As there is much to report this update is rather lengthy. Our goal with these updates is to arm you with the best information from multiple credible sources to keep you as current as we are.
Local Impact
Local officials are uncertain as to whether or not we have peaked in our case numbers. (See below for more details).
Angelina County is bound to follow the directives related to business openings and restrictions as prescribed by the Texas State Governor, Greg Abbott. Too, our civic leaders, Mayor Bob Brown, city manager Keith Wright and our City Council are in communication with local healthcare leaders to develop plans that maximize safety while attempting to restore and/or maintain local economies and businesses. Their decisions impact the very lives of thousands of people. We ask for your understanding and support as they formulate plans based on available information to thread a small needle.
As of today, Angelina County has reported 23 cases of COVID-19. No deaths have been recorded yet.
Concerns Regarding Local Testing
For Angelina County, we recommend significant expansion of testing as a critical element in determining the timing of the relaxation of current restrictions.
Of note, several of our patients have reported having specimens obtained inconsistent with recommended guidelines. Below is a brief summary of proper specimen collection from the CDC for COVID-19.
Nasopharyngeal (NP) Swab
A long flexible swab is introduced clear into the nose as shown by the illustration above. The swab should be rotated during the entire time it is in the nose to maximize absorption of secretions (15 to 20 seconds in each nostril).
Arguably, the greatest question immediately before us is when to begin to consider returning to “normal”. The answer will lie in the data from dramatically expanded testing in all of our population segments, from the very young to the very old. Only by so doing will we be able to piece together the true weighted range of disease expression from little or no symptoms to severe illness and death. The questions like - should we re-open schools, daycare facilities, restaurants, theaters, all businesses - will be better answered with more powerful data. As of today, it remains guesswork.
What To Do Now
- Remaining at least 6 feet away from people around you while in public must be more widely practiced. As this is our best protection against infection, we recommend strict observance of this singular measure as our greatest weapon against infection.
- Face masks remain recommended for children five years and older for travel outside of your residence.
- Routinely clean touched surfaces (for example: tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks, and electronics) with household cleaners that contain at least 60% - 90% alcohol.
- Wash hands frequently with soap and water. When using waterless hand wash, make sure it contains at least 60% - 90% alcohol.
- Sneeze or cough into your elbow fold, the back of your forearm or some kind of protective cloth.
- Shelter in place if you are at high risk (if you have moderate to severe lung disease, kidney disease, diabetes, immunocompromising conditions or are 65 years old and older.)
Reduce Your Risk of Getting Sick with COVID-19
- Continue your medications and do not change your treatment plan without talking to your doctor.
- Have at least a 2-week supply of prescription and non-prescription medications. Talk to your healthcare provider, insurer, and pharmacist about getting an extra supply (i.e., more than two weeks) of prescription medications, if possible, to reduce trips to the pharmacy.
- Talk to your healthcare provider about whether your vaccinations are up-to-date. People older than 65 years and those with many underlying conditions, such as those who are immunocompromised, have significant heart disease, diabetes, kidney disease or significant liver disease are recommended to receive vaccinations against influenza and pneumococcal disease.
- Do not delay getting emergency care for your underlying condition because of COVID-19. Emergency departments have contingency infection prevention plans to protect you from getting COVID-19 if you need care for your underlying condition.
- Call your healthcare provider if you have any concerns about your underlying medical conditions or if you get sick and think that you may have COVID-19. If you need emergency help, call 911.
If you have moderate-to-severe asthma,
- Follow your Asthma Action Plan
- Keep your asthma under control.
- Continue your current medications, including any inhalers with steroids in them.
- Know how to use your inhaler.
- Avoid your asthma triggers.
If you type 1, type 2 or gestational diabetes,
- Continue taking your diabetes pills and insulin as usual.
- Test your blood sugar every four hours and keep track of the results.
- Make sure that you have at least two-week supply of your diabetes pills and insulin.
- Follow the sick day guidelines.
New Challenges
The American public has feasted on a continuous news cycle for more almost 40 years (CNN began broadcasting June 1, 1980). We have grown accustomed to having questions posed on Mondays and answered by Fridays with all manner of inflammatory, often polarizing, opinions in between. The questions being currently posed regarding every facet of this pandemic will require months, at best, to answer. Unaccustomed to this new cadence we are programmed to look for alternatives that promise answers immediately. To wit, point of care testing for antibodies has a market that is preying on a worried American public. While American and international companies have been unleashed to develop cures and prevent or minimize infection you, our patients, families, employees and indeed the citizens of our county and service areas must understand the more protracted timeframe required for reliable solutions to the questions before us.
We are still in the early phase of data collection that then must be analyzed. The analysis will lead to the questions that must be asked. Developing trials and following those to conclusion will be the final step in conquering the challenges that this new infection presents.
As stated in the last update, we will prevail. We are 100% confident of that eventuality. Until then, we invite you, your friends and colleagues to remain informed by visiting our updates which are a synthesis of multiple sources including the CDC, Johns Hopkins University, the National Institute of Health, Harvard School of Public Health, Kaiser Permanente Healthcare System and many others.
Challenges Ahead
The most recent research indicates that we have underestimated the transmissibility of the virus as well as its ability to cause infection. While the question of whether the virus will spread as rapidly in warm, humid conditions remains, (most studies indicate a slowing in progression during warm humid conditions and resurgence when cooler, drier temperatures and conditions return in the fall) Dr. Anthony Fauci reports that his team of scientists believe that this new virus may be here to stay for a few years until effective vaccination protects us. As such, they anticipate a resurgence of infections once colder weather returns in the fall.
Testing for COVID-19
Many point of care tests are being released to the market prior to adequate scientific evaluation. Currently, there are no known reliable point of care tests that provide meaningful information.
Blood tests for COVID-19 are becoming increasingly available. Most are from China and have not undergone any significant reliability evaluations. Testing for antibodies suggest acute infection (IgM) or past exposure (IgG). A positive test may in fact be reacting with one of several common, harmless viruses within or related to the coronavirus family. (High likelihood of false positive). Hence, the reliability of the results are completely unknown. We simply do not know what level of antibody is protective and, if so, for how long. The tests are quite meaningless at this time and may give a dangerous sense of false security. “If you are getting an antibody test and it’s being conducted in your physician’s office, it’s a red flag,” said Kelly Wroblewski, director of the infectious disease programs for the Association of Public Health Laboratories. We agree.
Good News in the Fight Against COVID-19
Time from contracting the virus to developing symptoms has now been somewhat established. Research has now determined that the median incubation period for COVID-19 is just over 5 days and that 97.5% of people who develop symptoms will do so within 11.5 days of infection.
It usually takes about 10 to 15 years to develop a vaccine. The good news: leaps in technology, such as the ability to rapidly sequence virus genomes and to create vaccines out of messenger RNA, are speeding up the process of development. Developing new drug treatments can also take time—about a decade from discovery to getting on the market. But here technology also provides an advantage. New types of antiviral drugs and immunotherapy treatments can treat a wide range of other diseases which means that drugs already in the development pipeline or already treating diseases in patients could be useful to fight COVID-19, shortening the time it will take to make an effective medicine.
Many other drug combinations, 300 in all, are being tested at this time across the globe. It’s just a matter of time before we find the silver bullet.
Treatments
- Remdesivir is gaining momentum as a leading therapy within the hospital setting. Multiple studies are currently underway and early results are promising.
- Several monoclonal antibodies are being developed using related technologies and strategies against other known viruses including Ebola virus. Again, early results are bearing fruit.
- Data regarding hydroxychloroquine/chloroquine and Zithromax are inconclusive at this time. Studies remain ongoing and are having some mixed results although most seem to have some benefit.
- Ivermectin has been shown to inhibit viral replication in the laboratory setting and has had some success anecdotally. Formal studies are also underway investigating its potential therapeutic benefit.
- Immunoglobulin therapy: Antibodies from recovered COVID-19 patients could help with free virus and infected cell immune clearance. Further studies are warranted. On March 24, the FDA released guidance for screening donors for COVID-19 convalescent plasma and on emergency investigational new drug applications based on this modality.
Vaccines
Clearly, vaccines represent the “most effective long-term strategy” to prevent future COVID-19 outbreaks, though at least 12-18 months would be required until vaccines can be widely deployed. The company Moderna continues its early testing of the COVID-19 vaccine with the second dose of the immunization administered April 15. Subjects will have blood work performed in approximately 2 to 3 weeks and periodically thereafter to determine immune response. Stay tuned.
COVID-19 UPDATE April 5, 2020
Angelina County issued a stay-home, stay-safe order effective 11:59 PM April 3 for all county residents. This order will remain in effect until it is rescinded, suspended, or amended or until it expires on May 1. This is not shelter in place.
The order requires any business open to the public to enforce certain safety requirements and to have a written plan in place to enforce those rules, including procedures for maintaining a 6-foot distance between people and for regular cleaning. The number of customers in each store at one time will be limited. The new orders also state that travel in Angelina County is prohibited except for essential activities or going to work in an essential business. Essential activities are defined as performing tasks essential to your health and safety or the health and safety of family and household members, obtaining necessary services and supplies for an individual, family, or household or delivering those supplies to a person in need, outdoor activities provided social distancing requirements are followed, caring for another family member or pet in another household, school-related activities, and engaging in the work of an essential business.
The order can be found here: https://www.angelinacounty.net/files/pdf/order0402.pdf
Please be reassured that the Children’s Clinic and Angelina Pediatrics are following these guidelines, with screening of all employees, patients, and parents at the door, maintenance of social distancing, and constant cleaning. Consistent with the recommendations of the American Academy of Pediatrics we continue to provide well checks and vaccines. We are prioritizing well checks to the morning hours and sick visits to the afternoons, and are not allowing anyone who fails COVID-19 screening into the buildings. We are personally caring for all patients with fever, cough, congestion, or other such symptoms via telemedicine. See our website for more information.
On April 3 City of Lufkin officials recommended that residents over the age of five wear facemasks when in public. The mask should provide coverage of nose and mouth. Examples of masks include allergy masks, homemade masks, scarves, bandannas, or handkerchiefs. They are to be used when engaged in social settings. It is critical that citizens understand that this measure is additive to the social distancing 6 feet or more and not a substitute for social distancing.
LOCAL IMPACT
Officially the ACCHD lists ten cases of COVID-19 in our county as of this update. Due to limited testing the number is likely much higher. Perhaps the most important message of this update for our patients, families and employees is that COVID-19 is here. There is community spread now. We are reminding everyone that this virus cannot come and find you; you must go find it. Restated, travel only when necessary and maintain social distancing.
Keep in mind that SARS-Co V-2 (Severe Acute Respiratory Syndrome CoronaVirus 2), the official name of the virus causing COVID-19, is a novel, or new, virus first appearing in December in China. Thus, to our knowledge 100% of all humans are susceptible to infection. Our strongest and most effective tool against this novel infection is social distancing of six feet or more. Washing your hands with alcohol-based sanitizer or soap and water frequently, avoiding touching your face, mouth, eyes, or nose, and wearing a mask in public are our additional protections against infection.
Pre-symptomatic transmission has now been documented. This means that people who are infected with the virus have been documented to shed the virus before symptoms develop. This is a significant finding in that it means that people with virus in their system can spread it before they themselves know they are ill. Thus again, social distancing and the measures mentioned above are to be strictly observed.
The number of cases in Angelina County is going to climb, perhaps dramatically. The public must know that our county may experience higher numbers of patients with severe disease or death. The reason for this likelihood lies in the general health of our population. According to the 2020 Texas Department of State Health Services website Angelina County ranks number 207 out of 254 Counties in regard to health behaviors. That means we smoke more, drink more, and in general engage in more unhealthy behaviors, many of which increase our risk of severe disease or death if infected with the COVID-19 virus. Specifically, people with chronic lung disease, diabetes, heart disease, kidney disease, immune compromising conditions, along with people older than 75 are at highest risk of poor outcome. We strongly recommend that those with these risk factors shelter in place.
NEW DEVELOPMENTS
New Challenges
As discussed above, pre-symptomatic transmission has now been documented. People without symptoms may unknowingly transmit the virus. Our best weapon remains social distancing.
Age and Gender Matter
The overall risk of serious illness or death in children remains extremely small. However, there have now been reports of children becoming seriously ill and dying due to COVID-19. Fortunately children, with rare exception, seem to be spared severe disease. This observation has been documented in all countries. Research is underway as to why.
For reasons that are not understood men may be at increased risk of severe disease or death. This trend has been observed consistently across all countries.
Older people are developing more severe symptoms than younger people despite neither having immunity to COVID-19. There is no rational answer at this observation. People over age 60, particularly those with secondary medical conditions, are at greater risk of severe disease. People older than 75 with or without underlying conditions seem to be at risk of severe disease as well. These findings are also consistent across all countries.
Hopeful News
A few medication regimens seem to be gaining traction as treatment options for patients with COVID-19.
1) Remdesivir- The leading candidate to treat this highly infectious disease. The Chinese government in fact has undertaken mass production to synthesize the active pharmaceutical ingredients of Remdesivir.
2)Leronlimab- A medication typically used for patients with HIV and/or metastatic triple negative breast cancer. Its primary benefit is to reduce respiratory symptoms and complications in patients that have impending respiratory failure or are on ventilators by mitigating cytokine storm, an abnormal hyper-inflammatory response some people experience with infection, which if left untreated can cause multi-organ-system failure.
3)Ivermectin – this drug may block the virus’s attachment to our cells.
4)Chloroquine and Zithromax. Multiple studies are currently underway evaluating the efficacy of this combination.
5)Dr. Jacob Glanville reports that he has engineered an antibody that blocks the ability of the virus to attach to human cells. He developed a similar antibody against Ebola virus and reduced its mortality rate from between 50%- 70% to approximately 6%. More to come.
6)The second dose of the experimental vaccine (first dose given March 16) is due to be given April 16. Approximately two weeks afterward serum will be drawn from subjects to determine immune response. If effective, the vaccine should be available for healthcare workers in 4-6 months. The general public would have access to the new vaccine approximately 10 to 12 months later.
Keep in mind there is a global effort, a race, to find a cure as well as a means of preventing infection. The best and the brightest minds in the world are at work night and day. We will win the day.
Know too that the vast majority of all people with COVID-19 experience mild disease (82%). With widespread testing it is almost certainly going to come to light that many people did not even know they were infected. It is our belief that the 82% figure will rise significantly.
A Note on Transmissibility
It has been widely reported and repeated that the virus remains viable on plastic for up to 72 hours. A close look at the data that resulted in this report reveals that only 0.1% of the virus was viable at the 72nd hour. That viral mass is considered too small to lead to infection.
It has also been widely reported and repeated that the virus can linger in air for up to three hours. The aerosol used for that test was far smaller than 5 µm. Unless we are in conditions of extremely low temperatures and low humidity the droplet size in our speech is typically larger than 5 µm. Also, moisture in the air will attach to the virus-containing droplet making it larger and heavier. It will typically fall to the ground within 30 to 45 minutes or sooner. This explains why maintaining a safe distance of six or more feet from each other remains our best defense against infection.
