue with shortages of testing supplies now again becoming a limiting factor. While more readily available than a few months ago testing is still difficult to get, and worse, the time to get results is now 5-7 business days, making screening for asymptomatic and pre-symptomatic disease almost useless since those individuals will most likely still be out and about. This is especially noteworthy for younger individuals who are the most likely to spread the disease since their symptoms tend to be mild.
The discussion about when to reopen the schools is directly related to the inability to screen. As a parent of a school age child, I know my child is best educated in a classroom. However, until we can screen adequately, and more importantly, until we see our case numbers go down dramatically, the risk of infection to teachers, older students and the public is too high. As hard as it may be for some to imagine, our situation can get much worse.
On a positive note, one of the vaccines in development has shown tremendous promise and is now advancing to the final stage of testing. This final stage will take several months, so if everything goes as hoped it will still be early 2021 before it would be widely available.
The number of cases and deaths remain essentially unchanged from last week. We appear to have reached a plateau, with a little over 3,000 new cases each day. Things may be slowing down a little, yet the numbers will not reflect that for a few more weeks. Mask wearing and social distancing remain the mechanisms for reducing cases. While uncomfortable, there is no danger to wearing a mask for extended periods of time. Ask any surgeon or operating room nurse.
In the office we welcome a new assistant Cynthia and continue to see patients on a reduced schedule due to social distancing requirements. My next message will be in 10 days since my contact at MBS who sends out these messages will be on vacation next week. Take care.
Summary of therapies being looked at for Covid19
Here is a summary of different therapies being looked at for Covid-19 along with the scientific evidence and recommendations for their use.
It comes from this website which is a useful resource for information on medications from the American Society of Health System Pharmacists.
http://www.safemedication.com/
Medication information (click here to go to the website)
