COVID-19 Update December 18, 2020

Updates on the Novel Coronavirus (aka COVID-19): What You Need to Know

Information about the spread and about the safety concerns of the novel coronavirus (aka "SARS-Cov-2"), and the disease it causes, COVID-19, is evolving on an daily basis. It is also clear that politics has played a major role in the information that has been distributed and the recommendations made. So I wanted to try to bring you unbiased, non-political information about the of the virus in our community and in general. I will include some details on this topic from previous newsletters, as they remains important - new information will be in BOLD.

Vaccines are here! In the last week, people have started receiving the Pfizer/ BioNTech COVID-19 vaccine. And while the number of COVID-19 cases are still sky-rocketing and there are lots of challenges in getting the new vaccines to everyone, I finally feel like there is an end in sight....an end to social isolation, mask wearing, and an end to this newsletter :)

Alas, we are not there yet, so please continue to do the right (and hard) thing to stay safe!

General Information:

• As treatments have been improving, the mortality associated with COVID-19 has been steadily decreasing over the last few months. An article from the Journal of Hospital Medicine found a death rate of hospitalized patients of 25.6% from COVID-19 in New York in March. In August, the death rate had declined to 7.6%.

• COVID-19 has had negative health impacts on many people who don't contract the virus: 40% of U.S. adults surveyed in late June reported at least one or behavioral health problem associated with the pandemic.

• There has been a significant increase of Emergency Department visits of kids and teens for reasons with the pandemic - increases of 24-37%.

Transmission:

• The incubation period can be 14 days (or more), though most people develop symptoms within 5-10 days.

• The CDC has reduced the duration of isolation of a person infected with SARS-Cov-2: the CDC decreased the isolation period to 5 days after onset of symptoms.

• For people who have been exposed to the virus, the CDC has shortened the minimum amount of time they need to quarantine as well. The quarantine can end 7 days after exposure if such people have no symptoms and have had a negative COVID-19 test (done 5 days after exposure). Without the test, the quarantine can end at 10 days.

• People with a severely compromised immune system (like those receiving chemotherapy for cancers) may actually continue to shed the coronavirus for 2 months or longer after getting infected (New England Journal of Medicine). The current isolation precautions may therefore need to be adjusted for such people.

• Transmission occurs predominantly via respiratory droplets. Transmission is more likely the longer you are close to an infected person, the closer you are, and the worse the air ventilation is. Transmission via touch (touching a surface with the virus on it and then touching your nose, eyes, and mouth) is quite unusual.

• A recent review of studies shows that less than 10% of the spread of the novel coronavirus occurred outdoors (though it is possible!) and that we are 19-times more likely to contract the virus indoors vs. outdoors.

• A recent study (Nature Communications) again showed that men tolerate COVID-19 worse than women: men and women are equally likely to get infected with the virus, but men are about 3-times as likely to end up in the ICU and 40% more likely to die.

• We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them

• The American Academy of Pediatrics just issued a new guidance recommending face masks for kids participating in most youth sports. They should be worn during training, competition, as well as on the sidelines. Luckily, these recommendations don't apply to swimming and diving (too hard to breathe through a wet mask!), to gymnastics and cheerleading (masks could get caught or obstruct vision), or wrestling (choking hazard).

Symptoms and Risk Factors:

• People with COVID-19 usually develop achy muscles and a fever, as well as shortness of breath. A small number are also nauseated and have diarrhea. Loss of taste and smell is common. Severe cases usually involve a pneumonia that may lead to hospitalization and the use of a ventilator to allow the lungs to adequately transfer oxygen into the blood.

• Although COVID-19 is associated with a wide array of symptoms, 96% of infected people have either fever, cough, or shortness of breath. About 45% of infected people have all three of these symptoms.

• Most children who get infected do not exhibit any symptoms. However, a small percentage who end up in the hospital have symptoms of "vasculitis," which is an inflammation of the blood vessels. This syndrome, called "pediatric multisystem inflammatory syndrome (MIS-C)" is still rare, but can be very serious.

• An increasing number of COVID-19 patients seem to have long-standing sequelae of their infection:

• A study out of Michigan looked at patients who had been hospitalized for COVID-19 and recovered: two months after discharge, one third of people still had ongoing health issues such as a cough, loss of taste and smell, or shortness of breath.

Incidence/ Prevalence:

• To the best of our knowledge, only a handful of people world-wide have become re-infected with SARS-Cov-2, a tiny number given the prevalence of the disease. This is great news!

• An article published in the journal Clinical Infectious Diseases looked at blood donations collected by the Red Cross between December 13, 2019 and January 17, 2020: 106 of the 7,389 samples studied showed antibodies to SARS-Cov-2. This strongly suggests that people were getting infected with COVID-19 as early as December, a month before the first person known to have been infected with coronavirus arrived in the U.S. from China on January 15.

• At this time, about 33% of Americans live in an area where there is a critical shortage of ICU beds.

• Across the U.S., hospitals are teeming with with record number of COVID-19 patients. New cases nationwide totaled 244,365, a record. California, Maine, and Tennessee each reported single day highs. Wednesday was the worst day in the U.S. since onset of the pandemic, with 3,607 people dying. In California, the San Joaquin Valley and Los Angeles County are particularly badly hit. In L.A. County, 2 people are dying per hour.

• Some statistics:

  • San Mateo:

    • number of cases: 19,645 (15,040 two weeks ago)

    • number of deaths: 183 (170 two weeks ago)

    • number of people in the hospital: 120 (80 two weeks ago). Peninsula Hospital is not at capacity.

  • California:

    • number of cases: 1.76 Million (1.29 Million two weeks ago)

    • number of deaths: 22,150 (19,586 two weeks ago)

  • U.S.:

    • number of cases: 17.3 Million (14.2 Million two weeks ago)

    • number of deaths: 311,000 (276,000 two weeks ago)

  • World:

    • number of cases 75.1 Million (65.4 Million 2 weeks ago)

    • number of deaths: 1.67 Million (1.34 Million 2 weeks ago)

• Due to this shortage of hospital staff and space, Medicare is now allowing hospitals to care for patients in their own homes. Such programs will offer around-the-clock electronic monitoring for Medicare patients who are sick enough to be hospitalized but don't need to be in an ICU.

• The CDC announced this week that Black, Hispanic, and Native American people with COVID-19 are four times more likely to require hospitalization compared to others.

• I saw a scary summary of "excess deaths" in 2020: these "excess deaths" are calculated in comparing 2020 to previous years. I suspect many of these excess deaths are attributable to people not seeing doctors regularly or going to the emergency room for fear of contracting COVID-19

  • Diabetes: 15% above normal

  • Alzheimer's: 12% above normal

  • High blood pressure: 11% above normal

  • Pneumonia and flu:11% above normal

  • Heart disease: 6% above normal

Testing

• The FDA has authorized a new test that checks for both influenza and COVID-19. This test is saliva-based and can be collected at home. Once fully available, the test will be run through Quest labs and will provide results within 2-3 days. It still requires a doctor's prescription.

• The FDA also authorized LabCorp's Pixel COVID-19 home collection kit. This kit allows patients to self-collect a nasal swab at home and then send it for testing to LabCorp. This kit can be purchased online or in a store without a prescription.

• On 12/15/2020, the FDA authorized the first fully at-home COVID-19 antigen test. This test ("the Ellume COVID-19 home test" provides results in 20 minutes and can be purchased without a prescription. For those people with symptoms, the test accurately identifies 96% of positive cases and 100% of negative cases. For people without symptoms, the test identifies 91% of positive cases and 96% of negative ones. Results take 20 minutes to show up.

Treatment

• On October 22, the FDA approved remdesivir as a treatment for COVID-19 and therefore took it out of the "experimental/ emergency use" category. It is the only medication COVID-19 treatment in the United States.

• On 11/19/2020, the FDA granted emergency use authorization of the combination of remdesivir and the monoclonal antibody baricitinib. Recent studies suggest that adding the baricitinib to remdesivir will speed up recovery by one day.

• Vaccines:

  • The CDC Advisory Committee on Immunization Practices recommended on December 1 that health care personnel and residents of long-term care facilities should be the first to receive the upcoming vaccines (phase 1a). Phase 2 will likely include people with significant illness, "essential workers" who can't telework, teachers/ school staff, older adults, people in homeless shelters. Individual states will have the final say on allocation of vaccines and will tailor recommendations to the needs of their populations.

    Pfizer/ BioNTech:

    • On December 13, the CDC officially recommended use of the Pfizer/ BioNTech COVID-19 vaccine for those aged 16 years and above. This recommendation is based on a randomized trial of 43,000 people who were followed for about 2 months. The Pfizer vaccine was not tested on pregnant women or people who are immunocompromised. This does NOT mean that these groups of people can't get the vaccine, but that the CDC plans on offering special considerations down the line. There is no reason to believe that the vaccine would be less safe in people with immune problems. However, the vaccine may not be as effective in them. We will need to await further studies about vaccine efficacy for such people in the future

    • Specifically, the American College of Obstetricians and Gynecologists recommended that the Pfizer vaccine should NOT be withheld from pregnant or lactating women.

    • The Pfizer vaccine was given to the first patients on 12/14/2020 and has been given to people in San Mateo this week also.

    • Studies suggest that the Pfizer vaccines "starts working" within 10-14 days after the first dose. It seems effective across age groups, race/ ethnic groups, as well as in obese and non-obese patients.

    • There have been two instances in Britain and one within the United States in which people who had received the Pfizer vaccine subsequently developed a severe allergic reaction. It is unclear how common such an allergy in general, though I suspect that we all will know more about that soon. All of the allergic reactions occurred within minutes of receiving the vaccine. For now, it is recommended that people with a history of anaphylaxis (when the circulation shuts down and people have problem breathing) be observed for 30 minutes after receiving their vaccines. People who have a history of bad allergic reactions (but not anaphylaxis) should be observed for 15 minutes. All others should be observed for 10 minutes. Also, no other vaccines should be given within 2 weeks of receiving the Pfizer/ BioNTech vaccine.

    • California's Western States Scientific Safety Review Workgroup has reviewed the data on the Pfizer vaccine and found it to be safe and efficacious in a statement from December 13. This advisory group is made up of "nationally acclaimed scientists with expertise in immunization and public health" from Oregon, Washington, Nevada, and California

• Moderna:

  • An FDA advisory panel voted yesterday (12/17/2020) that the FDA issue emergency use authorization for the Moderna vaccine for people 18 and older; The actual authorization is expected today, 12/18/2020.

  • This vaccine showed 96% efficacy in people aged 18 to 64 and 86% efficacy in people older than 65. However, in all age groups the vaccine was 100% effective in preventing severe disease.

  • Moderna's vaccine does not have the deep-freeze requirement of the Pfizer vaccine.

  • Moderna will start testing its vaccine in adolescents soon.

  • Like with the Pfizer vaccine, people can get muscle aches and a fever after the vaccines. These side effects are more common after the second dose and usually last one day.

• Though the Pfizer and Moderna vaccines seem to be very good at preventing severe disease, it is not yet clear if they keep people from getting infected at all. The latter is an important question, as infected, asymptomatic people can still transmit the virus and make others sick. So we have to wait and see to find out if people who have been vaccinated can still make others sick...and we have to continue to wear masks to prevent virus transmission, even if we have been vaccinated.

• The Oxford/ AstraZenica vaccine:

  • This vaccine does not yet have emergency use authorization.

  • Preliminary results suggest that this vaccine is quite effective in preventing the symptoms of COVID-19 and is effective in young and old alike. However, older adults are less likely to have side effects.

• The Russian "Sputnik V" vaccine:

  • Russian developers published new trial results for this vaccine on December 14 and reported that it was 91.4% effective. At this time, more than 200,000 people have already been vaccinated with this vaccine as part of a mass vaccination drive in Russia.

• The United Arab Emirates issued the first government approval of a Chinese coronavirus vaccine on 12/9/2020, citing preliminary data that suggested an 86% effectiveness. Details on the data have not been released, however, so the effectiveness has not been verified by outside sources.

• HHS Secretary Alex Azar has announced that the government has come to an agreement with various large pharmacy chains (Costco, CVS, Kroger, Walgreens, and Walmart) to help distribute the coronavirus vaccine, once it becomes available. There will be no cost associated for the public.

• On 12/6/2020, the federal government downgraded the number of COVID-19 vaccines that will be available until the end of 2020: now only 40 million doses (down from 300 million doses) will likely be forthcoming this month.

• Antibody therapy:

  • The FDA has issued an emergency use authorization for the monoclonal antibody "bamlanivimab" produced by Eli Lilly. This treatment is indicated for people with mild to moderate COVID-19 not sick enough to be in the hospital or to require supplemental oxygen. On November 18, the NIH noted that there was insufficient information to recommend for or against this medication for people with mild to moderate disease.

  • In late November, the FDA granted emergency use authorization for two more monoclonal antibodies (casirivimab and imdevimab) that need to be administered together intravenously for the outpatient treatment of mild to moderate COVID-19. These too are recommended only for "high risk" individuals. This is the medication cocktail made by Regeneron.

Mills-Peninsula Hospital:

• Peninsula Hospital continues not to be full and is managing its share of COVID-19 cases as well as could be hoped for. ICU and acute care beds are still available and the surge capacity beds have not been activated yet. All the treatment modalities we discussed above are available here.

• Ryan Stice, who oversees pharmacy services at Sutter Health, has been preparing for the cooling requirements for the Pfizer COVID-19 vaccine (minus 94 degrees Fahrenheit!!) since the summer.

Our Community and Beyond:

• California Governor Newsom announced the launch of a new COVID-19 exposure notification system, known as "CA Notify." The system was developed by Google and Apple and relies on an app that can be downloaded by all Californians starting December 10. The system is entirely voluntary and will alert users to potential exposures without storing or transmitting any data involving a person's identity or location. All the user has to do is to keep the Bluetooth on and they will receive an alert if they were in close contact with someone who tested positive for COVID-19.

• On December 14, Gov. Newsom announced that California had received 33,000 doses of the Pfizer vaccine. The rest of the state's allotment of 393,000 doses will hopefully arrive within days. Unfortunately, there are 2.4 million health care workers and many more nursing home residents, that are in the first tier to receive the vaccine. By the end of December, California should have gotten 2.1 million doses, however.

• San Mateo is scheduled to receive 6,000 doses of vaccine next week. Health care workers as well as nursing home residents are supposed to receive the vaccine first. However, there are over 24,000 health care workers in San Mateo County, so many doctors, nurses, and therapists will have to wait for future shipments to become vaccinated.

• As of midnight on 12/17/2020, San Mateo has joined the rest of the Bay Area counties in a mandatory "Regional Stay At Home Order." The order is a result of the Bay Area now having less than 15% of ICU beds available. The order prohibits gatherings of any size (except for outdoor church services and political demonstrations). Restaurants can only provide take-out and delivery services. Many businesses, including salons and barbershops, must close. Retail is held to 20% capacity. The new order will stay in place for at least 3 weeks.

• San Mateo is still offering free PCR testing for COVID-19:

  • Scheduled testing occurs at the San Mateo County Event Center. Testing here can be scheduled Tuesdays through Saturdays from 8 am to 3 pm - all without a cost to the patients. Appointments are required and can be made at "projectbaseline.com/COVID19"

Our Office: What We Are Doing to Keep You Safe:

• All patients seen in person will be screened for COVID-19 exposure and symptoms prior to coming into the building.

• We disinfect all exam rooms and medical equipment as well as all door handles after EVERY patient visit, regardless of the medical issues involved.

• We are also using tele-health options that allow you to have video as well as audio interactions with us as part of a "remote office visit." With the recent surge of cases, we are postponing most routine physical exams and minimizing most in-person visits. Patients who require physical evaluations to diagnose and treat their medical issues will always be seen in person.

• For those patients seen in the office, we ask that friends and family members stay in the car (or elsewhere outside the office) during the visit. Of course we do welcome caregivers into the office with the patient if they are needed for improved safety or communication.

• All of us in the office are healthy and doing well.

• We have still are giving "regular" flu shots (i.e. NOT those for seniors). So if you are under 65 and have not yet received your flu shot, call our office and come on in!

• In addition to the "regular" Covid-19 testing that we have had all along (nasal swab, PCR-based test with approx. 24-48 hour turn around) our office also has two other COVID-19 testing options available:

• A saliva based PCR-test that can be done in a patient's home. It is then sent via Fed-Ex to a lab and usually gives results in 36 hours. This test is usually covered by insurances and is 100% sensitive and 100% specific. It is accepted as evidence of immunity for most travel (not including travel to Hawaii, which does not accept this test).

• A rapid 10-minute test that is based on a nasal swab and performed in our office. This test is 85% sensitive and 100% specific. This test is perfect for people without symptoms or prolonged exposure to a COVID-10 patient who "just want to make sure" they are ok. This test is not covered by insurance and costs patients $30/ test.

• Many patients have asked me when our office will receive our "allotment" of COVID-19 vaccines. Truth be told: I have no idea. No one has contacted me about this and I rather suspect that we won't receive any COVID-19 vaccines for distribution. The logistics of getting so many people vaccinated - but at different times based on their risk tier- is herculean. I suspect most of the vaccines will be given via hospitals, pharmacies, and County Health offices. I will let you know once I know more and point out where you can get your vaccines and when.

We will try to keep you updated as the epidemic evolves. Feel free to call or email with questions or concerns.

About Dr. Sujansky's Life in These Times

On a more personal note, my family and I continue to do well.

My oldest son, Stefan (20) is back in the U.S. and in our home. He arrived on Monday and is trying to adjust back to life in the U.S. along with the creature comforts that are afforded here. Believe me, I have been trying to spoil him rotten with said creature comforts all week! It is good to have him back.

Every year, my two college roommates and I meet in December and spend a day baking Christmas cookies together. At the end of the day, we have caught up on everyone's lives and have plenty of cookies for our own families as well as enough to distribute to a small city. Well, this year's pandemic threw a monkey wrench in our plans, of course. Instead of baking together, we each made several batches of cookies at home and then met in a Target parking lot to exchange the cookie tins. Then we met over Zoom an hour later for our taste testing. It was not like "old times," for sure, but it was pretty darn good...and we still have enough cookies to share with most of San Mateo. :)

Some of you have mentioned that you send my newsletter to friends and family. I could not be more flattered. Please also note that I put each week's newsletter under the "blog" section of my website (www.SujanskyMD.com) in case you want to share the newsletter that way or look at previous editions. Also, anyone can just google "Dr. Sujansky" and "blog" and it should come up.

We still have the 20% discount on Obagi skin products through the rest of December. Check out the "Holiday Hydrate Special" which includes the hydrate luxe, retinol, travel sizes of foaming gel and toner, as well as travel size facial elastiderm and hand sanitizer).

Finally, I think this is my last newsletter for the year. I want to wish each of you Happy Hanukah, Merry Christmas, and a Happy New Year! 2020 has been challenging, for sure. Thank you for being there for me at every step along the way. I am so grateful for all of your encouraging words, interests in my personal life, and wishes for my wellbeing. I can't tell you how much you have touched me. I hope that part of the world does not change in 2021...though I am ready for other parts of the world to normalize in 2021!

Thank you.

COVID-19 Update December 4, 2020

Updates on the Novel Coronavirus (aka COVID-19): What You Need to Know

Information about the spread and about the safety concerns of the novel coronavirus (aka "SARS-Cov-2"), and the disease it causes, COVID-19, is evolving on an daily basis. It is also clear that politics has played a major role in the information that has been distributed and the recommendations made. So I wanted to try to bring you unbiased, non-political information about the of the virus in our community and in general. I will include some details on this topic from previous newsletters, as they remains important - new information will be in BOLD.

Excellent news about vaccine development continues. The FDA has scheduled a meeting of its "Vaccines and Related Biological Products Advisory Committee," a group of outside experts, for December 8 through 10. At the end of that meeting, it is hoped that an emergency use authorization for one or multiple vaccines could be declared.

The revised forecast for COVID-19 infections is, quite frankly, bleak. The CDC predicts a surge of infections and deaths from the disease in December. Yesterday, 3,100 people died in the U.S. of the disease - this is a much higher number than ever in the past. In the week of December 19, an estimated 1.1 to 2.5 million new cases and 10,600 to 21,400 deaths are predicted. The predictions for California don't look any better: without any changes in behavior, the number of Californians needing to be hospitalized due to the virus could double or triple in the next month, putting a strain on the health care system. I don't want to give such awful news, but I do want every one of you to please hunker down, stay indoors, don't socialize, and stay safe, please! Health care officials continue to implore Americans not to travel this holiday season.

I know all of these restrictions are stifling, especially after so many months. At this time, I would like to try to simplify things a bit (these ideas are based on the opinions of over 700 epidemiologists, not my own personal wisdom!):

• One behavior that should be ELIMINATED: spending time in a confined space with people that are not wearing a mask and not part of your household. This means:

  • no eating at a restaurant or at a friend's house

  • no close conversations with people not wearing a mask (even if you are outside)

  • if you fly, try not to eat or drink on the plane

  • don't have lunch in the breakroom with your colleagues

• MINIMIZE if you can't avoid altogether:

  • spending extended time in indoor spaces with people outside your household...even if everyone is wearing a mask

• LESS RISKY activities include:

  • walking, biking, or jogging outside, even if you don't wear a mask

  • running errands (as long as you wear a mask, try to stay away from others, and wash your hands when you get home)

General Information:

• Pandemics are not new to our civilization and each pandemic is unique. What makes SARS-Cov-2 different and more challenging is the high degree of infectiousness as well as transmission from people who have no symptoms at all or only mild symptoms.

• As treatments have been improving, the mortality associated with COVID-19 has been steadily decreasing over the last few months. An article from the Journal of Hospital Medicine found a death rate of hospitalized patients of 25.6% from COVID-19 in New York in March. In August, the death rate had declined to 7.6%.

• Another piece of good news came in a recent study in BioRxiv (which was NOT peer-reviewed): 185 people with past COVID-19 infection were studied and their memory B-cells (a type of white blood cell) analyzed. The result of the study suggested that an immune response to SARS-Cov-2 may last for many years. This would suggest that past infections as well as vaccinations will protect you for a long time indeed!

• COVID-19 has had negative health impacts on many people who don't contract the virus: 40% of U.S. adults surveyed in late June reported at least one or behavioral health problem associated with the pandemic.

• There has been a significant increase of Emergency Department visits of kids and teens for mental health reasons with the pandemic - increases of 24-37%.

Transmission:

• The incubation period can be 14 days (or more), though most people develop symptoms within 5-10 days.

• The CDC has reduced the duration of isolation of a person infected with SARS-Cov-2: previously, people were told to isolate for 10 days after onset of symptoms. However, since most of the viral shedding occurs 2 days before symptoms develop and end 5 days after, the CDC decreased the isolation period to 5 days after onset of symptoms.

• For people who have been exposed to the virus, the CDC has shortened the minimum amount of time they need to quarantine as well. The quarantine can end 7 days after exposure if such people have no symptoms and have had a negative COVID-19 test (done 5 days after exposure). Without the test, the quarantine can end at 10 days. Note that these new recommendations were made in hopes that people would be more compliant with the restrictions. For travelers, the CDC recommended that people be tested 1-3 days prior to travel and again 3-5 days after return. They should also limit non-essential activities for 7 days after travel, even if they test negative.

• People with a severely compromised immune system (like those receiving chemotherapy for cancers) may actually continue to shed the coronavirus for 2 months or longer after getting infected (New England Journal of Medicine). The current isolation precautions may therefore need to be adjusted for such people.

• Transmission occurs predominantly via respiratory droplets. Transmission is more likely the longer you are close to an infected person, the closer you are, and the worse the air ventilation is. Transmission via touch (touching a surface with the virus on it and then touching your nose, eyes, and mouth) is quite unusual.

• It is estimated that over 50% of people get infected with SARS-Cov-2 by patients who do not have any symptoms.

• As many of you will know, Europe has been in a lockdown patter for the last 5 weeks. The good news is that it is working and the number of cases is coming down. The other part of the good news is that many European schools had stayed open during the lockdown, suggesting that we can get control of the the virus even if schools stay open.

• A recent study found that SARS-Cov-2 can stay alive on human skin for up to 9 hours! So wash your hands frequently and use hand sanitizer often!

• We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them

• The CDC estimated that if the number of people who wear masks increased by 15%, we could prevent lockdowns and decrease economic losses by up to $1 trillion.

• Indeed, experts estimate that the pandemic could be eradicated if at least 70% of the population used surgical face masks consistently and correctly.

• One article published in MMWR looked at the example of Kansas: those counties with mask mandates saw a 6% decrease in COVID-19 cases , while those without mandates saw an 100% increase.

Symptoms and Risk Factors:

• People with COVID-19 usually develop achy muscles and a fever, as well as shortness of breath. A small number are also nauseated and have diarrhea. Loss of taste and smell is common. Severe cases usually involve a pneumonia that may lead to hospitalization and the use of a ventilator to allow the lungs to adequately transfer oxygen into the blood.

• About half the patients with COVID-19 have neurologic symptoms.

• In some patients with COVID-19, the "fundamental framework" of the lungs can be destroyed and people require a lung transplant.

• Most children who get infected do not exhibit any symptoms. However, a small percentage who end up in the hospital have symptoms of "vasculitis," which is an inflammation of the blood vessels. This syndrome, called "pediatric multisystem inflammatory syndrome (MIS-C)" is still rare, but can be very serious.

• JAMA Network Open reported on 11/19/2020 that many patients with COVID-19 - especially if they were older than 65 - presented with delirium (severe confusion). Indeed, more than 25% of older patients presented at the emergency department with delirium and 37% didn't have any of the more typical signs such as fever or shortness of breath.

• An increasing number of COVID-19 patients seem to have long-standing sequelae of their infection:

• A study out of Michigan looked at patients who had been hospitalized for COVID-19 and recovered: two months after discharge, one third of people still had ongoing health issues such as a cough, loss of taste and smell, or shortness of breath.

• The CDC announced in mid October that people who are overweight have an increased risk of severe illness with COVID-19. This means that 75% of the U.S. population is at heightened risk.

Incidence/ Prevalence:

• To the best of our knowledge, only a handful of people world-wide have become re-infected with SARS-Cov-2, a tiny number given the prevalence of the disease. This is great news!

• An article published in the journal Clinical Infectious Diseases looked at blood donations collected by the Red Cross between December 13, 2019 and January 17, 2020: 106 of the 7,389 samples studied showed antibodies to SARS-Cov-2. This strongly suggests that people were getting infected with COVID-19 as early as December, a month before the first person known to have been infected with coronavirus arrived in the U.S. from China on January 15.

• New calculations by the CDC suggest that the actual number of people infected with SARS-Cov-2 is eight times higher than we realize...in part because previous estimates relied on those that had laboratory-confirmed disease and didn't include those that were not ill enough to seek medical care.

• Even so, a recent study from Jama Internal Medicine suggests that, in most communities, less than 10% of the population has evidence of past SARS-COV-2 infections as of late September.

• Across the U.S., hospitals are teeming with with record number of COVID-19 patients. At this time, the U.S. has more hospitalizations due to the virus than ever before - 80,000 to over 91,000 per day in the last 2 weeks. Many states have insufficient number of beds. There is also an increasing number of shortages of doctors and nurses due to front line workers falling ill.

• The U.S. has more than 14 million cases at this time, distributed all across the country. The state with the most cases is Texas, with 1,267,486 cases. Sadly, California is #2 with 1,238,379 cases. The bronze medalist is Florida, while Illinois and New York come next.

• Due to this shortage of hospital staff and space, Medicare is now allowing hospitals to care for patients in their own homes. Such programs will offer around-the-clock electronic monitoring for Medicare patients who are sick enough to be hospitalized but don't need to be in an ICU.

• At this time, over 65.4 million people in the world have contracted the novel coronavirus. 1.51 million people have died worldwide (compared to 1.34 million two weeks ago).

• In the United States, more than 14.2 million people have now contracted SARS-Cov-2 (11.8 two weeks ago). The U.S. has the highest number of deaths in the world at 276,000 (236,000 two weeks ago)

• California is reporting that it now has more than 1.29 million people infected with SARS-Cov-2 (compared to 1.08 million two weeks ago). 19,586 people have died.

• As of December 3, 2020, there have been 15,040 people in San Mateo County who have tested positive with the SARS-CoV-2 virus (compared to 12,878 people two weeks ago). 170 people in San Mateo County have died from the disease (compared to 168 people two weeks ago). Currently, there are 80 people in the county who are in the hospital with the disease. Peninsula Hospital is NOT at capacity.

• Over 1 million children in the U.S. have now been diagnosed with COVID-19 - 11.5% of all cases.

• The CDC announced this week that Black, Hispanic, and Native American people with COVID-19 are four times more likely to require hospitalization compared to others.

• Another study came out on November 24 and looked again at the correlation between blood type and risk of developing COVID-19. You may recall that previous studies had flipped back and forth about the influence of blood type on disease. This study again confirmed that patients with the "O" and "Rh-" blood groups may be at slightly lower risk of infection and severe disease....but there is certainly not a large discrepancy of risk.

Testing

• On November 18, the FDA granted an emergency use authorization for the first rapid at-home test for COVID-19. This test is made by Lampira and uses a technology similar to the PCR tests available. This test can supply results within 30 minutes. Accuracy of positive and negative tests seems to be quite high (above 94%). The cost is projected to be about $50 and a doctor's prescription is still needed.

• See also the notes (below)about what testing options are available through out office.

Treatment

• On October 22, the FDA approved remdesivir as a treatment for COVID-19 and therefore took it out of the "experimental/ emergency use" category. It is the only medication COVID-19 treatment in the United States. At the same time, the WHO just recommended AGAINST using remdesivir for hospitalized patients, due to lack of evidence that the drug reduces risk of death or need for a ventilator....I know, it's confusing!

• On 11/19/2020, the FDA granted emergency use authorization of the combination of remdesivir and the monoclonal antibody baricitinib.

• A very small trial (published in Jama Network on November 12) included 152 adult outpatients infected with COVID-19. They were treated with fluvoxamine, an anti-depressant closely related to prozac. It seems that this medication not only affects the serotonin system, but can also have some anti-viral effects. At any rate, none of the patients treated with fluvoxamine got worse, while 6 patients (8.3%) of the placebo patients deteriorated. These are interesting results, though they need to be validated in larger trials.

• An inhaled medication that stimulates the immune system (interferon beta-1) helped hospitalized patients with COVID-19. Those patients who were given the inhaled medications were two to three times as likely to get better; The treatment group had a 79% lower risk of developing severe disease or dying. This was just a phase 2 trial, so phase 3 trials are still needed until such a treatment could be considered.

• Vaccine development is ongoing and very encouraging:

  • In a 31-1 vote, the CDC Advisory Committee on Immunization Practices recommended on December 1 that health care personnel and residents of long-term care facilities should be the first to receive the upcoming vaccines (phase 1a). Phase 2 will likely include people with significant illness, "essential workers" who can't telework, teachers/ school staff, older adults, people in homeless shelters. Individual states will have the final say on allocation of vaccines and will tailor recommendations to the needs of their populations.

  • California will receive its first batch of vaccines (263,600 doses) between December 12 and 15. This is far short of the 2.4 million of the most vulnerable Californians, so there will be priorities even within the "phase 1a" grouping.

  • You may have heard about the novel technology employed with the Moderna and Pfizer vaccines, the mRNA technology that is ground-breaking. I just wanted to take a minute to explain what all the hype is about: most prior vaccines were "protein-based." Such vaccines usually inject parts of a virus or an inactivated virus into the human body. The human body identifies these particulates as "foreign" and develops an immune response to this virus part. Then, when the body actually gets infected with the real virus, the immune system "armies" are already formed and can be deployed. The mRNA technology of Pfizer and Moderna approach the immune response very differently. Their vaccines inject the RNA (genetic material) of the spike protein of the SARS-Cov-2 virus into human beings. The viral mRNA then coaxes the human body to make the actual virus spike protein. This spike protein is then recognized as "foreign" and an immune response ensues. This process more closely resembles what happens in an actual infection. A bigger portion of the human immune system is mobilized (not just antibodies and CD4+helper cells, but also CD8+ cycotoxic T-cells - if you want to know the details!). Also, protein-based vaccines are sometimes less effective if there is a preexisting immune response present already. This problem does not occur with mRNA vaccines.

  • The Russian "Sputnik V" vaccine, which is in phase 3 trials, seems to be 92% effective with "no unexpected adverse events." Unfortunately, very little information has been made available to the public, so this success has been greeted with a dose of skepticism also. Russian president Putin announced this week that large scale administration of the vaccine to doctors and teachers will begin next week.

  • In November, the vaccine produced by Pfizer/ BioNTech was shown to be up to 95% effective. Also, both mild and severe disease seems to be prevented. Seniors as well as younger people respond well to the vaccine. There are some difficulties in administration of the vaccine, however: it has to be given in 2 doses, 3 weeks apart. More importantly, however, it has to be stored in -70 decrees C temperatures, which is much lower than most freezer can provide. So the logistics still need to be worked out... Pfizer has already filed for emergency use authorization and the FDA will meet on December 10 to come to a decision. Once approved by the FDA, doses of the vaccine will be ready "within hours" to ship and to be administered.

  • However, this last week Britain already authorized the Pfizer vaccine for use and distribution. Why, you ask, has Britain done this while the U.S. has not yet given their ok? The U.S. is actually more careful in their review process of medications and vaccines and carefully looks at the raw data to make sure all the results are as they should be. The United Kingdom, conversely, reviews the pharmaceutical companies conclusions and then comes to a decision. I understand all of our eagerness to get the vaccine to the population, but I am rather happy that the U.S. is more careful in their review process....I know a few examples where this extra care allowed for the U.S. to avoid some of the catastrophes associated with medications that were allowed in Europe more easily...

  • Moderna announced on 11/16/2020 that it's two-dose vaccine showed 94.5% efficacy. It is important to note that none of the people who received the actual vaccine became severely ill. Moderna's vaccine does not have the deep-freeze requirement of the Pfizer vaccine. Moderna will start testing its vaccine in adolescents soon. Moderna requested U.S. and European regulators for emergency use authorization for it's vaccine on Monday, November 30. The FDA vaccine advisory committee will meet on December 17 to review this application. If the vaccine is authorized, people could start receiving it as early as December 21.

  • The Oxford/ AstraZenica vaccine showed great efficacy in recent trial as well. Depending on the dosing of the two-part vaccine, either 62% of 90% of recipients were protected. This vaccine is supposed to be very inexpensive ($4 per shot) and can be stored at regular refrigerator temperatures. AstraZenica is working on emergency use authorization from multiple countries and the WHO. However, AstraZenica's CEO, Pascal Soriot, just announced that they will be testing the vaccine in a new global trial now, as there were some concerns about the adequacy of the testing environment previously. Specifically, there are concerns that the patients receiving the lower (and seemingly more effective) vaccine dose did not include anyone over the age of 55. The new global trial will be therefore giving the lower dose regiment to older populations. The full details of the recent trial will be published in the British medical journal Lancet in the coming days.

  • HHS Secretary Alex Azar has announced that the government has come to an agreement with various large pharmacy chains (Costco, CVS, Kroger, Walgreens, and Walmart) to help distribute the coronavirus vaccine, once it becomes available. There will be no cost associated for the public. Various other public health agencies are also ramping up their efforts now to be able to provide the vaccine to people as soon as it becomes available.

  • U.S. officials announced in late November that they plan on releasing 6.4 million doses of vaccine as part of their initial distribution. The individual states will decide on how best to distribute their allocated amount. The first vaccines should be available in mid to late December.

  • Lt. Gen Paul Ostrowski, an official in the White House's Operation "Warp Speed" announced on December 1 that all Americans who want to be vaccinated, can get a vaccine by June.

  • Children younger than 18 will likely have to wait longer for immunization, as the trials on vaccine efficacy and safety have largely excluded kids.

• Antibody therapy:

  • The FDA has issued an emergency use authorization for the monoclonal antibody "bamlanivimab" produced by Eli Lilly. This treatment is indicated for people with mild to moderate COVID-19 not sick enough to be in the hospital or to require supplemental oxygen. Treatment consists of a one-hour intravenous infusion and should be given to outpatients as soon as possible after the diagnosis of COVID-19 is made. On November 18, the NIH noted that there was insufficient information to recommend for or against this medication for people with mild to moderate disease. It should not be considered the "standard of care" but be considered only for selected patients at high risk and preferably in the setting of a clinical trial. A similar recommendation came on from the November 18 guidelines of the Infectious Diseases Society of America.

  • In late November, the FDA granted emergency use authorization for two more monoclonal antibodies (casirivimab and imdevimab) that need to be administered together intravenously for the outpatient treatment of mild to moderate COVID-19. These too are recommended only for "high risk" individuals. This is the medication cocktail made by Regeneron that was administered to President Trump during his hospitalization.

  • A study published in late November in the New England Journal of Medicine found that blood plasma from COVID-19 survivors used to treat patients with severe pneumonia due to the virus showed little benefit.

Mills-Peninsula Hospital:

• Peninsula Hospital continues not to be full and is managing its share of COVID-19 cases as well as could be hoped for. Plenty of beds are still available in case more people fall ill and all the treatment modalities we discussed above are available here.

• Ryan Stice, who oversees pharmacy services at Sutter Health, has been preparing for the cooling requirements for the Pfizer COVID-19 vaccine (minus 94 degrees Fahrenheit!!) since the summer. Now Sutter, like other local health care providers and local health departments, is moving quickly to acquire about a dozen large and several smaller portable freezers for vaccine storage.

Our Community and Beyond:

• The State of California has come out with a new color-coded system to guide reopening of different parts of the state: this system has 4 tiers: certain criteria such as each region's number of positive COVID-19 tests, hospitalizations, and Intensive Care Unit admissions will dictate what tier is appropriate for each region.

• California has been divided in 5 regions: we are in the "Bay Area" region which includes the counties of Alameda, Contra Costa, Marin, Monterey, Napa, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano, and Sonoma). Each regions will be subject to additional restrictions if ICU availability falls below 15%. As of yesterday, none of the regions met that threshold yet, though all (other than the Bay Area) were expected to get there within a few days. The Bay Area is expected to reach this threshold in a matter of weeks. If this threshold is reached, the following restrictions will be instituted and supersede any rules based on the colored tiers:

  • personal care services (hair and nail salons), playgrounds, bars, wineries, movie theaters, museums, zoos will be closed.

  • retail and grocery stores as well as other businesses will operate at 20% capacity

  • restaurants will be able to offer only takeout or delivery. No outdoor or indoor dining will be allowed

  • all non-essential travel should be avoided

  • these orders will remain in effect for at least 3 weeks

• As of November 30, 51 of the state's 58 counties were in the purple tier, accounting for 99.1% of the state's population.

• On November 29, San Mateo County moved into the purple Tier 1, the most restrictive tier. In addition, a stay-at-home order has taken effect (see below).

  • Businesses and activities that may have been operating indoors (places of worship, movie theaters, gyms, and museums) must move outdoors or close.

  • Shopping malls and all retail must operate at no more than 25% capacity.

  • Indoor gatherings among members of different households are banned and outdoor gatherings can include people from only 3 households.

• There is now a curfew imposed on residents living in purple tier counties: residents are asked to stay indoors (except to buy essential foods and products or to walk their dogs) between 10 pm and 5 am. This curfew is expected to last until at least December 21.

• Gov. Newsom has warned that a new targeted stay-at-home order could be issued in the future, if the hospitalization rates continue to surge. At this time, COVID-19 cases are on track to rise by up to 30% by Christmas Eve in much of the state. The Bay Area is doing slightly better compared with the rest of the state, as currently 58% of the hospital beds and 72% of the ICU beds are occupied.

• As of November 30, all three of Santa Clara county's main hospitals canceled all adult elective surgeries.

• San Mateo is still offering free PCR testing for COVID-19:

  • Scheduled testing occurs at the San Mateo County Event Center. Testing here can be scheduled Tuesdays through Saturdays from 8 am to 3 pm - all without a cost to the patients. Appointments are required and can be made at "projectbaseline.com/COVID19"

Our Office: What We Are Doing to Keep You Safe:

• All patients seen in person will be screened for COVID-19 exposure and symptoms prior to coming into the building.

• We disinfect all exam rooms and medical equipment as well as all door handles after EVERY patient visit, regardless of the medical issues involved.

• We are also using tele-health options that allow you to have video as well as audio interactions with us as part of a "remote office visit." With the recent surge of cases, we are postponing most routine physical exams and minimizing most in-person visits. Patients who require physical evaluations to diagnose and treat their medical issues will always be seen in person.

• For those patients seen in the office, we ask that friends and family members stay in the car (or elsewhere outside the office) during the visit. Of course we do welcome caregivers into the office with the patient if they are needed for improved safety or communication.

• All of us in the office are healthy and doing well.

• We have still are giving "regular" flu shots (i.e. NOT those for seniors). So if you are under 65 and have not yet received your flu shot, call our office and come on in!

• In addition to the "regular" Covid-19 testing that we have had all along (nasal swab, PCR-based test with approx. 24-48 hour turn around) our office also has two other COVID-19 testing options available:

  • A saliva based PCR-test that can be done in a patient's home. It is then sent via Fed-Ex to a lab and usually gives results in 36 hours. This test is usually covered by insurances and is 100% sensitive and 100% specific. It is accepted as evidence of immunity for most travel (not including travel to Hawaii, which does not accept this test).

  • A rapid 10-minute test that is based on a nasal swab and performed in our office. This test is 85% sensitive and 100% specific. This test is perfect for people without symptoms or prolonged exposure to a COVID-10 patient who "just want to make sure" they are ok. This test is not covered by insurance and costs patients $30/ test.

We will try to keep you updated as the epidemic evolves. Feel free to call or email with questions or concerns.

About Dr. Sujansky's Life in These Times

On a more personal note, my family and I continue to do well

We spent Thanksgiving in Kirkwood, which was beautiful. The weather was cold but dry, so we were able to take some beautiful hikes...a necessity after consuming so much turkey. As mentioned in the last newsletter, there were three of us and a 16 pound turkey. Then there were leftovers, turkey fried rice, turkey tetrazzini...and it's still not quite gone.

My latest knitting project involved hot water bottle covers...for those of you who have not heard me rave about how water bottles, you have missed out. These old-fashioned things have kept me warm on many a cold winter night and have soothed sore muscles any time of year. At any rate, I can't show you a picture of these knitting masterpieces as one will go to my mother and she subscribes to this newsletter (Oh My!)

Finally, I wanted to remind you about the 20% discount on Obagi skin products through the rest of December. Many of you are already familiar with the wonderful products by Obagi that we carry at the office. Check out the "Holiday Hydrate Special" which includes the hydrate luxe, retinol, travel sizes of foaming gel and toner, as well as travel size facial elastiderm and hand sanitizer).

So treat yourself (and others in your family) for the holidays. I think we all deserve something special in these times.

I wish you all a wonderful weekend and coming week. I hope all of you stay safe and healthy. I am thinking of you often.

Sincerely,

Ulrike Sujansky, MD

COVID-19 Update November 20, 2020

Updates on the Novel Coronavirus (aka COVID-19): What You Need to Know

Information about the spread and about the safety concerns of the novel coronavirus (aka "SARS-Cov-2"), and the disease it causes, COVID-19, is evolving on an daily basis. It is also clear that politics has played a major role in the information that has been distributed and the recommendations made. So I wanted to try to bring you unbiased, non-political information about the of the virus in our community and in general. I will include details on this topic from previous newsletters, as they remains important - new information will be in BOLD.

• Despite the worrisome increase of coronavirus incidence and death in the U.S. and the world, I am more optimistic this week, given the positive results of some recent vaccine trials. I finally feel like there is an end in site - even if that end is still 6 months away or more. So let's please all pull together in this final stretch to minimize the number of people who suffer and die needlessly.

• In the early days of COVID-19, many of the Coronavirus cases were grouped around nursing homes. Things have changed, however. Researchers published an interesting study in the journal Nature: they used cell phone data to track people's movement to over 550,000 different locations (restaurants, religious venues, etc.) in 10 U.S. metropolitan areas. This information was correlated with a SARS-Cov-2 transmission model. As is so often the case, a minority of locations account for the majority of transmissions. Such locations included restaurants, gyms, and coffee shops - indoor venues where people congregate. Therefore, reducing the occupancy in inside public venues will be very helpful in making a significant impact in controlling the disease.

• Collins English Dictionary just announced its "word of the year:" it's "LOCKDOWN." It is a verb and a noun that indicates "a unifying experience for billions of people across the world, who have had, collectively, to play their part in combating the spread of COVID-19." I rather like it that this global need to work together on combatting a global crisis is the philosophy of this word of the year...

• Finally, on to Thanksgiving: I know many of us are planning travel and the traditional family gatherings. Please don't do it. The CDC - in their first news briefing in months! - strongly recommended yesterday to forgo travel and to limit celebrations to household members only. This recommendations was echoed "in the strongest possible terms" by the American Medical Association, the American Hospital Association, and the American Nurses Association and is based on the spiking coronavirus cases that are overwhelming hospitals.

General Information:

• Pandemics are not new to our civilization and each pandemic is unique. What makes SARS-Cov-2 different and more challenging is the high degree of infectiousness as well as transmission from people who have no symptoms at all or only mild symptoms.

• As treatments have been improving, the mortality associated with COVID-19 has been steadily decreasing over the last few months. An article from the Journal of Hospital Medicine found a death rate of hospitalized patients of 25.6% from COVID-19 in New York in March. In August, the death rate had declined to 7.6%. Indeed, it seems that the mortality associated with SARS-Cov-2 has dropped by a third! According to Dr. Christopher Murray, the director of University of Washington's Institute for Health Metrics and Evaluation (what a mouth-full!), the virus killed 0.9% of those known to be infected in the spring, while in now kills around 0.6%.

• Another piece of good news came in a recent study in BioRxiv (which was NOT peer-reviewed): 185 people with past COVID-19 infection were studied and their memory B-cells (a type of white blood cell) analyzed. The result of the study suggested that an immune response to SARS-Cov-2 may last for many years. This would suggest that past infections as well as vaccinations will protect you for a long time indeed!

• COVID-19 has had negative health impacts on many people who don't contract the virus: 40% of U.S. adults surveyed in late June reported at least one or behavioral health problem associated with the pandemic.

• The newest studies (published in the journal Science) suggest that the antibodies developed by people who have recovered from COVID-19 actually last for at least 5 months.

• There has been a significant increase of Emergency Department visits of kids and teens for mental health reasons with the pandemic - increases of 24-37%.

• As I mentioned in previous newsletters, doctors' practices have also suffered economically from the pandemic. A recent survey actually showed that 49% of respondent physicians either lost their jobs, were furloughed, or were subject to a reduction in pay due to the pandemic. Physicians in areas where the virus was rampant were/ are most affected financially.

Transmission:

• The incubation period can be 14 days (or more), though most people develop symptoms within 5-10 days.

• Transmission occurs predominantly via respiratory droplets. Transmission is more likely the longer you are close to an infected person, the closer you are, and the worse the air ventilation is. Transmission via touch (touching a surface with the virus on it and then touching your nose, eyes, and mouth) is quite unusual.

• Humans can transmit the Novel Coronavirus to dogs and cats but these animals don't get particularly ill. More importantly, these animals don't seem to be able to give the virus back to us!

• There is some concern that minks can transmit the SARS-Cov-2 virus to humans. Mutations acquired when the virus jumps from one species to the next can also make a possible future vaccine less effective. Since June, Denmark has reported 214 human cases of COVID-19 that likely were transmitted from minks. Five other countries (the U.S, Italy, the Netherlands, Spain, and Sweden) have also reported SARS-COV-2 cases in farmed minks.

• People are most infections the day prior to developing symptoms and then infectivity declines about one week after onset of symptoms.

• A study published in the journal Virology in October unfortunately showed that SARS-Cov-2 can stay alive and infectious on surfaces much longer than we thought: at room temperature, it can live up to 28 days! A recent study found that SARS-Cov-2 can stay alive on human skin for up to 9 hours! So wash your hands frequently and use hand sanitizer often!

• We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them

• There are rumors that wearing of masks is associated with lower oxygen saturations in the blood, a fact that can be critical in vulnerable populations. However, a study published in JAMA studied 25 senior citizens in Canada, all of whom were given a three-layer mask. Then their oxygen was check at rest and with activity. Luckily, there was no clear drop of oxygen saturations associated with the wearing of masks.

• It turns out that wearing a mask is not just protecting others from the virus if you are ill. The CDC has just announced that wearing the mask protects the wearer from the viruses of others also! Win-Win!

• More of us are traveling by airplane again these days. An interesting article from JAMA looked at the risk of flying and getting infected with SARS-Cov-2:

• The risk of getting COVID-19 during air travel is lower than from an office building, classroom, or supermarket.

• Current estimates suggest that only 42 people have gotten COVID-19 from being in an airplane.

Symptoms and Risk Factors:

• People with COVID-19 usually develop achy muscles and a fever, as well as shortness of breath. A small number are also nauseated and have diarrhea. Loss of taste and smell is common. Severe cases usually involve a pneumonia that may lead to hospitalization and the use of a ventilator to allow the lungs to adequately transfer oxygen into the blood.

• About half the patients with COVID-19 have neurologic symptoms.

• Most children who get infected do not exhibit any symptoms. However, a small percentage who end up in the hospital have symptoms of "vasculitis," which is an inflammation of the blood vessels. This syndrome, called "pediatric multisystem inflammatory syndrome (MIS-C)" is still rare, but can be very serious.

• JAMA Network Open reported on 11/19/2020 that many patients with COVID-19 - especially if they were older than 65 - presented with delirium (severe confusion). Indeed, more than 25% of older patients presented at the emergency department with delirium and 37% didn't have any of the more typical signs such as fever or shortness of breath.

• An increasing number of COVID-19 patients seem to have long-standing sequelae of their infection:

• persistent lung disease is common, with people experiencing cough and shortness of breath 12 weeks after hospitalization.

• A study out of Michigan looked at patients who had been hospitalized for COVID-19 and recovered: two months after discharge, one third of people still had ongoing health issues such as a cough, loss of taste and smell, or shortness of breath.

• Certain underlying conditions make you more prone to get sick with COVID-19. These include emphysema, diabetes, and heart disease. Also, obese people as well as smokers and people with kidney damage are also at higher risk.

• The CDC announced in mid October that people who are overweight have an increased risk of severe illness with COVID-19. This means that 75% of the U.S. population is at heightened risk.

• A new study showed that pregnant women with COVID-19 were more likely to give birth prematurely (13% compared to 10% prior to the pandemic). Pregnant women were also more likely to end up in the ICU and needing to be put on a ventilator compared with non-pregnant infected women.

Incidence/ Prevalence:

• To the best of our knowledge, only a handful of people world-wide have become re-infected with SARS-Cov-2, a tiny number given the prevalence of the disease. This is great news!

• At this time, more than 3 million people in the United States have ACTIVE coronavirus infections, according to experts out of Columbia University and the University of Washington. This means that about 1.1% or the U.S. population is currently infected and actively shedding virus that can infect others.

• The nationwide uptick in cases which started in September is now in its ninth week and is longer than the surge of cases in the Northeast in March/April or the June/July upswing in the Sun Belt. The entire country is now involved.

• On November 10, the number of COVID-19 hospitalizations were above 60,000 for the first time - over 2000 higher than the previous record in April.

• At this time, over 55.6 million people in the world have contracted the novel coronavirus. 1.34 million people have died worldwide (compared to 1.24 million two weeks ago). The United States has the highest number of cases. The U.S. also has the highest number of deaths (at 252,000) in the world (236,000 two weeks ago).

• In the United States, more than 11.8 million people have now contracted SARS-Cov-2 (9.76 two weeks ago).

• California is reporting that it now has more than 1.08 million people infected with SARS-Cov-2 (compared to 962,000 two weeks ago).

• As of November 19, 2020, there have been 12,878 people in San Mateo County who have tested positive with the SARS-CoV-2 virus (compared to 11,710 people two weeks ago). 168 people in San Mateo County have died from the disease (compared to 162 people two weeks ago).

• For the week ending in November 10, San Mateo had an adjusted case rate of 5.7 cases per 100,000 residents per day, which is twice as high as the previous week. Also, the county's test positivity rate rose from 1.3% to 2.1%. Though this increase is extremely worrisome, it is still well below the positivity rate of 5.2 of all of California.

• Over 1 million children in the U.S. have now been diagnosed with COVID-19 - 11.5% of all cases.

• As we discussed in the past, most children infected with the virus do not develop any symptoms. The current thinking is that this is due to the presence of antibodies to other coronaviruses. 43% of kids had antibodies to different coronavirus strains in a study done by the Francis Crick Institute.

• The CDC announced this week that Black, Hispanic, and Native American people with COVID-19 are four times more likely to require hospitalization compared to others.

• People with intellectual disabilities are three times more likely to die of COVID-19 than others.

Testing

• On November 18, the FDA granted an emergency use authorization for the first rapid at-home test for COVID-19. This test is made by Lampira and uses a technology similar to the PCR tests available. This test can supply results within 30 minutes. Accuracy of positive and negative tests seems to be quite high (above 94%). The cost is projected to be about $50 and a doctor's prescription is still needed.

• See also the notes (below)about what testing options are available through out office.

Treatment

• On October 22, the FDA approved remdesivir as a treatment for COVID-19 and therefore took it out of the "experimental/ emergency use" category. It is the only medication COVID-19 treatment in the United States. At the same time, the WHO just recommended AGAINST using remdesivir for hospitalized patients, due to lack of evidence that the drug reduces risk of death or need for a ventilator....I know, it's confusing!

• On 11/19/2020, the FDA granted emergency use authorization of the combination of remdesivir and the monoclonal antibody baricitinib.

• Low doses of the steroid "dexamethasone," given intravenously, have been found to reduce death rates by 33% in people with COVID-19 who are on a ventilator.

• A very small trial (published in Jama Network on November 12) included 152 adult outpatients infected with COVID-19. They were treated with fluvoxamine, an anti-depressant closely related to prozac. It seems that this medication not only affects the serotonin system, but can also have some anti-viral effects. At any rate, none of the patients treated with fluvoxamine got worse, while 6 patients (8.3%) of the placebo patients deteriorated. These are interesting results, though they need to be validated in larger trials.

• An inhaled medication that stimulates the immune system (interferon beta-1) helped hospitalized patients with COVID-19. Those patients who were given the inhaled medications were two to three times as likely to get better; The treatment group had a 79% lower risk of developing severe disease or dying. This was just a phase 2 trial, so phase 3 trials are still needed until such a treatment could be considered.

• Vaccine development is ongoing.

  • In the U.S., 8 vaccine candidates have received federal support under Operation Warp Speed. Of these, 4 companies (Moderna, Pfizer/ BioNTech, Oxford/ AstraZenica, and Janssen) have entered phase 3 trials.

  • By the end of December, there should be enough vaccines available to protect up to 20 million Americans.

  • The Russian "Sputnik V" vaccine, which is in phase 3 trials, seems to be 92% effective with "no unexpected adverse events." Unfortunately, very little information has been made available to the public, so this success has been greeted with a dose of skepticism also.

  • Brazil has halted a late stage trial of a Chinese Vaccine on November 9 due to a "serious adverse" reaction. However, there are concerns that politics (rather than science alone) have figured into the trial being halted at this time.

  • On November 9, the vaccine produced by Pfizer/ BioNTech was shown, in an interim analysis, to be 90% effective in preventing COVID-19 disease. Just a week later, they announced that the data now suggests it is up to 95% effective. Also, both mild and severe disease seems to be prevented. Seniors as well as younger people respond well to the vaccine. This is still preliminary data, as the phase 3 trial is still ongoing. Also, the safety data looks good, but is not yet finalized. But, this 90% efficacy is fantastic, as most vaccines are not nearly this effective. There are still some stumbling blocks, however, if this vaccine comes to market: it has to be given in 2 doses, 3 weeks apart. More importantly, however, it has to be stored in -70 decrees C temperatures, which is much lower than most freezer can provide. So the logistics still need to be worked out... Pfizer hopes to apply for an emergency use authorization for their vaccine as early as today!

  • Moderna announced on 11/16/2020 that it's two-dose vaccine showed 94.5% efficacy in an interim analysis of its phase 3 trial. The trial has enrolled 30,000 U.S. participants. In the analysis, 5 people who had received the vaccine developed COVID-19 (none severe) while 90 people who received the placebo were sickened by the virus (11 of whom were severely ill). Moderna's vaccine does not have the deep-freeze requirement of the Pfizer vaccine.

  • On 11/19/2020, researchers at Oxford University confirmed that the COVID-19 vaccine produced by AstraZenica produced a strong immune response in older adults. The final findings of the last phase of testing are expected to be available in the next few weeks.

  • Johnson & Johnson has launched phase 3 trials for it's vaccine. This vaccine candidate is good because it requires only one administration dose and does not have to be kept frozen.

  • J&J reported on October 23 that their vaccine trials would resume after having concluded that prior adverse events noted with the vaccine were unlikely to be a result of the vaccine administration.

  • HHS Secretary Alex Azar has announced that the government has come to an agreement with various large pharmacy chains (Costco, CVS, Kroger, Walgreens, and Walmart) to help distribute the coronavirus vaccine, once it becomes available. There will be no cost associated for the public. Various other public health agencies are also ramping up their efforts now to be able to provide the vaccine to people as soon as it becomes available.

• Antibody therapy:

  • The FDA has issued an emergency use authorization for the monoclonal antibody "bamlanivimab" produced by Eli Lilly. The EUA is based on an interim analysis of a phase 2 trial of 465 patients. This treatment is indicated for people with mild to moderate COVID-19 not sick enough to be in the hospital or to require supplemental oxygen. Treatment consists of a one-hour intravenous infusion and should be given to outpatients as soon as possible after the diagnosis of COVID-19 is made. By doing this, the risk of hospitalization or emergency department visits can be reduced from 10% to 3%. Unfortunately, the logistics of administration of this treatment is not clear yet. As the medication needs to be given intravenously, it would need to be given in a hospital infusion center. However, people sick with COVID-19 are not currently allowed in the hospital infusion centers - this is also the place where cancer patients receive their chemotherapy! Similar concerns were raised in JAMA, when the authors opined about the limited availability of bamlanivimab, the complicated administration, and potentially high costs of the medication. At this time, tnei NIH's Covid-19 Treatment Guidelines Panel says that there is not enought evidence to recomend for or against the use of this medication. They say that the treatment should not be the "standard of care" at this time.

  • A recent study published in the British Medical Journal found that plasma from convalescent patients (i.e. those who had COVID-19 in the past) was NOT effective in treating active coronavirus patients.

• Another new and interesting therapy comes in the form of a preventative nasal spray: in a trial involving ferrets (!!), researchers have inoculated ferrets with a daily nasal spray that blocks the absorption of the SARS-Cov-2 virus. This data is based only on a small number of animals tested and needs to be studied further. However, if this strategy proves effective in humans, then a daily nose spray of such a medication could function like a vaccine and keep us safe from COVID-19. Interesting...

Mills-Peninsula Hospital:

• Peninsula Hospital continues not to be full and is managing its share of COVID-19 cases as well as could be hoped for. Plenty of beds are still available in case more people fall ill and all the treatment modalities we discussed above are available here.

• Ryan Stice, who oversees pharmacy services at Sutter Health, has been preparing for the cooling requirements for the Pfizer COVID-19 vaccine (minus 94 degrees Fahrenheit!!) since the summer. As you can well imagine, this could be a logistic nightmare. Now Sutter, like other local health care providers and local health departments, is moving quickly to acquire about a dozen large and several smaller portable freezers for vaccine storage. Sutter is still finalizing the exact location of the freezers.

Our Community and Beyond:

• The State of California has come out with a new color-coded system to guide reopening of different parts of the state: this system has 4 tiers: certain criteria such as each region's number of positive COVID-19 tests, hospitalizations, and Intensive Care Unit admissions will dictate what tier is appropriate for each region.

• On November 17, San Mateo moved back into the more restrictive red tier. Though this is not good news, we are actually lucky, as 94% of Californians are now under the most restrictive purple tier. For San Mateo, the following changes will now apply:

• Theme parks must close.

• Zoos and museums must be at 25% capacity.

• Bars that do not offer food service must close.

• Indoor dining is limited to 25% capacity.

• Houses or worship are limited to 25% indoor capacity.

• Gyms are limited to 10% indoor capacity.

• Movie theaters are limited to 25% capacity.

• No fans are allowed at professional sporting events.

• Only outdoor pools may be opened.

• Santa Clara is now in the more restrictive purple tier. There, restaurants will only have outdoor dining and all worship services will need to be outdoors as well.

• Starting tomorrow, November 21, there will be a curfew imposed on residents living in purple tier counties: residents are asked to stay indoors (except to buy essential foods and products or to walk their dogs) between 10 pm and 5 am. This curfew is expected to last until at least December 21. For now, at least, San Mateo is not in the purple tier...but over 90% of the state is!

• Last week, health officials of 10 Bay Area jurisdictions issued guidelines for the holidays, advising people to keep gatherings small and short to prevent spread of the coronavirus. This is particularly important because the Bay Area still has a relatively low incidence of COVID-19. Traveling will increase your risk of contracting the disease and bringing it home with you.

• On November 10, the San Mateo Board of supervisors approved nearly $6 million for the "Coronavirus Aid, Relief, and Economic Security Act" funding. Many businesses and households will continue to suffer as a consequence of the business restrictions inherent in the pandemic lockdown.

• San Mateo is still offering free PCR testing for COVID-19:

• Scheduled testing occurs at the San Mateo County Event Center. Testing here can be scheduled Tuesdays through Saturdays from 8 am to 3 pm - all without a cost to the patients. Appointments are required and can be made at "projectbaseline.com/COVID19"

Our Office: What We Are Doing to Keep You Safe:

• All patients seen in person will be screened for COVID-19 exposure and symptoms prior to coming into the building.

• We disinfect all exam rooms and medical equipment as well as all door handles after EVERY patient visit, regardless of the medical issues involved.

• We are also using tele-health options that allow you to have video as well as audio interactions with us as part of a "remote office visit."

• For those patients seen in the office, we ask that friends and family members stay in the car (or elsewhere outside the office) during the visit. Of course we do welcome caregivers into the office with the patient if they are needed for improved safety or communication.

• All of us in the office are healthy and doing well.

• All patients coming into the office will be required to wear masks.

• We have finally received more "regular" flu shots (i.e. NOT those for seniors). So if you are under 65 and have not yet received your flu shot, call our office and come on in! Unfortunately, we have run out of our flu shots for seniors, for now. We are on the wait-list to get more, but are not sure when that will be. We'll let you know as soon as we know. Until then, we encourage our senior patients to get their flu shots from a pharmacy.

• In addition to the "regular" Covid-19 testing that we have had all along (nasal swab, PCR-based test with approx. 24-48 hour turn around) our office also has two other COVID-19 testing options available:

• A saliva based PCR-test that can be done in a patient's home. It is then sent via Fed-Ex to a lab and usually gives results in 36 hours. This test is usually covered by insurances and is 100% sensitive and 100% specific. It is accepted as evidence of immunity for most travel (not including travel to Hawaii, which does not accept this test).

• A rapid 15-minute test that is based on a nasal swab and performed in our office. This test is 85% sensitive and 100% specific. This test is perfect for people without symptoms or prolonged exposure to a COVID-10 patient who "just want to make sure" they are ok. This test is not covered by insurance and costs patients $30/ test. We hope to have this test available by early next week!

About Dr. Sujansky's Life in These Times

On a more personal note, my family and I continue to do well.

The new restrictions on travel and social interactions will allow me to have more time at home and to get a jump start on sending out holiday cards and decorating the house. Also, I am trying to come up with holiday gifts that are more home-made and more personal - another possible upside of the pandemic. I think that also means that everyone is getting something knitted from me...

Thanksgiving will be a low-key affair at the Sujansky household: we are planning on going up to our condo at Kirkwood and dining on a 16 lb turkey between the three of us. I look forward to a change of scenery! And I will try again to be thankful for the many things that we have that others are lacking: shelter, a warm bed at night, love, good food, and the occasional glass of wine. And it goes without saying that I am grateful daily for all of my patients and friends in these difficult times.

My older son Stefan is scheduled to return from Greece in mid December. I am so looking forward to that. From his accounts, we are living lives of luxury and health compared to the conditions of the refugee camps on Samos.

Some of you have mentioned that you send my newsletter to friends and family. I could not be more flattered. Please also note that I put each week's newsletter under the "blog" section of my website (www.SujanskyMD.com) in case you want to share the newsletter that way or look at previous editions. Also, anyone can just google "Dr. Sujansky" and "blog" and it should come up.

Finally, I wanted to let you know that we are having another "Obagi Event" on December 3: many of your are already familiar with the wonderful skin care products by Obagi that we carry at the office. On December 3, our Obagi rep will hold one-on-one meetings virtually (via phone, zoom, or face-time) with anyone who wants some good tips for healthier skin. And to tempt you even more: we are offering 20% off all Obagi products from November 30 through December 31. So call and make an appointment for this or just come in and treat yourself (and others in your family) to Obagi. I think we all deserve something special in these times.

I wish you all a wonderful weekend and coming week. I hope all of you stay safe and healthy. I am thinking of you often.

COVID-19 Update October 23, 2020

Updates on the Novel Coronavirus (aka COVID-19): What You Need to Know

Information about the spread and about the safety concerns of the novel coronavirus (aka "SARS-Cov-2"), and the disease it causes, COVID-19, is evolving on an daily basis. You may have noted some flip-flopping on recommendations from the government and scientific community in the last 7 months. Some of this is certainly due to the novelty of the virus: early on, we had very little information about the disease and this uncertainty was reflected in the changing recommendations. It is also clear that politics has played a major role in the information that has been distributed and the recommendations made. So I wanted to try to bring you unbiased, non-political information about the of the virus in our community and in general. I will include details on this topic from previous newsletters, as they remains important - new information will be in BOLD.

"Herd Immunity" occurs in any population, when a certain percentage of the people becomes immune to an infection - either because they have had the infection already or because they are vaccinated. This percentage is different for each infectious disease - for COVID-19 the epidemiologists guestimate that the herd immunity lies at about 50-67%. At this time researchers estimate that about 9% of the U.S. population has been infected by SARS-Cov-2.

On October 4, three scientists (one from Harvard, one from Stanford, and one from Oxford University) presented the "Great Barrington Declaration" to provide an alternative strategy to the current lock-down strategies set up to prevent COVID-19 spread. These scientists argued that most younger people do fine with SARS-Cov-2 infection and do not suffer significant harm. At the same time, ongoing social isolation causes increases in depression, anxiety, and substance abuse and also devastates the economy. So the scientists suggested allowing the lower-risk individuals to go back to normal socialization (no masks, no social distancing, etc), with the understanding that they would likely get infected. Meanwhile, higher risk groups would continue to stay isolated. This way, they argue, a rapid herd immunity could be achieved as the younger people will become immune (after being infected) and can not spread it to the vulnerable.

This concept certainly has its appeal, but - in my opinion - the devil is in the details and there are some issues that need to be addressed:

• 20% of the deaths of COVID-19 occur in people younger than 65.

• A large number of people who survive COVID-19 go on to have chronic symptoms that can last months.

• What happens in the many households that include grandparents, parents, and children - how are the elders safe-guarded if the children and parents allow themselves to become increasingly exposed?

• What happens to the front line workers like doctors and nurses: they are more likely to get their vulnerable patients ill if they are more likely to become ill themselves.

• We are unclear how long any immunity from past COVID-19 infections lasts...

Subsequently, the so called "Snow Memo" followed the Great Barrington declaration. In it, over 6,200 scientists, researches, and health care professionals have disavowed the Great Barrington proposals, calling it reckless and ill-advised. They argue that ongoing care with masks, distancing protocols, and (hopefully soon) vaccination will achieve the same herd immunity, but at a lower social cost. We have yet to see which philosophy will be adopted by the country.

General Information:

• Pandemics are not new to our civilization and each pandemic is unique. What makes SARS-Cov-2 different and more challenging is the high degree of infectiousness as well as transmission from people who have no symptoms at all or only mild symptoms.

• An article published in the Annals of Internal Medicine on Sept 2, 2020 calculated the mortality rate of COVID-19 by randomly testing people (with and without symptoms!) for COVID-19 in Indiana in late April, 2020. The researchers found that the incidence of death increased with age: people older than 60 had a mortality rate of just under 2% - a mortality rate that is about 2.5 times as high as influenza. People younger than 40, however, had a mortality rate of 0.01%. Looking at the experience of New York between March and June, 2020, researchers found the mortality rate to be 1.4% overall. However, for adults between 65 and 74, the mortality rate was 4.9% and those over 75 had a mortality rate of 14.2%.

• The United Kingdom announced on October 20 that it will start infecting healthy volunteers with SARS-Cov-2 as part of a clinical trial, so that scientists can better understand the amount of virus that is needed to cause illness. In a later phase of a trial, volunteers will be vaccinated for SARS-Cov-2 and then exposed to the virus itself.

• COVID-19 has had negative health impacts on many people who don't contract the virus: 40% of U.S. adults surveyed in late June reported at least one or behavioral health problem associated with the pandemic. In general, young adults, Hispanic and Black people, as well as essential workers and unpaid caregivers had the highest rates of issues.

• Anxiety is rising during the pandemic: 62% of respondents in a recent poll reported increased anxiety. Prior years' polls found anxiety at 32% to 39%....at the same time, if 62% of people are now feeling more anxious, what about the other 38%?? Isn't everyone more anxious these days...just saying...

• The CDC has extended its ban on passenger cruise ship travel through the end of October. Between March and September, 2020, there have been at least 3700 people who fell ill with COVID-19 that they contracted while on a cruise. 41 people have died.

• The World Bank warned this week that the coronavirus pandemic could push over 100 million people into extreme poverty worldwide. Extreme poverty is defined as living on less than $1.90 per day.

• To help prevent the spread of misinformation related the pandemic, the World Health Organization has partnered with Wikipedia to provide accurate information on the website. This joint effort allows Wikipedia to use the WHO published information, graphs, and video free of charge.

Transmission:

• The incubation period can be 14 days (or more), though most people develop symptoms within 5-10 days.

• Transmission occurs predominantly via respiratory droplets. Transmission is more likely the longer you are close to an infected person, the closer you are, and the worse the air ventilation is. Transmission via touch (touching a surface with the virus on it and then touching your nose, eyes, and mouth) is quite unusual. The virus can also be spread through the air beyond a 6 feet distance, especially in poorly ventilated spaces. Although it seems likely that COVID-19 can be transmitted via both droplets and aerosols, preliminary research suggest that droplet spread is much, much more common.

• The CDC has re-defined what it means by "close contact" vis-a-vis the coronavirus: in the past, a "close contact" of a coronavirus patient had been in continuous contact with the patient for 15 minutes and was therefore thought to be at risk of getting the disease themselves. Now, however, a "close contact" is someone who has been within 6 feet of a patient for at least 15 minutes spread out over 24 hours...so they could have had 2 minutes of contact here, 5 minutes of contact there - as long as it totaled to at least 15 minutes over 24 hours. This too will put them at risk of contagion.

• Humans can transmit the Novel Coronavirus to dogs and cats but these animals don't get particularly ill. More importantly, these animals don't seem to be able to give the virus back to us!

• People are most infections the day prior to developing symptoms and then infectivity declines about one week after onset of symptoms.

• A study published in the journal Virology in October unfortunately showed that SARS-Cov-2 can stay alive and infectious on surfaces much longer than we thought: at room temperature, it can live up to 28 days! In comparison, the influenza virus can stay alive on surfaces for 17 days. Glass surfaces (such as smart phone covers!) are particularly likely to carry the virus, so please clean your smart phone surfaces frequently!

• It now seems likely that re-infection with SARS-Cov-2 does occur, but is rare

• A study published in the journal Pediatrics suggests that child-care centers do NOT hasten the spread of SARS-Cov-2, even if the infectious rates are high in the community. This finding will be important as our country is once again grappling with decisions as to what schools and centers can open safely.

• There is an excellent article published in the Atlantic about SARS-Cov-2 transmission. It focuses on how many "super spreader events" have been responsible for transmissions of the virus and how this could explain why, for example, Northern Italy was an early focus of the disease, while Central Italy wasn't. In addition to some people being "super-emitters" of the virus, other circumstances (large indoor events, crowding, poor ventilation) also play a large role. This is why events with large congregations of people - like weddings, large church gatherings, restaurants - are likely to become hot spots of transmission, especially if there is loud talking or singing involved. The article is worth reading in its entirety:

https://www.theatlantic.com/health/archive/2020/09/k-overlooked-variable-driving-pandemic/616548/

• We need to all recognize that face masks are extremely important and effective in protecting the wearer as well as the people around them

• Please, folks, wear the face masks properly! I see so many people walking about wearing face masks with their noses not covered. This doesn't protect anyone!

• On October 19, the CDC issued a "strong recommendation" that all passengers and employees on airplanes, trains, buses, taxis, subways, and ride-share vehicles wear a face mask. In addition, people in airports or trains stations are also asked to wear facial coverings.

• More of us are traveling by airplane again these days. An interesting article from JAMA looked at the risk of flying and getting infected with SARS-Cov-2:

• The risk of getting COVID-19 during air travel is lower than from an office building, classroom, or supermarket.

• The low infectivity has to do with the relatively low airflow between rows.

• Half of the airflow in a plane is from fresh air from outside - the other half is recycled through HEPA filters similar to the ones used in an operating room.

• Current estimates suggest that only 42 people have gotten COVID-19 from being in an airplane.

• if you want to see more details, please refer to the article itself at:

Symptoms and Risk Factors:

• People with COVID-19 usually develop achy muscles and a fever, as well as shortness of breath. A small number are also nauseated and have diarrhea. Loss of taste and smell is common. Severe cases usually involve a pneumonia that may lead to hospitalization and the use of a ventilator to allow the lungs to adequately transfer oxygen into the blood.

• SARS-Cov-2 has been found not only in the lungs and airways, but also in the brain, heart, liver, kidneys of patients.

• About half the patients with COVID-19 have neurologic symptoms.

• Most children who get infected do not exhibit any symptoms. However, a small percentage who end up in the hospital have symptoms of "vasculitis," which is an inflammation of the blood vessels. This syndrome, called "pediatric multisystem inflammatory syndrome (MIS-C)" is still rare, but can be very serious.

• An adult version of the multisystem inflammatory disease of children has now been described as well: a total of 27 adults with COVID-19 have been found to have signs of inflammation of the heart, digestive system, and nervous system. Three patients have died.

• An increasing number of COVID-19 patients seem to have long-standing sequelae of their infection:

• persistent lung disease is common, with people experiencing cough and shortness of breath 12 weeks after hospitalization. Nonetheless, most people do recover.

• Certain underlying conditions make you more prone to get sick with COVID-19. These include emphysema, diabetes, and heart disease. Also, obese people as well as smokers and people with kidney damage are also at higher risk.

• The CDC announced in mid October that people who are overweight (but not obese) have an increased risk of severe illness with COVID-19. This means that 75% of the U.S. population is at heightened risk as 75% of the U.S. population is overweight or obese.

• Adults with vitamin D deficiency are at greater risk for severe COVID-19 disease and death.

• In the United States, Black people and Hispanic people are three times as likely to become infected with COVID-19 compared to Caucasians. Moreover, Black and Hispanic people are twice as likely to die of the disease compared to White people.

Incidence/ Prevalence:

• To the best of our knowledge, only about 5 people world-wide have become re-infected with SARS-Cov-2, a tiny number given the prevalence of the disease. This is great news!

• COVID-19 illnesses and infections have been increasing in recent weeks, suggesting that the long-dreaded fall spike of cases is beginning. In the last week, the U.S. has confirmed an average of 54,000 new cases per day, an 25% increase compared to the previous week - a change that can not be explained by increased testing alone. Hospitals across the U.S. are facing an increase of COVID-19 hospitalizations. Hospitalizations have risen by at least 5% in 37 states as of last Sunday. At this time, more than 41,000 people are in the hospital with COVID-19 in our country, an increase of 40% in the last month. This increased need for hospitalization has turned into a significant issue in parts of rural America, where hospitals tend to be further away and smaller in size.

• At this time, over 42 million people in the world have contracted the novel coronavirus. 1.14 million people have died worldwide (compared to 986,000 two weeks ago). The United States has the highest number of cases. The U.S. also has the highest number of deaths (at 223,000) in the world.

• In the United States, more than 8.49 million people have now contracted SARS-Cov-2. The current rise in nation-wide cases is driven by the rapid transmission in Midwestern states.

• California is reporting that it now has more than 897,000 people infected with SARS-Cov-2 (compared to 848,000 two weeks ago).

• As of October 22, 2020, there have been 10,961 people in San Mateo County who have tested positive with the SARS-CoV-2 virus (compared to 10,452 people two weeks ago). 157 people in San Mateo County have died from the disease (compared to 155 people two weeks ago).

• A bit of good news: even as coronavirus disease is spiking throughout most of the country, the incidence of COVID-19 infection and deaths has been flat or decreasing in California.

• Teenagers are about twice as likely to become infected and transmit SARS-Cov-2 as compared to younger children.

• At this time, about 100 children and teenagers have died of COVID-19 in the U.S. (compared to over 200,000 fatalities overall).

• Some more bad news: a recent study published in JAMA looked at the per capital death rate in the United States and compared it to 18 other countries with populations larger than 5 million people and a per capital GDP of more than $25,000 per year. This "all-cause" mortality takes into consideration those fatalities that may have been related to the coronavirus, but were never confirmed. Overall deaths in the U.S. in 2020 are more than 85% higher than in places such as Germany and Israel. Even if we look at the deaths clearly due to COVID-19, the number of people dying of the disease since May 10 is about 50% higher than every other country in the study. Possible reasons for this excess mortality is assumed to be weak public health infrastructure and a decentralized, inconsistent US response to the pandemic. Also, the U.S. population has more associated underlying disease (such as diabetes and obesity) compared to many other countries.

Testing

• On September 28, President Trump announced a plan to distribute 150 million rapid coronavirus tests in the coming months. These tests had been purchased by the government previously and can deliver results within 15 minutes. The tests will be distributed to the individual states based on their population.

• Another rapid COVID-19 test has been approved by the FDA. This one is called "CareStart" and functions much like a home pregnancy test. I only hope that small physician's offices like mine will have access to such testing in the near future....other rapid tests have been on back-order and not available to small private practices.

• Also, another saliva test ("SalivaDirect") has been approved by the FDA and will be distributed to laboratories - hopefully soon!

Treatment

• As treatments have been improving, the mortality associated with COVID-19 has been steadily decreasing over the last few months.

• On October 22, the FDA approved remdesivir as a treatment for COVID-19 and therefore took it out of the "experimental/ emergency use" category. It is the only medication COVID-19 treatment in the United States. Unfortunately, recent reports on the efficacy of remdesivir have been mixed:

• On October 8, the New England Journal published the final report on the NIH trial of this medication: although use of remdesivir significantly improved the time to disease improvement with this drug, mortality rates were not affected.

• On October 15, the WHO released interim trial results of a 30-country randomized trial of the drug, suggesting that remdesivir (as well as hyddroxychloroquine, lopinavir, and interferon) had little or no effect on hospitalized COVID-19 patients.

• Other recent results showed that administration of remdesivir to patients requiring oxygen reduced the recovery time of COVID-19 by 5 days compared to placebo.

• A new trial found that the combination of remdesivir with baricitinib improved the time to hospital discharge from 8 days to 7. Also, this regimen increased the survival of patients with COVID-19.

• Low doses of the steroid "dexamethasone," given intravenously, have been found to reduce death rates by 33% in people with COVID-19 who are on a ventilator.

• On October 8, the New England Journal of Medicine published a randomized study on hydroxychloroquine, suggesting that patients on this medication were actually LESS likely to be discharged from the hospital alive.

• Plasma therapy (using blood plasma of people who had been infected with SARS-COv-2 previously) also did not show a survival benefit (Clinical Infectious Diseases, October 10)...however, it seems that patients older than 65 may have benefitted more than others.

• Vaccine development is ongoing.

• Dr. Fauci was "cautiously optiministic" this week that we will have a safe and effective vaccine for the novel coronavirus by November or December.

• There are more than 200 COVID-19 vaccines under development overall.

• Both Pfizer and BioNTech have entered phase 3 trials. The mRNA technology for vaccine development is new and could usher in a new era of faster and safer vaccine development in general. Fingers crossed!

• Pfizer announced in mid October that it would not apply for an emergency authorization of its COVID-19 vaccine prior to the third week of November, citing the need to collect additional safety and manufacturing data.

• Johnson & Johnson has launched phase 3 trials for it's vaccine. This vaccine candidate is good because it requires only one administration dose and does not have to be kept frozen.

• Unfortunately, the J&J trials have been paused on 10/13/2020 due to one unexplained illness in one participant.

• Invio Pharmaceuticals have had to put a hold on their final vaccine trials as the FDA tries to obtain some answers related to the novel delivery method of the vaccine. The hold was not due to any adverse effects seen in earlier investigation.

• An October article in the New England Journal of Medicine explains why a 2 month follow-up requirement for vaccines is appropriate:

• Most adverse events occur within 6 weeks after receiving a vaccine.

• The two month post-vaccination time frame allows scientists to make sure that the immune response doesn't wane after one month.

• The WHO actually requires a 3 month follow up of COVID-19 vaccines; other vaccines (like the shingrix shingles vaccine) required a follow up of 3-4 years.

• The FDA has approved Pfizer to include children over the age of 11 in its late-stage vaccine trials. This will let us know how children respond to the vaccines and hopefully allow for children to receive the vaccines as well - especially children that are particularly vulnerable due to underlying health conditions.

• Antibody therapy:

• Eli Lilly has developed an experimental treatment involving SARS-Cov-2 antibodies.

• On 10/13/2020, Eli Lilly had to pause their clinical trials due to "a safety concern." Although it is understandably frustrating that this treatment may ultimately be proven to be risky, it is good that the safety procedures are alive and well and we know that vaccines and treatments that will eventually come to market will likely have been adequately vetted.

• Regeneron Pharmaceuticals, the company responsible for the experimental antibody medication administered to President Trump, has asked for emergency authorization for use of its medication. Preliminary results have shown reduced viral levels in patients treated outside the hospital. Supplies are limited and only 50,000 patients could be treated at first.

• A recent study published in the British Medical Journal found that plasma from convalescent patients (i.e. those who had COVID-19 in the past) was NOT effective in treating active coronavirus patients.

Mills-Peninsula Hospital:

• Peninsula Hospital continues not to be full and is managing its share of COVID-19 cases as well as could be hoped for. Plenty of beds are still available in case more people fall ill and all the treatment modalities we discussed above are available here.

• People hospitalized at Peninsula Hospital for reasons other than COVID-19 may now have one visitor per day during visiting hours (10 am to 5 pm daily). Visitors will be screened for symptoms and asked to provide their name and phone number for contact tracing purposes. Also, visitors must wear specific face masks provided by Sutter.

Our Community and Beyond:

• The State of California has come out with a new color-coded system to guide reopening of different parts of the state: this system has 4 tiers: certain criteria such as each region's number of positive COVID-19 tests, hospitalizations, and Intensive Care Unit admissions will dictate what tier is appropriate for each region. Also, each region needs to be in a certain tier for at least 21 days and have improved their COVID-19 metrics for this time period prior to being able to "advance" to a higher/ better tier. The lower the tier, the more likely the region can open services.

• On October 19, San Mateo mandated a new compliance unit that will monitor businesses on issues related to compliance with county-related health orders. Specifically, businesses must implement social distancing protocols, require face coverings, and provide hand sanitizer or soap and water. If businesses are not in compliance, they will first be issued a warning. If the issues continue, civil penalties will be implemented (such as fines between $250 and $3000 per violation). Finally, the state reserves the right to criminally prosecute repeat offenders.

• Santa Clara County has closed pro sporting events and amusement parks for the foreseeable future

• On October 19, Gov. Newsom announced his plans to launch a scientific working group to examine the safety of any coronavirus vaccines that receive federal approval.

• California is also preparing to launch a massive vaccination campaign, according to plans released last week. The details of the plan, which presumably include information on where the vaccine will be distributed and stored as well as what populations will be prioritized, have not been released. Given the size of California's population, such a vaccination campaign is a huge undertaking and requires careful planning.

• On September 23, San Mateo announced a plan to significantly increase testing opportunities. The county's strategy involves a three-pronged approach:

• Scheduled testing at the San Mateo County Event Center. Testing here will occur Tuesdays through Saturdays from 8 am to 3 pm - all without a cost to the patients. Appointments are required and can be made at "projectbaseline.com/COVID19"

• Mobile testing in under-served communities.

• Targeted neighborhood testing.

• The CDC has recommended that children NOT trick-or-treat this Halloween, considering this a "higher risk" activity. Boo-hoo!

Our Office: What We Are Doing to Keep You Safe:

• All patients seen in person will be screened for COVID-19 exposure and symptoms prior to coming into the building.

• We disinfect all exam rooms and medical equipment as well as all door handles after EVERY patient visit, regardless of the medical issues involved.

• We are also using tele-health options that allow you to have video as well as audio interactions with us as part of a "remote office visit." Tele-health is one change associated with the COVID-19 crisis that is likely to remain long after this pandemic is over. However, video visits can never replace in-person visits in our ability to make diagnoses and to really get to know our patients.

• For those patients seen in the office, we ask that friends and family members stay in the car (or elsewhere outside the office) during the visit. Of course we do welcome caregivers into the office with the patient if they are needed for improved safety or communication. Other office guidelines will be based on recommendations of the American Medical Association and local public health ordinances. We have installed Plexiglas screens in the front office. We will do everything possible to make sure you feel safe to come back to our office.

• All of us in the office are healthy and doing well.

• All patients coming into the office will be required to wear masks.

• As in previous years, our office will be offering both quadrivalent flu shots as well as the flu vaccine for "seniors." We have received our shipment for the senior flu shots already and you are welcome to stop by the office any time (no appointment needed!) to get yours. We also have a limited supply of influenza vaccine for the under-65-crowd. More of those are expected to arrive in our office shortly!

We will try to keep you updated as the epidemic evolves. Feel free to call or email with questions or concerns.

About Dr. Sujansky's Life in These Times

On a more personal note, my family and I continue to do well.

Many of you know that I have taken up knitting during this pandemic. I want to thank my lovely patient who came into the office last week to help me figure out how to cast on stitches for my latest project. I am so touched by your time and efforts.

The days and nights are definitely cooler these days and fall is here. I, for one, am enjoying the change in seasons and the coziness that seems to come with it....not to mention the pumpkin lattes!!

Also, the California medial authorities are advising against trick-or-treating this year. On one hand, this is really a shame, especially for the many, many children that consider Halloween the best holiday of the year. But I must be honest also and express some relief: our house sits on the "Halloween loop" in our town and we get about 650 trick-or-treaters most years. I won't mind not having to stand at the door for 2 hours straight as kids crowd in. I think I will be retiring to my bed early and watching a scary movie with my husband this year...perhaps with an appropriately-themed drink in hand.

I wish you all a wonderful weekend and coming week. I hope all of you stay safe and healthy. I am thinking of you often.

Ulrike Sujansky, MD | tel: 650 393-5851 | fax: 650 393-5871 | email: doctor@SujanskyMD.com

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Sincerely,

Ulrike Sujansky, MD