5/20/2020

COVID ANTIBODY TESTING UPDATE

Since March, I have been very interested in any data from SARS-CoV-2 antibody testing.  We were hopeful that this information would provide some COVID prevalence information for Douglas County.  In Oregon, the PCR assays became available relatively late in the course of this pandemic and were initially limited for use in those that met CDC testing criteria (COVID-like symptoms, foreign travel and hospitalized patients). I have impatiently waited for COVID antibody testing to become available in Douglas County to better understand our urgent care experience treating thousands of patients since January.

I was interested in using an antibody assay that had some reasonable validity data to avoid too many false positive and negative results.  To date, LabCorp seemed to have the most complete validity testing available.  From May 11th to May 15th, we tested the COVID-19 antibody status of 46 urgent care staff and found that no one tested positive for COVID antibodies.  This observational study is posted below.

Some people may think that this is additional evidence that COVID-19 prevalence is very low in Douglas County and non-existent in our Urgent Care staff.  Although possible, I think that this is unlikely to be the case.  First, the urgent care had direct contact with 7 out of the 25 confirmed COVID positive patients and likely saw thousands of patients with COVID- like symptoms from January to the present.  Second, there is evidence that antibodies may become undetectable rapidly during the recovery phase in other coronavirus strains. This may explain the unexpected negative antibody results among Evergreen Urgent Care staff since they were exposed months before the testing was performed. Third, there is a local example of one who tested positive by PCR testing but approximately one month later tested negative using the Quest IgG antibody assay.

Even if antibodies do become undetectable soon after recovery, there may be some protection by T-cell or cell-mediated immunity.  Unfortunately, if antibodies do not last very long, a vaccine that makes a meaningful long-term impact may be even more difficult to develop.  Recently, Moderna announced evidence of positive results for their novel messenger RNA (mRNA) vaccine in a phase one trial.  They tested 45 people between the ages of 18 and 55 and saw an antibody response similar to those who were infected with COVID.  They intend to test another 600 volunteers in the next phase using this vaccine.   Will the antibodies remain effective for very long and if not, does the vaccine stimulate other aspects of the immune response to provide some level of protection? This will take time to determine and will require extensive testing for safety before it will be ready for mass inoculation.  Vaccine safety will be particularly important since we understand that the infection lethality rate of COVID-19 is much lower than initially feared.  Also, a novel method of producing a vaccine would usually require additional scrutiny by the FDA.

With these developments, I have the following thoughts:

  1. Unfortunately, I think that using current serology testing to determine community prevalence of or immunity to COVID is of little value at this time.

  2. It is important to understand that there has never been a successful vaccine for coronaviruses to date – including SARS and MERS. 

  3. The novel Moderna mRNA vaccine method or any vaccine for that matter, will need to show meaningful protection to those most at risk (the elderly and those with multiple comorbid conditions). Demonstrating efficacy and safety for any COVID-19 vaccine will likely be measured in years, not months. The fastest that we ever produced a vaccine for a novel virus was for the Mumps.  It took approximately 4 years and it was done using a standard, well-understood method.

  4. It is unlikely that we will eradicate COVID-19 from the planet any time soon.  More likely, it will become endemic in our population like the other strains of coronavirus that we deal with every year. Fortunately, as exposures increase and reoccur, the severity of the illness will likely lessen.  Fortunately, COVID-19 is not smallpox with a 30% mortality rate.

  5. At this time, it is unlikely that any metric other than regional emergency department, intensive care, and other hospital capacity measures will be helpful in determining who gets to “open up”.  Community support will be important as it relates to the discharge of hospitalized elderly and chronically ill people who had COVID and are unable to immediately return to a skilled nursing or assisted living facility.  I see very little value in strict contact tracing at this point other than estimating an “R0” or the reproduction number to describe the intensity of the outbreak. These numbers do not reflect a community’s capability to manage a surge of COVID cases. Douglas County is ready to open up in my opinion.

  6. In the U.S., we are approaching 40 million newly unemployed citizens in the last 2 months.  The adverse impacts of this economic disaster on physical health, mental health, and other social determinants of health are real and attributable to the current pandemic restrictions.  The effects are tearing through the social fabric of our community. I understand that there are no risk-free paths forward but I do not accept that a life adversely impacted by the current policy is worth less than a life impacted by COVID-19. Deaths will continue to occur in both circumstances.  We need a balanced approach to minimize the total harm.

  7. I would recommend that the elderly and especially those with comorbid conditions to avoid crowds and to use reasonable social distancing.  There is no convincing data for the use of face masks on asymptomatic individuals in my opinion.  If one is ill, they should not depend on a mask to prevent the spread of COVID-19 and if a person is fragile from advanced age and/or chronic illness, they should not depend upon masks worn by themselves or others to protect them.  Ultimately, everyone will need to come to terms with their own risk tolerance.  For all Douglas County citizens, I recommend that we wash our hands often and for those who can, let’s get back to working, recreating and stimulating the economy - lives depend on it.

 

 

John Powell M.D.

 

P.S. I have attached a link of an interview from 5/5/20 with Professor Hendrik Streeck, a virologist from the University of Bonn in Germany.   He authored an antibody study in Germany. His research and insight about vaccines and other coronaviruses were helpful.

https://www.youtube.com/watch?time_continue=4&v=vrL9QKGQrWk&feature=emb_title

An Urgent Care Experience with COVID-19 IgG Antibody testing of Staff in Roseburg, Oregon

 

Purpose:

To understand the prevalence of COVID-19 antibodies among Evergreen Urgent Care staff members in order to estimate a high exposure cohort prevalence rate for a population in Douglas County, Oregon.

 

Background:

Evergreen Urgent Care is a high volume semi-rural clinic that had 40,518 patient visits in 2019 and 10,918 patient encounters from 1/1/20 through 3/31/20. The clinic has served as an access point for Douglas County residents with COVID-like symptoms during the pandemic.

As of 5/17/20, there have been 25 PCR confirmed cases and zero deaths from COVID-19 in Douglas County, Oregon. The urgent care staff had direct contact with 7 of those confirmed positive SARS-CoV-2 cases.

Forty-six Evergreen Urgent Care staff participated in this antibody assay. They included receptionists, managers, physicians, advanced level providers, lab personnel and clinical staff.

Methods:

Evergreen Urgent Care front office and back office clinical staff were offered LabCorp IgG antibody (serological) testing.  They must have been symptom free for at least 14 days to ensure improved sensitivity of the test.  Potential participants were informed that PCR testing would be more appropriate if they were symptomatic or were within 14 days of onset of their illness.

Forty-six Evergreen staff volunteered to participate in a LabCorp COVID-19 IgG antibody test offered by our clinic free of charge. Six of the staff had been previously tested using COVID-19 PCR testing in the previous months. Of the 6 PCR assays, 4 staff members were negative and 2 individuals had inconclusive PCR results (QNS). Forty-two reported either a prior known COVID-19 exposure or COVID- like symptoms between January and March 2020.  Four individuals reported no known exposure to the virus or symptoms consistent with the disease. Twenty-six individuals reported a known COVID-19 exposure. Thirty participants were physicians, advanced level practitioners or clinical support staff with direct patient care duties. Six were laboratory staff or phlebotomists.  Six were urgent care receptionists and 4 were managers.

We used a LabCorp IgG serologic test approved for diagnostic use under an FDA Emergency Use Authorization. The testing was performed between May 11 – 15, 2020. The LabCorp validation testing showed a sensitivity of 100% for 88 PCR confirmed COVID-19 positive patients 14 days or longer after their symptoms began. There were 4 “false positive” tests in 997 patients’ blood samples that were drawn in September 2019- before the outbreak of the COVID-19 pandemic.  This data was the basis for selecting this particular serologic test for our Evergreen employees. Unfortunately, IgG detection rates were not reported for patients beyond 14 days after they became symptomatic in LabCorp’s validity testing. 

LabCorp provided the following validation data in their clinical performance statement.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Results:

There were no positive COVID-19 IgG antibodies identified in any of the 46 tested staff members.

Discussion:

This COVID-19 antibody screen of Evergreen Family Medicine Urgent Care staff was performed to understand the prevalence of SARS-CoV-2 virus in a high exposure setting in our semi-rural community.    There were no members of our staff who tested positive for COVID IgG antibodies. These findings were unexpected since our staff members participated in the care of 7 known positive COVID positive cases and likely thousands of patients with COVID-like symptoms since January 2020.  Many patients who had a febrile respiratory illness tested negative for influenza but were evaluated before COVID PCR testing was available or limited by CDC testing criteria. Staff use of PPE to care for patients with respiratory illness did not begin until COVID-19 was declared a pandemic in March of 2020 and guidance on appropriate use of PPE was provided by the Oregon Health Authority.

There are many possibilities to consider in this observational study.  First, the prevalence of COVID-19 may actually be zero in the Evergreen urgent care staff.  Second, Douglas County and urgent care staff are extremely effective at preventing the spread of COVID-19.  Third, the overall prevalence of COVID-19 in Douglas County is very low and the 25 confirmed PCR cases per approximately 100,000 residents represents the prevalence of the disease in our county.  It is understood that the majority of the 25 positive cases in Douglas County were without a travel or a known exposure history.  Public health authorities have been unable to explain how these sporadic cases occurred. Therefore, it seems unlikely that the number of confirmed COVID-19 cases represent an accurate assessment of the prevalence of the disease in our community. Fourth, our findings may suggest that individuals infected with this virus were very effective in preventing the spread of the disease before and after their positive status was known and it may also reflect Douglas County’s low population density.

Finally, the validation process for this serology test may be flawed or more likely, the assay may not detect COVID IgG antibodies for more remote infections because antibodies rapidly become undetectable in the recovery period.   There is a possibility that serologic testing is unable to detect IgG antibodies months after exposure to SARS-CoV-2.  Our staff experienced exposures or illness months prior to the antibody testing.

 A rapid decline in IgG antibody levels would be consistent with other “common cold viruses” including other strains of coronavirus and rhinoviruses.  Unfortunately, this might also suggest that humoral immunity does not last long and securing a meaningful vaccine may be more challenging. Perhaps, other cell-mediated immunity mechanisms provide some level of protection to reduce the severity of reinfection.

After considering the possibilities above, the presently understood transmissibility of COVID-19 and our urgent care clinical experience, it seems more likely that serology testing is not currently useful in determining the prevalence of COVID-19 among our staff and by extension, our community.   These findings may suggest that this assay may not be effective in determining seropositivity in persons with more remote infections to COVID-19.

Conclusion:

The seroprevalence of COVID-19 remains unknown at the Evergreen Family Medicine Urgent Care. It remains unclear how effective the current serology testing is to detect IgG antibodies for those who may have been exposed to or infected by SARS-CoV-2 over a month prior to this method of testing. We recommend continued study of the current commercial serologic assays regarding the length of time that IgG antibodies remain detectable in individuals with confirmed positive COVID-19 infections.  At this time, we do not recommend the current serology assays to diagnose previous infections or to determine immunity to SARS-CoV-2.  We are not confident that the currently available commercial serologic assays accurately measure seroprevalence of this virus in a population.  Our experience supports the hypothesis that COVID-19 IgG may become undetectable soon after recovery from an infection.  This would be consistent with other coronavirus strains.

 

John Powell M.D.

5/1/2020

Dr. Giesecke and Sweden’s Approach to the Pandemic

I have attached an interview below with the Swedish epidemiologist and infectious disease expert, Dr. Johan Giesecke that took place on 4/17/20. He articulated a rational and realistic approach to managing the COVID-19 pandemic.  He addresses the challenges of walking back or sustaining draconian measures to prevent the spread of COVID-19 to an entire population. He makes the case for protecting the elderly and those with comorbid conditions but allowing the rest of the population to proceed with their lives. The positive byproduct of this moderate approach is to gain community (herd) immunity.  This increased immunity will ultimately reduce the transmission of the virus to the vulnerable population.  The Sweden approach also mitigates the devastating impacts on the economy, non COVID illness and other social determinants of health.

The British interviewer was excellent in my view.  He asked direct and difficult questions but he was actually interested in the physician’s response.  The point of the interview was to inform and educate, rather than attempt to advance a particular political agenda -refreshing.

For those that argue that Sweden has paid a heavy price for their approach, I provide the following numbers from the Johns Hopkins Dashboard that follows “critical trends”.  Below, I have listed the number of deaths per 100,000 people in various countries.

 

U.S.:                      19/100K

Italy:                     46/100K

UK:                       40/100K

Spain:                   52/100K

Belgium:              66/100K

France:                 36/100K

Netherlands:       27/100K

Switzerland:        20/100K

Ireland:                25/100K

 

All of the countries above have had more restrictive policies than Sweden.  Sweden has be severely criticized by the WHO and other countries for their approach.  As of today, Sweden’s death rate is 25/100K.

John Powell M.D.

Dr. Giesecke’ s interview link is below.

https://www.youtube.com/watch?v=bfN2JWifLCY

4/28/2020

Science should not be suppressed.

Over the course of the last two weeks of the COVID-19 pandemic, I have shared the scientific observations and opinions of Dr. John Ioannides, a Stanford University professor of Epidemiology, Infectious Disease, Biostatistics and Population Health. He presented a partly contrarian viewpoint to our current pandemic approach.  His opinions appear to be grounded in fundamental epidemiological and statistical principles.  He was a coauthor of a recent Stanford antibody study in Santa Clara County, California.  Other recent antibody studies evaluating the antibody prevalence in L.A., Miami, Germany, Boston, New York and the Netherlands have corroborated the Stanford antibody data.  These data confirm that the prevalence of COVID-19 is much higher than the daily updates displayed on the Johns Hopkins Dashboard.   Dr. Ioannides’s previous concerns about the WHO using mathematic models that severely overstated the mortality rate of COVID-19 are being validated.  Yet, these models continue to shape many of the policies and protocols of our public health response during this pandemic. 

The antibody studies are also supported by superior South Korean data that reflected population testing early and often since January.  As of today, South Korea has still not registered a single death under the age of 30 despite 3,678 confirmed positive results and for those under the age of 60, there have been 20 deaths out of 8,210 confirmed positives (0.2% infection lethality rate). 

There have been valid selection bias criticisms and concerns about false positive results in the Stanford antibody study (also present in the other antibody studies).  This is fair and the peer review process will continue to determine if they are meaningful.  Dr. Ioannides has said that he accepts that the study is not perfect.  Nevertheless, he believes that the essence of these numbers will hold up. It is interesting that the mortality rate of less than 0.2% suggested by these antibody studies is consistent with the South Korean PCR test results for those under the age of 60.  I find it concerning that critics highlight Dr. Ioannides study for selection bias but I have not seen as much concern about the Boston study where authors found a prevalence of approximately 31% among those passing by on the street – many in a homeless shelter. Real population testing results are better than mathematical predictive modeling.  A virus is a virus; it does not think or care about your sex or ethnicity. However, population density, health and age of the individual appear to be very important determinants of the disease’s impact.  This is precisely why a “one size fits all” solution to respond to the pandemic does not seem to be indicated.

 I am writing this perspective today because I am concerned about the increased political posturing during this pandemic.  Science should never suppress observations and data.  Most importantly, science should never attack the scientist, only the value of their data.  I am very concerned about the recent marginalization of Dr. Ioannides by the media and even by some in the scientific community.  This is not science; it is politics.  We need to recognize the difference.

I have included the Wall Street Journal article below about the political backlash against Dr. Ioannides.  We need to move forward with data -not feelings, hysteria or politics.

John Powell M.D. 

“The Bearer of Good Coronavirus News”  https://www.wsj.com/articles/the-bearer-of-good-coronavirus-news-11587746176?fbclid=IwAR1S0gUW8G1wuXREOsVsn2-BYPk4TI3zcoV36IAWCeymGkfpe1x-YQ6dlMg

4/23/20

 

Dr. John Powell talks about COVID-19 policy with Kyle Bailey on KQEN radio

4/23/2020  https://kqennewsradio.com/wp-content/uploads/2020/04/IDC-4-23-20.mp3

 

 

4/22/20

 

Science is a Discipline based upon Skepticism not Consensus

 

I have found the following two YouTube links interesting as we navigate alternative solutions to our current pandemic.

The first is an update from Stanford physician and epidemiologist, Dr. John Ioannides and the second is Dr. David Katz, a professor of Medicine and Public Health from Yale University. As the public may be coming to realize, science is not a democracy but rather, a skeptical discipline. Ultimately, it will self-correct as data evolves. This is a healthy process and should be not be suppressed.  The pandemic response will require a balancing of science, economics and politics.  In my view, they should be prioritized in that order.

Dr. Ioannides – https://www.youtube.com/watch?v=cwPqmLoZA4s

 

Dr. Katz - https://www.youtube.com/watch?v=VK0Wtjh3HVA&list=FLqc3YC10umcr1J7y9Un8msA

 

4/18/20 (This letter was sent to the Governor and elected representatives)

 

COVID-19 Policy in an Era of Uncertainty

 

COVID-19 Policy in an era of uncertainty

 

At this time, public policy decisions and disease modeling are based in large part upon the “known unknowns” and “unknown unknowns”.  This means that much of our information about the prevalence and incidence of COVID-19 is still not reliable. As a result, there have been and there will continue to be unintended consequences of these policy decisions. It is time to account for them.

 

As a Family Physician in Roseburg, Oregon, I have already seen the harm of well-intended executive orders and public health policies that adversely impact the patients for whom my group provides care.  Here are some examples:

 

1.    An elderly man with diabetes had intermittent loss of consciousness and low blood sugar readings. He had an insulin pump but he had no access to his regular physician. Because he lived in an assisted living residence that was in “lock down”, he did not know where to go for help.   Our staff visited him at his facility and decreased his basal insulin dose. He was referred for a telemedicine visit with our endocrinologist. We drew labs and informed him about his newly recognized heart murmur. Many more seniors will suffer decline or death due to neglect of their chronic conditions. Many patients in nursing homes and assisted living facilities have limited access to care.

2.    A man that I admitted to the hospital had profound anemia and needed a blood transfusion.  His “elective” endoscopy was canceled weeks before due to Oregon’s executive orders forbidding elective procedures.

3.    Another man was hospitalized for worsening of his chronic obstructive lung disease (COPD). He explained that his daughter and ill granddaughter had recently moved in with him because his daughter had lost her job due to the closure of her employer’s “non-essential business”.   

4.    A patient needed to have his painful, broken abscessed tooth extracted. However, he could not see his own dentist because his Medicaid contracted dental office was closed to save PPE. Sometimes antibiotics and pain medication alone simply aren’t enough. We were able to secure a non-contracted dentist to provide his care.

5.    An elderly woman living alone and was afraid to step outside her home for a walk or to schedule her mammogram.  She had anxiety and was panicking due to the daily media headlines -assigning a number to every new COVID case and death. 

6.    A patient with a nephrostomy tube and a 2 cm kidney stone remains in pain because elective lithotripsy is not available.

7.    A woman with moderate dementia, new to her memory care facility, whose behavior changed from a happy demeanor to violent requiring increased sedative medication after social isolation requirements separated her from her daughter.

8.    A son providing care to his 95-year-old mother, who has recurrent urinary tract infections, reports that she is ill with temperature over 103. They are afraid to access the health care system due to COVID-19 fears.

9.    In the last month, our local hospital lost 9 million dollars and had to furlough the equivalent of 350 employees.  These job losses resulted from current restrictions on elective procedures and from patient fears of entering the hospital or visiting outpatient diagnostic sites.

 

I am trying to provide a sense of increased morbidity not related to COVID-19 but related to the executive orders and “shelter in place” policy, which was intended to flatten the curve and to avoid overwhelming hospitals. This policy was reasonable especially in New York City where they have closed nearly 20 hospitals due to underfunding over the last decade. However, Oregon is not New York and Roseburg is not Seattle. Most physicians understood that these social distancing measures would not eliminate COVID-19 in our population but would only reduce the rate of spread of this disease. 

 

The opinions and recommendations of Dr. Anthony Fauci deserve respect but there have been other valid opinions and approaches to this pandemic. I refer readers to the link below to an opinion piece from Dr. John Ioannidis, professor of medicine, of epidemiology, of population health, and biomedical data science, and of statistics at Stanford University. https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/. The article appeared in “Stat” on March 17th. He identified many of the unintended consequences of the current policy implemented to control the pandemic.

 

The data gap remains a problem today. Current models used to project future peak disease activity and mortality rates have not been accurate.  The daily headlines reporting confirmed COVID cases represent increased testing capability but the reports do not speak to the actual prevalence of the disease in our population.  The widely publicized WHO and CDC mortality rates are based upon extrapolated numbers from biased testing protocols that adversely select for the most ill individuals with SARS-CoV-2.   Even determining the cause of death in this pandemic has proved challenging. We are not differentiating between those that die with and those that die from SARS-CoV-2.  Going forward, antibody testing will provide better information in regard to the true prevalence and mortality rates. 

 

I am not questioning whether measures taken to date have been well-intended and worthwhile. Public authorities and Governors must consider medical, economic and social risks in real time. There are no risk-free choices.  Unfortunately, we will never have enough epidemiologic data or a golden process that will result in “zero” COVID-19 deaths by June as proposed by some officials. Remaining sheltered in place while waiting for a vaccine is not a viable option and doing so, would devastate the economy, health systems, families and the health of citizens. The Oregon tax base would be even more severely compromised. My hope is that future alternative approaches will not be suppressed, dismissed or deemed dangerous by those who are seeking to project virtue.  Those who propagate fear without sufficient data need to take a backseat to those who are seeking real solutions to this complex problem. 

 

Physicians have the duty to question policy when other aspects of patient health have been adversely impacted.  The demographic most at risk with COVID-19 is not the same as the pandemics of 1918 or 2009.  I recall multiple patients under the age of 30 on ventilators in our local ICU in the 2009 H1N1 influenza pandemic and we did not take the types of public health measures then that we are taking now. Yes, there may have been some latent community immunity and a relatively ineffective flu vaccine in 2009 but there were also discussions about using APACHE scoring systems to ration ventilators. Fortunately, the unthinkable did not occur. We have much better intensive care capacity now.

 

Death and human suffering have occurred and will continue to occur as a result of the unintended consequences of current isolation measures and restriction of hospital services.  The extreme measures to close schools, businesses, parks, and enforce social distancing were a cost that most were willing to accept in the short term. The pause allowed time for the development of local systems and resources to meet our community’s needs. Douglas County has risen to meet the challenge. In my view, it is time to change our approach in a targeted, rational way.

 

To this end, I have the following recommendations:  

 

1.    Allow hospitals and communities that have adequate capacity and systems in place to manage a COVID surge to resume normal operations – including elective procedures while continuing stringent and practical measures to prevent virus spread.  This action would serve to maintain hospital system solvency and reemploy critical health workers who were furloughed due to the current circumstances.  We have been fortunate that hospitals have not been overwhelmed by patient volumes.  However, at this time, these policies are restricting access to essential medical care, causing harm and benefitting no one.

2.    Reopen all businesses, parks and recreational opportunities in areas where the hospital(s) and the community have the ability to address capacity issues during a COVID surge.  This move would soften the already devastating blow to our Oregon economy and reduce the level of unnecessary public anxiety.

3.    Reopen schools and colleges to reduce achievement gaps and develop additional herd immunity among the young and healthy. This step may ultimately protect others who are elderly and with chronic conditions as they choose to resume their normal activity. 

4.    Continually monitor the impact of relaxing these isolation measures with active testing and ensure that adequate healthcare capacity remains as the virus activity vacillates – indefinitely.

 

My plea is that our political leaders and policymakers also seriously consider the importance of other health, economic and social issues. We can continue to be vigilant and fine tune our approach as needed.  In Douglas County, it is now time to begin relaxing hospital restrictions and extreme public isolation measures.  It is time to acknowledge the unintentional harm of our current policies. Going forward, I am confident that independent Oregonians will be able to make informed choices based upon their own risk tolerance and hopefully, better data.   

 

John Powell MD

 

4/18/20

 

Please consider viewing the short YouTube video link from Dr. Iannidis.  Although the data is a bit dated, his concern remains valid.

 

https://www.youtube.com/watch?v=QUvWaxuurzQ

4/6/2020

COVID-19 by the Numbers as of 4/6/2020

The last time I posted on March 23, 2020, there was 1 documented case of COVID-19 in Douglas County.  I indicated that there would be many more cases because we were just beginning to test for the disease. I also suggested that COVID-19 mortality rates were likely overstated by the CDC and World Health Organization because there was very little testing of those with limited or no symptoms and the majority of testing was performed on the most ill and those who required hospitalization. We did not know the prevalence of the disease in general population and there was clear adverse selection bias in the testing process.  These problems remain. I also mentioned at the time that antibody testing would be a better measure of immunity in a community.  These tests are coming but not as fast as I had hoped.

So, where are we now in regard to known COVID-19 statistics as of 4/6/2020?

Globally:            1,345,048 confirmed positives and 74,565 deaths.

United States:     366,614 confirmed positive and    10,783 deaths

Douglas County:            12 confirmed positive and    zero deaths

Notice that I did not attach a mortality rate to the numbers above.  Why? It is not a difficult calculation.  The number of deaths is divided by the number who had the disease. The problem is that we do not know how many people really have or have had the disease. We only know how many have tested positive. With the numbers above, the global mortality rate is 5.5% and U.S. mortality is 2.9%.  These mortality rates are not accurate values in my view.

I have found the South Korean data the most helpful since they tested people early and often. You can review the data yourself at https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030.

As of today, South Korea have tested over 466,000 people. The calculated mortality rate for those under the age of 60 is 0.2% (16 deaths divided by 7,839 confirmed positives). Unfortunately, those over the age of 80 had a mortality rate of approximately 19%, this is tragic number but not unexpected.  In the United States, mortality rates for those over age 80 from viral pneumonia has been documented to be between approximately 15-20% and for this elderly population with pneumococcal pneumonia and bacteria in the blood, the mortality rate has been measured to be 37% in a 20-year study published in 2019. It is important to remember that the average life expectancy of a U.S. citizen is 78.6 years.

From 2018 U.S. CDC data, I found the following:

7,708 people, on average, died daily in the United States

 2,813,503 U.S. deaths in a year.

55,672 died of pneumonia and another 160,201 died of exacerbations of chronic lung disease.

47,173 died from suicide

169,936 died in accidents

The New York situation is unfortunate.  According to a Wall Street Journal Article, New York City closed nearly 20 hospitals over the course of the last decade.  They have had significant capacity issues prior to the pandemic.  It really isn’t a surprise that they are struggling now.   I am confident that they will meet the challenge.  Oregon has loaned over 140 ventilators to New York and Washington State has given 400 ventilators back to Federal government to distribute as needed. Perhaps, these states do not need them? The people in New York seem to be very motivated to do the right thing to slow the spread of the disease and medical professionals will navigate the crisis. I realize that the worse is predicted to come over the next several weeks.  We shall see.

In early March, Evergreen had 34 patients on our inpatient hospital census.  Today, I have 10 patients in the hospital.  We have one elderly inpatient with COVID-19 who is improving due to great efforts from the patient and those that I have the privilege to work with as colleagues. In my opinion, there are many people who have or have had COVID-19 that are not counted in the daily statistics.  This is not cause for alarm, it means the mortality rate is lower and we are hopefully developing some herd immunity.  Evergreen is actively seeking out testing opportunities that evaluate our community’s immune response to this virus.  We will let you know when that occurs.  In the meantime, we are still targeting our limited available PCR testing for whom the results will impact care plans.

Why am I telling you all this?  I hope to restore some perspective and hope. The pandemic has challenged us and changed routines in so many ways, but we will cope.  Do not allow the alarm bells, statistical distortions and sensationalism to wear you down. Enjoy this time with your family and take the opportunity to reacquaint your teenager to the lawn mower and the weeds.   They need the exercise and their eyes need to get adjusted to the sunlight as opposed to the light of the LED screen for a change.

Continue to use reasonable precautions as recommended by our public health partners. It is especially relevant if you are older or have significant chronic medical issues such as asthma, chronic obstructive lung disease or an immunosuppressed condition. I know there is a lot of stress in our community as it relates to the economic consequences to this pandemic. Don’t suffer alone, reach out for help if you need it.

 I am so proud of the kindness and generosity of our community.  Evergreen has benefited from the generosity of individuals who made or donated masks and local companies who donated N95 masks for our providers (Lone Rock Resources, Western Equipment & supply and many others). I have witnessed people show gratitude to grocery store clerks, health care personnel and other employees of businesses who are fortunate to remain open.  Thank you, Douglas County for setting the bar so high. 

We hope the next steps will be to get a better idea of the prevalence of this disease locally, deescalate the quarantine in a rational fashion, and get people back to their normal routines soon. 

 

John Powell M.D.

 

 

 

3/22/20

Evergreen’s Response the COVID-19 Pandemic

As of today, there has still been only one documented case of COVID-19 in Douglas County but I believe there will be more identified as we actually test for this disease. The one identified in the press does not work for Evergreen Family Medicine. But if they did, we would openly support that person since a pandemic is not the fault of any individual. Additionally, health professionals and staff at Evergreen who are ill for any reason are asked to remain at home and not risk exposure to our patients or community. 

I am grateful of Evergreen Family Medicine’s team of professionals and staff who have acted in innovative ways to serve our community.  Below are some of the positive steps that Evergreen have taken to meet the challenge:

  1. We continue to be an important access point for health care in our community.

  2. We are offering car waiting and triage to isolate ill patients from our waiting rooms.

  3. Masks are being placed on ill patients outside the clinic setting before entering the building to receive more care. 

  4. Designated spaces within our clinic are being used to evaluate patients with respiratory complaints.

  5. We are sending Evergreen personnel to nursing homes and assisted living facilities, as those entities are on lock down and we want to reduce exposure to this vulnerable population.

  6. We have increased physician staffing for hospitalized patients.

  7. We are initiating tele medicine visits to see patients in their homes.

  8. Evergreen is using personal protection equipment judiciously but appropriately.

  9. Evergreen members have volunteered in so many ways in our community – including staffing the public health hotline.

  10. Our staff has recently handled over 4,000 Evergreen calls/day to address questions and concerns of our patient community.

  11. The above measures have reduced the demand on important hospital emergency resources.

English philosopher, Francis Bacon wrote in the 16th century of his observation that persons with fortitude will not be shaken by adverse changes in their circumstances whereas a person who is fearful will suffer much. I recognize there are a lot of people selling fear right now.  It is not helpful.

There will be a marked increase in the number of COVID-19 cases identified going forward because we are just now rolling out more testing capacity.  This does not necessarily mean we have a nation-wide spike in cases of COVID-19.  It likely means that we are just better at identifying the disease.  The virus has already spread across the United States.   Hopefully, in the coming weeks, we will have an antibody test to better gauge the true denominator of this disease- including those who experienced no or minimal symptoms.  If that is the case, we will likely understand publicly that the mortality and morbidity rates are overstated by the World Health Organization and CDC. It is understood that there has been an adverse selection bias in our previous CDC testing process.  I hope that antibody testing will also provide reassurance to those who have immunity and we can deescalate our quarantine efforts soon.

In the meantime, it is important to keep our most vulnerable safe and use reasonable precautions to reduce the spread of disease.  Evergreen will remain a community partner to help weather this storm.  At this time, I would urge everyone to support our local businesses and temporarily unemployed persons as they are impacted by the significant but hopefully brief, disruptions to our economy.

Sincerely,

John Powell M.D.

 

3/20/20                         


A message About the Pandemic to Evergreen Family Medicine Personnel

"Nothing is so much to be feared as fear.”

A journal entry by Henry David Thoreau on September 7, 1851.

The sentiment was shared nearly 300 years prior by Francis Bacon, an English philosopher, who wrote of his observation that persons with fortitude will not be shaken by adverse changes in their circumstances whereas a person who is fearful will suffer much.

Speaking only for myself but as a physician, I am concerned that the U.S. public health, political and legal response has been less than ideal during the COVID-19 pandemic -spreading fear without real solutions. There has been inconsistent messaging followed by unexecuted promises.  The media have amplified misinformation and propagated fear.

These entities have used incomplete World Health Organization and CDC data with obvious selection bias and extrapolated false assumptions to the U.S. population.  This narrow perspective in turn has become the foundation to drive U.S. public policy.  Each official seems to be trying to out-do another without a basic understanding of data analysis or health system needs.  Yes, the goal to “flatten the curve” to avoid over burdening our hospitals is a laudable goal.  But at what cost and is there another way?

I remember the H1N1 swine flu pandemic in 2009.  At that time, we had teenagers and 20 somethings on ventilators in the intensive care unit.  However, we had enough ventilators and we did not shut down the economy, schools or require mass quarantine.  Yes, we did have a flu vaccine that was approximately 30% effective that year and perhaps there may have been some latent immunity that impacted public health decision making. However, I do not accept the mortality rates estimated by the World Health Organization to date.  They have provided all age mortality rates between 2 to 4% and mortality rates approaching 15% for those over the age of 80.  These are pretty intimidating numbers – if they were accurate.  The problem is that the testing is largely confined to those being hospitalized with the most severe illness.  We do not know the actual denominator and we know that COVID-19, in many people, especially the young is asymptomatic or minimally symptomatic. So, when it was clear that we had incomplete information, I looked for better data and found it in South Korea.  They tested early and often. I refer you to the website that is updated daily: https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030

As of 3/20/20, South Korea has tested 316,664 people for COVID-19 (as compared to 49,681 in the U.S) and they had 8,652 positive cases with an overall mortality rate of 1%. Under the age of 30, they have 2,914 positive and zero deaths. Under age 50, they cite exactly 5000 positives with 2 deaths. This relates to a mortality rate less than 0.2%.

What about the older population?  South Korea has documented 329 COVID-19 cases in people above the age of 80 and 33 have died.  This corresponds to a mortality rate of 10%.  This is unfortunate and definitely a concern but not really unexpected.  After all, the mortality rate now in the U.S. for viral pneumonia (including the flu) is approximately 20% for those over the age of 80.

Moving forward we need to think clearly and rationally.  We need to kick politics and legal posturing to the curb. South Korea did not shut down their economy and they have been criticized for not shutting down their borders.  However, they definitely got out in front in regards to testing their population and took reasonable public health measures to limit the spread.

In the coming days and weeks, as U.S. COVID 19 testing becomes more available, the number of cases will be publicized loudly, creating a fever pitch of hysteria and anxiety.  Do not buy in to it.  I hope that we will eventually come to understand that this virus was already out of the bag in the U.S. and that preventing the spread to some degree was futile.  COVID 19 testing will be of limited value to those who are hospitalized and for those who need to care for our most vulnerable.  Perhaps someday, we will get serum antibody testing to get a better estimate of the United States’ true denominator for this disease.  For now, rational containment and focusing our resources on emergency and hospital capacity should be our focus. 

What does this mean for you?

  1. Keep a proper perspective and don’t buy into the fear.

  2. Do the same things you would do to protect yourself from the flu in an unvaccinated state.

  3. Protect the most vulnerable – the elderly, immunocompromised and those with chronic respiratory conditions.

  4. Use PPE as appropriate.

What is my hope?

  1. We stop spreading fear.  We propagate meaningful information to the public.

  2.  We execute on promises of adequate supplies and testing.

  3. We increase hospital capacity by discharging patients from the hospital that do not need to be there. Hospital capacity could be increased by creating stepdown units in hotels or other facilities that are staffed by generously paid caregivers. Many patients are waiting discharge from the hospital for social reasons.

  4. For those who are at low risk for complications, we send them back to school and get back to our normal routines as soon as possible. (weeks not months).  This reduces the risk of an economic catastrophe which also carries health risks.

  5. We protect those at high risk such as those in assisted living and nursing homes with a rational quarantine protocol.

This is doable.  I am proud to be associated with such a fine group of professionals and staff. Thank you for your service to Douglas County.  You will continue to make a difference.

 

John Powell M.D.