Frequently Asked Questions about COVID-19

  “Shared expectations lead to predictability.”

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  1. When, where and how to register to be vaccinated – as of January 18 

       Q. Has anything changed since last week on how we can get vaccinated? 

       A:  Last Thursday, Connecticut started booking vaccinations for the first group in Track 1b – those aged 75 and older.  Other groups in this track will soon be able to make appointments:  These include those between the ages of 65 and 75 and front line essential workers including teachers, first responders and others.  A complete listing appears at[1]:

https://portal.ct.gov/Coronavirus/COVID-19-Vaccination—Phases

Following new national guidelines, some of these other groups will be blended in as doses become available.  Strict compliance to sequencing groups in a priority order is no longer required.  For example, recent news articles have shown firefighters being vaccinated, and complaints have been heard because teachers are starting to book appointments.  Organized groups will notify their members when appointments can be made.  For those qualified by age or health conditions, people need to learn of their eligibility through the news media or website shown above.

Everybody can immediately register on the state Vaccine Administration Management (VAM) website.  This will inform everyone who is registered when their turn for making appointments arrives.  Every state has this CDC VAM program resource.  The CT site is located at:1

https://dphsubmissions.ct.gov/OnlineVaccine

After providing your name, email address, birth date and “occupation,” you will be told if your registration is accepted.  After as much as a two-week delay for processing, you will be notified when your group becomes eligible and how to make an application.

Or you can call the Connecticut Vaccine Line on the phone: (877) 918-2224 to register.

Be patient!  Several have stated when they call for an appointment, there are long waiting times – similar to calling for concert tickets before they sell out!  Hopefully things will improve!  For one person it took four minutes of rapid redialing to get through the busy signals.  Then 2 hours 55 minutes on hold before an agent picked up.  After that, only 4 minutes was required to schedule the appointment.  Keep the power cord and coffee maker close by!

  1. Confusion continues matching available doses to demand

       Q: Is it true that many people making appointments may not be vaccinated because they have run out of doses?

       A: Yes, this has been a problem, but will soon be rectified.  The Trump administration moved last week Tuesday to release all the vaccines stored in warehouses to expand the number of vaccinated people.  But this move was embarrassing when it was later learned that all reserved doses had already been released.  Some states with unused doses ready to be thrown out have opened up their vaccinations on a “first come-first served” basis.  This resulted in long lines, hours of waiting time, and eventually unvaccinated people being turned away.  President-elect Biden’s transitional team has been developing plans to both enhance product availability and the efficiency of administering doses.  Once he takes office this week, he is expected to invoke the Defense Production Act to order larger quantities of the vaccine.  Pfizer has announced that they will initially cut back on the number of doses immediately released to other countries, making up for this when US production increases.  Large-scale arena-sized vaccination centers are planned within each of the states, and National Guard mobilization is planned to run these centers.  Funds will be asked for from Congress to employ significant numbers of new public health personnel to expand testing and contact tracing.  Originally, the national plan was to hold back the second doses required for everyone receiving their first one.  Later, it was proposed to increase the number of people getting the first dose by releasing all vaccine doses immediately.  Dr. Fauci stated last week he was against this because it might mean  people might never get their second dose.  But he now agrees.  On January 17, he stated “the flow of COVID-19 vaccines is steady enough to ensure everyone will get their second dose to ensure 100 million vaccinations in Joe Biden’s first one hundred days in office.”

Of course, it will take time to build the resources and structures to vaccinate more efficiently.  People are advised to focus ahead and remain patient.

  1. Pain medications not advised before getting vaccinated

       Q:  Should I take a painkiller before getting my shot ?

       A:  Paul Offit, MD is a professor at the Perelman School of Medicine at the University of Pennsylvania.  He recently stated that some studies indicate that pain killing medications, taken before getting the vaccine, especially fever-reducing medications like aspirin, ibuprofen or acetaminophen, can interfere with the immune response.  Mild pain, soreness, swelling or aching are all associated with getting the COVID vaccine.  Knowing this, many people may want to take a pain medication before they get their shot.  Based on the evidence, this is not recommended.  This does not mean one cannot take medication to relieve the aftereffects.  The advice is given to wait at least 6 hours after being vaccinated before you take such medication.  And remember, you will be asked to wait for about 15 minutes after getting the shot to be sure  there is no allergic reaction.

  1. Gut bacteria tied to COVID-19 disease severity

       Q:  What’s new in research on coronavirys-19?

       A:  One scientific report has been published in a medical journal focusing on the digestive system.  “COVID patients lack certain good bacteria known to regulate our immune system,” said Siew Ng, MD, of the Chinese University of Hong Kong in the recent issue of the scientific journal Gut.  Her team has developed an oral formula of live bacteria and a special capsule to protect the organisms until they reach the gut.  “Compared with patients on standard care, our pilot clinical study showed that more COVID patients who received our microbiome immune formula achieved complete symptom resolution,” Ng said.  She added that “those who got it had significantly reduced markers for inflammation in their blood, increased favorable bacteria in their stool and they developed neutralizing antibodies to the virus.”

  1. Mental health concerns gaining attention.

       Q:  What about mental health and COVID – All we hear about is the public health?

       A:  Mental health aspects are less boldly defined and are not seen as great a threat as an inability to breath, or cardiovascular collapse.  In spite of this, studies and investigations are emerging that focus on the mental health aspects of COVID-19.  In a recent article in the Hartford Courant, “Steven Rogers, MD. An emergency physician at the Connecticut Children’s Hospital said before the pandemic, schools would often refer children having behavioral health issues to them for care.  But with many schools operating in a hybrid or remote model, ‘that’s not happening as much.  Our sense is that families are either not recognizing it, or are waiting longer.’”  He cited the fear that parents might be coming to a hospital emergency room that may be filled with COVID patients to address behavioral issues.

A study conducted in June and July in England and reported last Wednesday in the Journal of Occupational Medicine identified that nearly half of the staff working in intensive care units have severe anxiety, depression, or post-traumatic-stress-disorder, some even having suicidal thoughts.  This study is taking on new importance with the UK-variant coronavirus-19 dramatically increasing the number of patients in hospitals in Great Britain.  Their findings show an urgent need for mental health services to be promptly available to all healthcare workers.

[1] To open this website, copy the entire URL (underlined and in blue), and paste it in your internet browser.

 

Frequently Asked Questions about COVID-19

  “Shared expectations lead to predictability.”

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  1. When, where and how to register to be vaccinated – as of January 12  

       Q: Has anything changed since last week on how we can get vaccinated?

       A:  YES!!  WFSB TV announced during its 11:00 news broadcast on January 11 that the Connecticut guidelines for Track 1b groups to get vaccinations has been released.

  • The first group to be allowed vaccinations will be people over age 75
  • The first mass vaccination site will be Rentschler Field in East Hartford
  • Another site will be the Connecticut Convention Center in Hartford
  • Several pharmacies will be included
  • Appointments can be made starting on Thursday, January 14
  • Vaccination appointments will start on Monday, January 18

Appointments can be made starting Thursday using the Vaccine Administration Management (VAM) website[1]  https://vams.cdc.gov/vaccineportal/s/login/?ec=302&startURL=%2Fvaccineportal%2Fs%2F

Further details including the phone numbers to use for making an appointment will be forthcoming.  You can find more updated information on the WFSB or the CT websites:1

https://www.wfsb.com/news/a-breakdown-of-the-vaccine-rollout-in-connecticut/article_172cf82a-5421-11eb-a098-5b6d493f3339.html

https://portal.ct.gov/Coronavirus/COVID-19-Vaccination—Phases

186. Lack of planning for distribution of vaccines to sites creates bottlenecks

         Q: Is it true that some vaccine doses delivered to states aren’t being used?

         A: Yes.  In many states, doses received from the manufacturers are not making their timely way to regional and local sites where they can be administered.  The federal “Project Warp Speed” did plan for a rapid manufacturing of the initial doses of the vaccines and transportation to each state.  Communication between the states and the manufacturers for additional periodic shipments has been somewhat ineffective.  But more critical is the lack of federal guidelines and incomplete state planning for moving the stockpiles to localities where the vaccinations can be given.  CDC has reported that as of January 4, 15,400,000 doses of COVID-19 doses have been sent to the states, but only 4,500,000 (29%) of these have been administered.  Without detailed national guidelines, some states have avoided trashing unused vaccines by allowing anyone to be vaccinated on a first-come-first-served basis.  Their vaccination sites have quickly become overwhelmed.  Other states have held tightly to their sequential eligibility for getting shots and they had to destroy unused doses that exceeded the time limits for storage.  The emerging nation-wide planning by the new Biden administration will need to address these issues.

  1. More implications from the emerging mutation coronavirus-9

       Q:  How widely has the variant mutation of coronavirys-9 spread in the US??

       A:  Since last week, the more infectious variant of coronavirus-19 has been identified in eight states including Connecticut.  The other states are New York (3 cases identified), California (32 cases), Florida (22 cases), as well as Colorado, Georgia, Pennsylvania and Texas.  Few states have ramped up their gnomic testing to identify these mutant viruses.  Thus, it is expected the prevalence of this variant virus in each state may be much higher than the number reported.  As a result, it becomes increasingly more important to wear masks and keep an even greater social distance from others.  As the New York Times reported, “In a positive development, Pfizer and BioNTech announced last Friday that their vaccine was effective against one of the mutations present in the new contagious variants identified in Britain and South Africa.”  Another new finding has just been announced that may explain why this mutation is more infectious.  The FDA last Friday announced that some of the authorized COVID tests show an increased number of false negatives with this mutation.  This means many of those actually infected with the variant virus do not show a positive finding.  The contagious person can therefore remain less vigilant to take strict measures to stop the spread.  Thermo Fisher Scientific’s TaqPath COVID-19 combo kit, and Applied DNA Sciences’ Linea COVID-19 assay kit were both found to have significantly reduced sensitivity to the mutations including the ones now rapidly – explosively – expanding.

  1. Hospitals teeter on the brink of crisis

       Q:  How widespread is the problem of hospitals filling up?

       A:  One way that hospitals guard against running out of beds is to initiate programs to increase “surge capacity.”  Planning calls for setting up additional beds and adjusting staffing schedules to expand critical capacity.  Another planned response is to identify critical care capability in other hospitals.  Hospitals can then redirect ambulances on the way in, or transfer out patients already there.  In several locations across the country, these measures have not been enough.  Southern California is so overwhelmed with COVID-19 patients for which there is no staff or space for expansion, and no nearby facility available to transfer patients.  As a result, ambulances arriving have had to wait many hours in the parking lot before patients can be seen inside.  “When we get filled up with COVID patients, we can’t take care of the community in general,” said Jim Kearny, the managing partner for emergency physicians at Providence Mission Hospital in Mission Viejo.  “Every bed is full, every nurse and doctor is occupied taking care of COVID patients.”  The rationing of care – following the crisis standard of care – is becoming a more frequent necessity.

Another cause for the lack of beds goes to the end of care. There is no space in some hospitals to hold all the dead bodies this making room for new patients to occupy the freed-up beds.  For hospitals throughout California, the Office of Emergency Services has arranged to send 88 refrigerated trailers to hospitals to help meet their need to clear space where bodies are accumulating.

189. Vaccinated nurse in the US contracts COVID-19

        Q:  I heard that people getting vaccinated are coming down with COVID.  Is this true?

        A:  A nurse in California contracted COVID-19 more than a week after being vaccinated.  Pfizer and medical experts immediately reacted by saying the vaccine needed more time to build immunity.  Apparently fearful that a single case might be used by those who are opposed to vaccines to prove their case, the response was made quickly after the situation was publicized.  The incident also illustrates that the public health benefit of the vaccination program is not to guarantee immunity for everyone who receives the shot.  An “effective vaccine” defines how many people who gets the vaccine will be protected.  The Pfizer vaccine in its clinical trials was found to be 95% effective.  This means 95% of the people vaccinated will be protected, and that 5% can still contract the disease.  The public health goal is to reduce the number of people from which others can become infected.  This will reduce the spread of the disease over time as more and more people are vaccinated.  We all know people who got a flu shot yet still came down with influenza.

This and any similar future cases do not prove the COVID vaccine is ineffective.

  1. Five more people have shown severe allergic reactions to the Pfizer vaccine

        Q:  How badly are people showing allergic reactions to the vaccine?

        A:  The FDA is investigating five events last week where people suffered severe allergic reactions to the Pfizer vaccine.  Peter Marks, MD, director of the FDA’s Center for Biologics Evaluation and Research identified that these patients were from several different states, including one from Alaska.  He identified an ingredient of the vaccine – polyethylene glycol – as the suspected culprit causing these reactions.  The number of people with allergic reactions to the COVID-19 vaccine is frequently found in people who have had previous anaphylactic reactions to other medications.  It remains an FDA recommendation that people who know they had previous allergic reactions to medications should not get the COVID vaccine.  It also justifies the recommendation that everyone getting vaccinated remain on-site 15 minutes for observation.  Immediate treatment for anaphylaxis – the most critical result of an allergic reaction – is an EpiPen or injection of epinephrine.  Space is required for each person being vaccinated to remain for 15 minutes after getting their shots.  EpiPens must be available with people trained to administer this.  These requirements make planning for large-scale vaccinations more difficult.

[1] To access this website, copy the complete URL (underlined and blue in color)  For VAMS, you can register in advance of January 14.

Frequently Asked Questions About COVID-19

“Shared expectations lead to predictability.”

181. When, where and how to register to be vaccinated as of Jan. 4.

         Q: Has anything changed since last week on how we can get vaccinated?

         A: No! The current Connecticut vaccination program is still focused on Tier 1a, which includes “healthcare personnel,” “long term care residents,” and “first responders at risk of exposure to COVID-19.” Earlier, the State Health Department estimated this tier included 167,500 people. Bloomberg News reported that as of last week, 149,900 doses have been received in Connecticut. 78,940 doses had been administered (50% of the doses available). The Connecticut Department of Health has not yet updated its procedures for people in the next Tier, 1b. This next group includes “critical workforce” (yet to be defined), “other congregate settings” (e.g., prisons), “adults over age 65,” and “high risk individuals under age 65.” Unofficial sources speculate that this next grouping will begin vaccinations by the end of January. Announcements might soon be made telling where people in the Tier 1b groups can call to make a vaccination appointment. It is not yet known, but each of the above groups may be separated into sequential time blocks. If so, people over age 65 might begin to be vaccinated in the summer rather than in just a few weeks. We’ll soon find out. In addition to local pharmacies, medical offices and health centers, it is expected that large vaccination centers will need to be made available. Planning has yet to consider the scale of effort this project will require! To vaccinate the estimated 3,000,000 people in Connecticut over age 16 by December 31, 2021, it will require more than 8,200 people to be vaccinated (or 16,400 shots to be given) per day including weekends and holidays! To reach herd immunity leading to a “return to normal,” at a more conservative 70% vaccination level, more than 5,750 vaccinated people (11,500 shots) each day will be required! The costs for the extensive full time staffing and support of these vaccination centers for this length of time will be monumental! Stand by! More on Connecticut developing its procedures will be reported next week.

182. Implications from the emerging mutation or variant  coronavirus-9

         Q: Why are so many people concerned about the mutation found in the UK?

         A: In the United Kingdom, a rapid regional rise in the cases of COVID has been taking place over just the past few weeks. This was centered in the southeast area around London, and is spreading rapidly outward. Unlike the United States, the UK routinely does genetic testing of the coronavirus-19 virus sampled from diseased patients. Starting in November 2020, the prevalence of a variant or mutated virus was found. Currently, this variation accounts for 60% of the infections in London. Typically, mutations occur quite frequently, and are the result of incomplete or altered replication of the ribonucleic acid (RNA) as the virus multiplies in an infected person. This mutation has been scientifically identified and given the name: “B.1.1.7.” It differs from the earlier virus in the composition of the “spike protein” that allows the virion to enter a human cell where it replicates into multiple copies of itself, expanding the infection within the patient. The significant result of this particular mutation is an increase in the infection rate by as much as 70%. Each person that carried the earlier virus and gave the disease to 2 people, now if infected with this variant can infect on average about 3.4 others. One factor causing this greater contagion may be the dramatically increased upper respiratory viral load resulting in a greater concentration of the variant virus when the patient exhales. Wearing a mask, and keeping an even greater distance between people are clearly indicated to avoid contagion.

The impact is a rapid increase in the number of cases that require hospitalization within a given period of time. Hospitals that had been discharging patients at the same or faster pace than newly arriving patients now find themselves overwhelmed.

Other factors can cause hospitals to become overwhelmed. People not wearing masks when in public, ignoring warnings to avoid large gatherings – especially indoors, and not following guidance to limit travel over holiday periods are among the other reasons why available hospital resources become stretched. Medical care must be rationed at the point where diversion of ambulances to other hospitals is impossible, and when additional temporary hospital facilities and/or external trained manpower are not available. The Crisis standard of care is defined by the AMA , to address the ethics of rationing medical care. The AMA also defines procedures on how to develop these standards for lesser caregiving. Currently, Los Angeles County and adjacent areas have reached the limit for the normal standard of care. Multiple hospitals there are now implementing this care-rationing process.

The United States is just now establishing a national program of routine genetic evaluation to identify mutations and variant forms of the disease. The variant B.1.1.7. is now identified as being in California, Colorado, Florida and upstate New York. Scientists are now working to determine if this variant has any other implications. To date, the CDC has stated there is no evidence that the variant results in more serious illnesses or deaths. There is also no evidence that the current vaccines will be less effective in preventing infections. Studies are underway to scientifically determine the validity of these and other effects from this new variant.

183. New vaccines with lower effectiveness – private v. public health considerations

        Q: Can I choose the vaccine I want to take? I want one that is more effective.

        A: If you consider only your personal health, the only choice you will have is to delay scheduling an appointment until a vaccine with a higher effective rate is available. To do so, you will remain unvaccinated until you can find a site that offers your preferred vaccine. Public health considerations are the reason officials are strongly urging immediate use of any vaccine offered when it is your turn to be vaccinated. This contrast is an example of the difference between private health and public health. Personal health would lead an individual to want to receive the Pfizer or the Moderna vaccine with its 90% to 95% effectiveness. But when the AstraZeneca vaccine later becomes available – perhaps in April – it may be rated at about 70% effective. This next-in-line vaccine will be easier to transport and to store. It will only require refrigeration, not a freezer or cold-chain ultra-cold equipment. More people can thus receive this future vaccine in a given period of time than the two mRNA vaccine products currently being used. This gives the public greater protection by rapidly decreasing the number of people who are contagious. That is the goal of public health. Most authorities recommend that any approved vaccine should be taken as soon as it becomes available for people in each of the priority groups. The delay by deciding to wait for a higher efficiency vaccine actually places the unvaccinated person at greater risk than the less effective protection immediately taken.

184. “Living room spread” of COVID used to illustrate its contagion

          Q: We want to “get back to normal!” Why not visit often with a few of our best friends?

          A: One reason for the explosion of the number of cases is the “vigilance fatigue” that everyone is experiencing to limit contagion from infected people. Many have already developed the “habit” of wearing a mask and maintaining social distance when leaving the home. But with the emergence of the variant virus, vigilance against indoor contact is becoming more important. One physician, Dara Kass, MD published online a case study about a man who was tested for COVID-19. Dr. Kass is an Associate Professor of Emergency Medicine at Columbia University Medical Center.

After testing negative for COVID-19, this man decided to visit his family including his parents and siblings. The following day, his mother had her own parents come for dinner. They were frequent visitors, and were considered part of the same “bubble” or cohort. Everyone felt comfortable being together indoors without masks or social distancing. A day later, a nanny arrived to spend the day tending to a younger child.

“However, the older brother who came to visit actually tests positive after developing symptoms. The mom and the entire family began developing symptoms themselves. It wasn’t long before mom tested positive herself and everyone begins quarantining.” It turns out that the most serious health implications fell upon the nanny, who became critically ill, and who had no health insurance. “Dr. Kass highlighted this case as a clearly delineated instance of ‘living room spread’ and how this is one of the most seemingly harmless, but actually pernicious ways that COVID-19 keeps surging up again after leveling off for a few weeks or days.” One has to remain vigilant about how family and friends might actually be contagious, even if they live at home with their family or are frequent visitors. Wearing masks indoors and keeping distant from others are habits worth developing in the months ahead!

Frequently Asked Questions about COVID-19

  “Shared expectations lead to predictability.”

   176.When, where and how to register to be vaccinated – as of December 28.

          Q: My wife is aged 62 with a medical condition. I am 68 years old.  Where do we register to be vaccinated?

          A:  Each state is defining for itself how the people who are not “essential healthcare workers” will next be prioritized and the process they will follow.  The State of Connecticut as of last Monday has not yet defined these details.  There are several groups in the next “1b” group of vaccinations yet to be scheduled.  It is stated on their website, “Those who will be eligible for vaccination in upcoming phases between January and May has not been finalized, but we anticipate it will include:
  • Critical Workforce
  • Other Congregate Settings
  • Adults Over 65
  • High Risk Individuals Under 65”

The state indicates that these four main groups in the next scheduled track may be differentiated and further defined.  The groups may also be prioritized, meaning that qualified people in three of these groupings may be delayed before they are eligible after others are vaccinated within the “January-May” schedule.  Another detail that needs to be defined will be defining the proof people will need to show they are in their authorized group.  For example, a driver’s license showing the birth date and photo can be used to show one is over age 65.  But what other proof of identity and age can be used for someone who no longer has a driver’s license?   What proof does a 30-year-old need to show they really are at “high risk?” In last Monday’s Hartford Courant, an article was published showing that Hartford HealthCare, the parent company of seven Connecticut hospitals including Hartford Hospital, is opening a major vaccination clinic at the Connecticut Convention Center located at the intersection of I-91 and I-84 in Hartford.   They are currently vaccinating essential healthcare workers finishing up the “1a” priority group.  This facility already has an essential requirement – ample space for large numbers of people to each wait 15 or more minutes after being vaccinated for observation of any rare but possible severe allergic reactions.  Other sites including medical offices, and participating CVS and Walgreens pharmacies may also be announced as possible vaccination sites.  Details on how to make appointments, and other details will soon be announced by the State.  Meanwhile, the current advice for everyone not now being vaccinated is to “remain in close contact with their medical providers as more detailed plans are released.”  Or you can directly check the Connecticut coronavirus website[1]:      https://portal.ct.gov/Coronavirus/COVID-19-Vaccination—Phases

  1. The professional pros and conspiratorial cons of vaccinations

        Q:  Will the “anti-vax” movement interfere with the vaccination program achieving its goal?

        A:  The goal of all vaccinations is two-fold.  To protect the medical health of the person being vaccinated and the public health by preventing the disease from being passed along to others.  Science has shown that the two approved COVID-19 vaccines in phase 3 clinical trials have shown 90% to 95% effectiveness – preventing the vaccinated person from contracting COVID-19 and minimal risks or side effects.

For many people, however, the fear of vaccines – all vaccines – has led to their reluctance to being vaccinated.  In 1998, an article was published in The Lancet authored by Andrew Wakefield and eleven coauthors.  It claimed to link the measles, mumps and rubella (MMR) vaccine to colitis and autism spectrum disorders.  This study was found to be fraudulent and was later retracted in 2010.  The repercussion has been felt to this date with parents refusing to vaccinate their children against MMR.  A wide distrust of medicine, especially by African-Americans began when the U. S. Public Health Service, working with the Tuskegee Institute in 1932 began a study to record the natural history of syphilis.  The study initially involved 600 black men without the benefit of patients’ informed consent.  They also did not receive the proper treatment and the study actually went on for 40 years before it was halted.

The challenge now for public health officials is to have a significant percentage of the population be vaccinated to stop the spread of COVID-19.  The success of the polio vaccine did achieve this goal, as well as the earlier success of stamping out the deadly smallpox disease.  But if a significant percentage of the population refuses to be vaccinated against COVID-19, the disease may linger and become endemic.

The increasingly broad fear generated from these previous events has led to many people who are against vaccinations to become known as “anti-vaxxers.”  Among the many conspiracies these people share openly with each other is that “COVID-19 is just a hoax created to force global vaccinations.”  It was recently learned that multiple leaders of several anti-vax groups in the United Kingdom have banded together stating that the COVID-19 vaccine is a “pivotal opportunity to sow distrust in vaccinations.”  They are now laying out extensive campaigns for both the UK and the US to accomplish this.

  1. “Failure to thrive,,,” a different look at loneliness because of isolation

        Q:  Why does everyone react differently, yet significantly, from being so isolated?

        A:  Pediatricians have long seen and treated a condition in children identified as a failure to thrive (FTT).  In children, this condition is often correlated with a slower growth rate (height, weight, etc.) compared to others of the same age.  One of the causes is abuse or prolonged absence of stimulation.  During this COVID pandemic, Megan Sandel, co-director of the GROW Clinic in Boston saw that many “children from families who face barriers to their basic needs may struggle to get the necessary developmental nourishment to keep them healthy and thriving.”  Food scarcity is recognized as an element of this FTT.  Closing of schools, discouraging group activities and isolation is also cited in this pandemic-caused FTT.  Jeff Johnson, AARP Florida State Director stated. “The way isolation and loneliness work on the body is that it adds to stress.  And if you are already frail, (and) you already have other health conditions, they’re going to make these even more dangerous.”  A newly released study by AARP shows two-thirds of adults in the US have reported experiencing social isolation during this epidemic.  One Florida resident in a nursing home lost his wife of 70 years.  Family members were unable to visit him and provide solace.  Two weeks later, he died.  The death certificate listed the cause of death as “adult failure to thrive.”  Recently, this term has been more widely adopted to define the effects of isolation and loneliness on adults.  Perhaps this helps all of us realize why so many feel distress while functioning “normally” in isolation.

179. “Impatience with vigilance” extends to the near-distant future – traveling

          Q: When will it be safe to become a tourist?  I just can’t wait!

          A: The Washington Post recently published an article indicating people everywhere are now booking international travel and cruises that will take place as early as summer of 2021.  The release of a vaccine and the optimistic view that hundreds of millions of people worldwide can be vaccinated in just a few months seemingly has joined with an impatience from all the isolation we’ve been through for less than a year causing the need to leap ahead with planning.  Experts are urging caution, however.  There is agreement that returning to pre-pandemic normalcy will not be sudden nor universal.  At home, unless a significant percentage of  the population becomes vaccinated, herd immunity may not be achieved and restrictions could remain in place until 2022.  And travel restrictions to other locations may remain for some time if vaccinated people can still become infected and while asymptomatic, spread the virus to others.  “Patience is a virtue!”

180.  Roles school nurses play in pandemic responses.

          Q:  What can we do to encourage school nurses who play a key role COVID-19!

          A:  Not all schools have a nurse available, and fewer have one in the building at all times classes are in session.  Some school systems have a nurse that rotates by the day of the week or other periods between several schools.  The National Association of School Nurses (NASN) has pointed out the many unique functions school nurses perform.  One problem identified is that many local healthcare organizations and school districts often plan and create policies for managing COVID-19 outbreaks in schools without including school nurses.  Even when involved with planning, school nurses often work with inadequate personal protective equipment or in a crowded space, restricting social distancing.  They not only treat common symptoms of “bumps and bruises” and “not feeling well,” but are responsible for educating children and their parents on many related health matters.  They guide staff and teachers on appropriate ways to protect the children while in school.  Parents of children who are still in classes, or who will soon return to in-person sessions are encouraged to reach out directly to their school nurses to offer encouragement and to help by being their advocate to shore up this often-overlooked part of healthcare.

[1] To go to this website, copy the complete URL as shown in blue, then paste this into your browser.

Frequently Asked Questions about COVID-19

  “Shared expectations lead to predictability.”

  171. Impact of a mutation of coronavirus-19 in the UK is being studied.

         Q. How dangerous is the new strain of coronavirus-19 emerging in the United Kingdom?

         A:  This variant of the coronavirus-19 has just recently been identified.  Mutations of viruses are very common and authorities have speculated this virus has already mutated many, many times.  A mutation occurs when the virus replicates incorrectly in an infected person.  Many mutations don’t further become replicated and they die out.   This mutation, however, is rapidly expanding and is marked by its increased infectivity.  One study has shown this expansion is as much as a 70% increase over the earlier contagion.  The sudden rapid expansion of new cases of COVID-19 caused by this mutation has been identified in Southeast England including London.  Prime minister Boris Johnson has quickly reacted by ordering new national lockdown measures and travel restrictions in advance of the Christmas holidays.  This has caused political and public reactions, and many questions are being raised that are now being studied.

William A. Haseltine, PhD is the chairman and president of ACCESS Health International, and a recognized authority on COVID-19.  On Monday this week, he identified that this mutation was identified from mathematical modeling.  Laboratory analysis, which may take months to be completed, is now underway.  The identified mutation is on the “spikes” on the virion making it much easier to penetrate into host cells increasing the rate of replication.  He reported that parallel mutations in the seasonal influenza virus has led to the flu becoming “endemic” or more difficult to stamp out completely.  The rapid public awareness of this mutation has led many in England to relocate.  This encourages the spread of the variant virus elsewhere.  As many as 30 countries (including Canada, but not the US as of last Sunday) have restricted anyone traveling from the United Kingdom.

Moncef Slaoul, MD, chief scientific advisor for the White House Operation Warp Speed said.it was unclear whether the mutated variant has already made its way to America.  He continued, “we are, of course… looking very closely into this.”  He added that this mutation was “very unlikely” to be resistant to current vaccines, saying “We can’t exclude it, but it’s not there now.”  Other considerations are being studied, including if it results in more severe disease.  Assistant U.S. health secretary admiral Brett Giroir stated, “I don’t think there should be any reason for alarm right now.  We continue to watch.”  Stand by!

172. Importance of using a pulse oximeter to indicate the need for seeking care

         Q: What is the COVID program in Vermont encouraging pulse oximeters at home?

         A:  The Vermont Health Department has adopted a program guiding COVID-infected people when to go to the hospital for care.  Richard Levitan, MD has written about the progression of COVID-19 in an infected person.  “This disease causes pneumonia, which causes your oxygen levels to go very low.  Oxygen levels below 92 percent should prompt patients to… speak to their doctor.  If you suddenly fell to such levels, you would normally pass out in minutes.  We now know that this happens slowly in COVID patients, but many patients don’t feel short of breath until their numbers get alarmingly low.  Patients with COVID (develop) pneumonia normally 6 to 10 days after getting sick.  If we knew their oxygen level earlier, and we started treatment earlier, many fewer patients would need a ventilator.”  A pulse oximeter can help individuals monitor their own changing oxygen saturation levels.  Dr. Levitan continued, “This way, we can tell in advance if a person is silently getting sicker before more serious symptoms develop.  For the vast majority of patients, we can get ahead of it with proper monitoring.  They don’t need ventilators, and they shouldn’t be scared to come to the hospital.”

In Vermont, within 24 hours of a person testing positive for COVID-19, public health workers call the patient to trace their contacts.  This interview now includes asking if the patient has their own pulse oximeter.  Through November, the Vermont Department of Public Health has given out over 300 pulse oximeters to those who don’t have one.  Connecticut and most other states do not have such a formal program, but individuals can self-monitor and be guided when to seek medical care to best prevent more serious disease outcomes.  Anyone can obtain a pulse oximeter without a prescription from a local pharmacy or on-line source.  The cost ranges from $15 to $45 for a basic unit.

173.  Allergic reactions encountered with Pfizer’s vaccinations.

           Q:  How much of a problem is the reported allergic reactions to the COVID vaccine?

           A:  Many reports have been made about people having an allergic reaction to the Pfizer vaccine.  When first reported with vaccinations in the United Kingdom, severe allergic reactions were not expected, and this caused great public concern.  In the US, clinical trial data on this was reported and considered by the FDA before the Pfizer vaccine was granted its Emergency Use Authorization.  Procedures were drafted for those giving the vaccinations to prevent any serious outcomes.  Public education was provided to expect soreness at the injection site, mild temporary fevers and fatigue after receiving a dose.  Many may equate these minor results as being “allergic reactions,” but that term is used by those administering vaccines to be life-threatening reactions.  “Anaphylaxis” is an adverse over-reaction of the immune system caused by a substance the person is allergic to.  As of last week, only 5 people reacted this way – out of more than 500,000 vaccine doses given.  Peter Marks, MD, Director of the FDA Center for Biologics Evaluation and Research speculates that an ingredient in both Pfizer’s and Moderna’s vaccine: polyethylene glycol, “could be the culprit” causing these reactions.   Signs and symptoms of anaphylaxis include the rapid appearance of hives, swollen tongue or lips, struggling to breathe, dizziness, or a feeling of weakness.  It can lead to loss of consciousness and sometimes death.  People who have experienced even mild anaphylaxis from previous vaccinations are cautioned not to take the Pizer vaccine.  For everyone, after receiving the vaccine dose, they should stay at the vaccination site visible to vaccination staff.  If any of the signs of anaphylaxis appears, staff can react.  The remedy for severe anaphylaxis is to use an EpiPen to inject epinephrin (adrenaline).  Relief is usually quite rapid.

174.  Priorities and scheduling for receiving vaccinations are updated.

           Q: I am 70 years old and in good health.  When will it be my turn to be vaccinated?

           A: The CDC convened an advisory group last week to further plan for who gets the vaccine and in what priority ranking.  These recommendations go to the states where the final decisions are made.  Thus, the exact order of priorities may differ between neighboring states.  The CDC recommended that people over age 75 be given vaccinations before those aged 65 to 74.  But Connecticut combines these into one group – age over 65.   At first, it was anticipated that this group would be able to receive vaccinations after mid-January.  Last week, this was revised to be after the end of January.  The latest projection is in February.  Future revisions are expected based on the variable future of numbers available.  Other decisions remain to be made.  CVS and Walgreen pharmacies are now expected to offer vaccinations in their retail stores.  Yet if everyone must wait 15 minutes after their shot to be certain they don’t have an allergic reaction, there would be as many as 30 people continually present inside the pharmacy for each employee giving the shots.  Another consideration is how to qualify people coming in for their shots.  If physicians offices can administer the vaccines, they will have qualifying information available.  But at public clinics and pharmacies, what will prevent a retired 60-year-old from “jumping ahead” by saying he/she is an essential worker as the next round begins?  Also, while the vaccine is offered at no charge to the patient, what fee will be charged for administrating the shot?

175. COVID scams have been identified.

          Q.  I was offered a low cost COVID home test by a phone call last week. Is this legitimate?

          A:  No.  The US Department of Health and Human Services Office of Inspector General is alerting the public about fraud scams related to COVID-19.  “It is unlawful to advertise that a product can prevent a disease unless you can prove it with scientific evidence.  Scammers are using telemarketing calls, text messaging, social media platforms, and door-to-door visits to promote these bogus offers.”

  • Be vigilant. No state or federal government representative will call to request money, personal information to enhance your ranking, or to receive services relating to COVID.
  • Beware of scammers pretending to be COVID contact tracers asking for your Medicare number or financial information including payment for a COVID test they offer to schedule for you.
  • If you suspect a COVID-19 health care fraud, report it immediately to 800-HHS-TIPS (800-447-8477).

The most recent CDC guidelines on celebrating winter holidays can be found at[1]:

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/holidays/winter.html?ACSTrackingID=USCDC_2067-DM45255&ACSTrackingLabel

[1] To open, copy the following URL and paste it into your browser.

Frequently Asked Questions about COVID-19

          “Shared expectations lead to predictability.”

166. Public health measures are still required of vaccinated people.

          Q. I hear that anyone who is vaccinated must still wear a mask. This makes no sense!

          A:  It makes a great deal of sense – if you understand the meaning of public health.  Many people use the term as synonymous with medicine or personal health.  But they are not the same.  Personal health is what we deal with every day.  Actions taken to stay well and healthy.  Individual decisions acted on that just affect ourselves.  In medicine, the accepted practice is to not impose a curative therapy or healing procedure when the patient does not want it.  A prolonged therapy to treat cancer may become overwhelming with limited success, and if the patient wants to stop such treatment, it will cease.  To the contrary, public health is when the community at large is facing an unhealthy situation.  Tainted community water supply, bacterial infection of food supplies, and infectious diseases are examples where many people are affected.  In public health, decisions are needed that go beyond the individual.  If a disease is spreading, it cannot be up to each person to decide if they want to take the risk of getting infected, because individual decisions won’t stop the spread to others who want to avoid the contagion.  In public health, collective decisions are required, usually by government, that can be imposed so that all members of the community can benefit.

In a classic case, an immigrant, Mary Mallon, came from Ireland to New York in 1883.  She worked in several different homes as a domestic servant and a cook over the next several years.  By 1907, more than two dozen individuals had become ill from the bacterium Salmonella typhi.  Affected homeowners hired George Soper, the sanitary engineer at the New York City Health Department to track down the cause.  Contaminated water was found to be the source of the illness, and Mary Mallon was identified as being present in each affected household.  Mary was ordered to go into an isolation center in the Bronx.  An appeal to the U.S. Supreme Court failed to release her. She died in isolation in November 1938.  She was immune from this typhoid fever, but did infect over 50 people, 3 of whom died.  She earned her legacy by becoming known as “Typhoid Mary.”

Last Thursday, the independent FDA’s Vaccine and Related Biological Products Advisory Committee recommended approval of the Pfizer’s vaccine.  This decision was based on demonstrated effectiveness that outweighed any actual or potential risks from its use.  The key word here is “effectiveness.”   Pfizer’s Phase 3 clinical trials measured effectiveness as “showing no evidence of infection.”  This was measured by signs and symptoms of COVID-19 being displayed by the participants.  Data was not collected if the participant had become infected without symptoms, thus being contagious and capable of spreading the disease to others.  Further testing will be done to learn of this possibility.  But for now, anyone who receives the vaccine must continue to guard against becoming later infected and spreading the disease to others even while they are protected from becoming sick themselves. This is Public health as opposed to personal health. 

167. Further study needed before certain people should become vaccinated

          Q: Are there individuals who should not be vaccinated at this time?

          A:  Yes!  The Pfizer Phase 3 clinical trials did not include several groups of people – hence these people are not covered by the FDA approval at this time and should not become vaccinated.  Further studies for these groups will be made and guidance offered when ready to revise the appropriate guidelines:

  • Pediatrics – under age 16.
    • It is planned that these studies and revisions will be made soon to permit children to become vaccinated before school begins again in 2021.
  • Pregnancy
  • Immunocompromised – as defined as people whose immune system is impaired or weakened as by medications or illness.

Other studies are anticipated by Pfizer to improve the future administration of its vaccine include vaccines that allow refrigeration instead of super-cold storage and transportation Also being researched is simultaneous administration with the seasonal influenza vaccine.  All changes proposed must first be approved by the Vaccine and Related Biological Products Advisory Committee and then approved by the FDA before being allowed.

  1. Current Connecticut timetables for vaccinations

          Q:  What are the current plans for groups in Connecticut to become vaccinated?

          A:  Connecticut has released a recently updated schedule for different groups to become vaccinated.  31,000 doses are expected to be received from Pfizer on December 14, and 61,000 doses from Moderna (if FDA approved) on December 21.  Some aspects from previous expectations have remained the same.  Currently,  in priority order:

  • Immediately:
    • Health care workers
    • Long-term care facility residents
    • First responders (fire, police and EMS)
  • Starting by late January 2021
    • Senior citizens over age 65
    • Anyone who is at risk (with comorbidity)
    • “Critical workforce”
      • Teachers
      • Daycare workers
      • Foodservice workers
      • Those who deal on a daily basis with the population on a critical basis
    • Starting in June 2021
      • The rest of the population

The stated goal is to vaccinate everyone in Connecticut by “early fall of 2021.”

  1. Known and anticipated barriers to reach effective vaccination levels.

          Q: What can go wrong?

          A: The assumption is almost universal – vaccinations are the “light at the end of the tunnel and we can finally get back to normal!”  Even leaders can’t wait and end up projecting idealistic expectations.  Several states projected last week that Pfizer’s shots would be given by Friday, the very day the FDA approved its use.  The time to move millions of doses to hundreds of locations nationwide was overlooked.  The public will soon become unhappy, even angry, if expectations are not realistically established.  There are several anticipated delays that lie ahead, and many more that will appear on their own.

  • Supply chain shortages – Pfizer has already announced the quantity of doses ordered in the future will be held up because of delays in getting the supplies needed to manufacturing the vaccine. It turns out an essential ingredient used in its manufacture is the same reagent used for testing.  With the explosion of the COVID cases, testing has dramatically increased, restricting the quantity needed for timely vaccine production.  Perhaps president-elect Biden can invoke the Defense Production Act to secure an adequate future supply – but that can’t be done for more than a month, and president Trump is no longer running this program.
  • The vaccine is fragile. It cannot be shaken, and if its deep-freeze is interrupted in transit or in storage, it cannot be refrozen.   If doses are thawed and not used in a few days, it must be destroyed.  This “slippage” should be calculated in the number of people that can be vaccinated per number of doses ordered.
  • Two shots are required. Many people who receive the first dose may experience mild side effects such as soreness, muscle aches or a temporary fever.  If they become discouraged, they may not return for the second shot and immunity will not be achieved.
  • “Anti-vaxers” are significant in their numbers. A recent poll shows that as many as half the population won’t show up for their vaccinations.  It will require at least 70% of the population to be vaccination to eliminate this disease.

“Shared expectations lead to predictability!”

  1. Celebrating Christmas and New Years 

          Q. I usually party New Year’s Eve with friends?  With vaccinations under way is this OK?

          A:  No.  Look what happened at Thanksgiving!  Many people ignored the advice to spend that holiday with just member of a household that live together.  The incidence of COVID-19 has sharply risen and as many as 3,000 people a day are now dying.  Vaccinations can protect an individual in just over a month, but even vaccinated people may still be spreading the disease if they become infected later.  (see FAQ #166, above.)  No, the vaccine cannot give you the disease – that is impossible.  But there is a chance that once vaccinated, you can be infected by another person and then become contagious!

Remember, if you think it’s worth the risk to your personal health to party with others on Christmas or New Year’s Eve, think of the risk to others and the public health by doing so.

Don’t let the light at the end of the tunnel lower your vigilance.  You might just find it was a fast-approaching train!

Frequently Asked Questions about COVID-19

  “Shared expectations lead to predictability.”

 161. Mixed messages over upcoming vaccinations.

          Q: Why are there so many contradictory news reports about vaccination availability?

          A:  There is confusion and conflicting expectations over the imminent distribution of COVID-19 vaccines.  For example: When can we get it?  Who will get theirs before it’s my turn?  Where will it be given?  As the title of this ongoing column suggests, this unpredictability is the result of expectations not being shared – by and between the government, the pharmaceutical companies, and scientists (the epidemiologists).  The primary cause for this lack of shared expectations is the continuing absence of a national coordination program since the disease emerged as a pandemic ten months ago.

For the vaccines now being readied for distribution, this lack of central coordination has created uncertainty.  The messaging on each vaccine product has been left to the different pharmaceutical companies.  Their focus is on their individual products through press releases.  The necessary public education on the role of vaccinations in public health has remained absent.  The planning for distribution and providing vaccinations have been left to the states.  Yet the CDC is responsible for setting guidance for the states to follow – which has just now been updated.  The unique logistics required for each vaccine including storage, transportation, multiple dosages required, etc. will be formally established as the vaccines are individually authorized.  The states have assumed the manufacturers’ proposals will be adopted by the FDA, but if the federal authorizations change any of these recommendations, the states will have to rapidly modify their plans.

  1. Differences between vaccinations with the Pfizer and Moderna products

          Q: Once they are distributed, will the two proposed vaccines be managed the same way?

          A:  What we know now is the Pfizer vaccine product will be scientifically reviewed prior to authorization on December 10.  Moderna’s review will be on December 17, a week later.

  • Pfizer’s proposal is that this vaccine must be administered in 2 doses, the second being given 21 days after the first.
  • Moderna’s vaccine is also proposed to be given in 2 doses, the second 28 days after the first.

To demonstrate the considerations (and costs) to deploy these vaccines, Connecticut, as with all the states, must plan for and put in place the mechanisms for transporting and storing the vaccines at very super-low temperatures once arriving at designated sites from the manufacturer:

  • Pfizer recommends its vaccine must be stored at 90o F before being thawed before use. It can be stored in a regular refrigerator for only 10 hours.
  • Moderna recommends its vaccine be stored at 4o F before thawing. It can be stored in a refrigerator for up to 30 days.

Storage at super-cold temperatures may require specialized freezers that cost $10,000 each.  These can each hold 30,000 doses.  Portable freezers cost $8,000 each and can store 12,000 doses.  Portable freezers can be deployed in mobile units that move from site to site.  The costs for this are not provided by the federal government, and lack of state funding could seriously impede the timely vaccination of the public.

To implement the priorities for vaccination of groups. the CDC has identified broad outlines as new doses are being produced over time.  But then the CDC has asked each state to set their own priorities.  The complete federal guidelines have only partially been defined for the first priority groupings, and as a result, each state is waiting for further guidance before their plans are finalized.  This “work in progress” approach has led to confusion when adjacent states are setting different schedules from their neighbors, and overlapping news media appear to be stating different, often contradictory decisions.

  1. Connecticut’s “draft state distribution plan” for vaccinations

          Q:  Is there a state plan for when vaccines are scheduled to arrive as they are continually being manufactured?

          A:  Connecticut recently submitted to the CDC a 77 page “draft state distribution plan”: for COVID-19 vaccines.  This plan is really a discussion guideline to develop an ongoing flexible plan, working into the future as new information requires attention to the new issues that lie just ahead.  This “plan” identifies the initial doses of vaccine that are expected very soon.

  • If the FDA grants emergency use authorization (EUA) for Pfizer after a December 10 review, and Moderna after its review a week later, the following medications will be shipped to Connecticut.
    • By December 14 31,000 doses from Pfizer will be received in CT.
    • By December 21 61,000 doses from Moderna will be received.
    • By January 4, 2021 31,000 doses will arrive.
    • By January 25 212,000 doses are expected
  • This will allow 167,500 people to become vaccinated (2 doses each) into February, 2021.
  1. Initial priority of groups to be vaccinated

          Q: How long do I wait before it’s my turn to be vaccinated?

          A: The first priority group to receive the vaccine is identified as “1a” and includes:

  • Healthcare Workers:
    • 204,000 staff in hospitals, nursing homes, and in other clinical settings;
    • 22,000 nursing home residents
    • 6,000 first responders

This first priority (1a) group totals 232,000 people (464,000 doses.)

The second priority group “1b” will start in “Mid-January, 2021”, and includes:

  • People 65 and older
  • People in congregate settings – prisons, jails, group homes
  • “High-risk” people under age 65
  • “Critical Workers”
    • Teachers,
    • Child care employees
    • Correction staff,
    • Public transit workers,

The number of people in these group is not yet identified.

The third priority group will start in “early June 2021” and includes:

  • Children and teens,
  • Others under age 65
  • “the rest of the population”.

The best way to anticipate when an individual might become eligible to be vaccinated would be to remain vigilant to the changing timelines in the daft state plan.  Unanticipated resources and demands can and will alter this current preliminary time line:

  • Group 1a – starting in late December,
  • Groups 1a continuing and 1b starting after “mid-January”
  • Groups 1a, 1b continuing, and “remaining populations starting after “early June.”
  1. Special considerations affecting future vaccinations   

          Q: What other factors are there that will affect future vaccinations?

          A:  Several considerations have been identified as this process is advancing:

  • A major issue anticipated is the “anti-vax” movement. Many people will not take the vaccine when it is available – they either want to wait to be see if it is safe, they are against all vaccinations, or they believe COVID-19 is a hoax.  It will take greater than 70% of the population to be immunized before community spread can be halted.  Immunity is assumed to be two weeks after the second dose is taken. 
  • If the effectiveness of the first two vaccines is as high as 95%, as many as 500 of every 10,000 vaccinated people will not gain immunity. Everyone should continue to wear a mask when outside, keep socially distant, and maintain hand hygiene.
  • Clinical studies will be done to determine the appropriate dosing for children. This will lead to formal approval not currently in place to vaccinate people under age 18.
  • Data from the original Phase 3 clinical trials will be retrospectively studied to identify women who did not know or who later became pregnant. This could then lead to formal approval to vaccinate pregnant women.
  • Additional vaccines by different manufacturers will become approved over time. CDC advises each of us to not “overthink” in deciding which one is best.  Take the one that is available when your turn comes up.
  • The first dose may cause soreness or mild side effects. It is important not to become discouraged – immunity will not come until about two weeks after the second dose is taken.  Get that second shot!
  • On Sunday, December 6, Moncef Slaoui, chief advisor to the U.S. government’s Operation Warp Speed initiative stated “the US plan relies on the state health agencies to deliver the vaccine. “I think that plans are out there,” he said, “things are well planned.” He intends to meet with Biden’s team this week.  Stand by…!

Frequently Asked Questions about COVID-19

  “Shared expectations lead to predictability.”

 158. The US Supreme Court rules on New York’s religious attendance restriction.

          Q. Does the Supreme Court’s decision on COVID-19 religious restrictions affect us?

A. On November 25, the US Supreme Court ruled that New York governor Andrew M. Cuomo’s “strict virus limits – capping attendance at religious services at 10 people in ‘red zones’ where risk was highest, and at 25 in slightly less dangerous ‘orange zones’ – violated the First Amendment’s protection of the free exercise of religion.” The opinion resulted from a 5-4 vote with the deciding vote cast by the newest justice, Amy Coney Barrett. Justice Barrett was apparently the author of the majority opinion, although that opinion was unsigned.  It took issue with what it said was Mr. Cuomo’s unduly harsh conditions that were opposed by several church organizations, and that he “singled out a particular religion for blame and retribution for an uptick in a society-wide pandemic.”

The opinion also said less restrictive measures would work.  “Among other things, the maximum attendance at a religious service could be tied to the size of the church or synagogue.  It is hard to believe that admitting more than 10 people to a 1,000-seat church or 400-seat synagogue would create a more serious health risk than the many other activities that the state allows.”

This column recently discussed the issue of risk assessment.[1]  It was proposed that vigilance over specific situations (e.g. ventilation and air exchange, people tightly packed, eating without wearing masks, etc.) would be more effective than assigning attendance restrictions to different locations (e.g. schools, retail stores, religious facilities, etc.).  This Supreme Court ruling identifies the weakness of our current system of reducing risk by adding restrictions on different locations where people congregate.

In summary, this ruling specifically applies to the specific restriction New York had made (and later withdrawn) regarding size of attendance at religious events.  The guidance offered by the ruling would apply to government agencies to set minimum attendance restrictions evenly when based only on the of locations that events are held.

 159. Vaccination updates

          Q:  What’s the latest in treatment for COVID-19?

          A: The popular press has been reporting on the imminent approval and availability of several vaccines.  This has led many to speculate that in just a few more weeks, we might be able to return to normal.  That will not be the case, however.  It will take many months before enough people can be vaccinated.  Two vaccines are in the immediate pipeline for Emergency Use Authorization (EUA).  Pfizer (in partnership with BioNTech) was the first to apply for approval.  Moderna followed on Monday, November 30 with its application.

Both vaccines are made using the genetic code of the coronavirus contained in its messenger RNA (mRNA).  Generating this mRNA and including it in the vaccine has never been used before to immunize humans, and many safety concerns had to be addressed.  The mRNA in a vaccination causes the human body to generate antibodies to fight the virus as if there was an infection.  This, while the mRNA cannot itself cause an infection as it cannot replicate into complete virus cells.  The following steps will now be required:

  • This past Tuesday, the CDC Advisory Committee on Immunization Practices met to vote on how scarce initial supplies the vaccines will be given out once it is approved. Both applicants require two shots, several weeks apart.
  • The CDC Planning Guidance Allocating and Targeting Pandemic Vaccination Guide (2008) will be reviewed, modified and updated as needed for COVID-19.
    • Five tiers are proposed. (note that while children and pregnant women are listed, they weren’t included in either of the Phase 3 COVID clinical trials.)
      • Tier 1: 26 million people – health care workers, first responders, public health and pharmacy workers, pregnant women and toddlers.
      • Tier 216 million people – military support personnel, mortuary services, community IT and utility services, and high-risk children.
      • Tier 368 million people – other health care, military, infrastructure and government services personnel, and healthy children.
      • Tier 4 – 79 million people – adults at high risk and over age 65
      • Tier 5132 million people – healthy adults 19-64 years of age,
    • An independent review panel will meet on December 20 to review the data and clinical trial findings of at least Pfizer’s application and recommend to the FDA its recommendation for EUA approval.
    • The FDA will act on this recommendation in the following few days. Approval will activate the initial distribution of the already manufactured doses of the vaccine to the states.  Note: this will probably take place in the midst of the holiday season.
  1. Length of quarantines

          Q:  News reports say the CDC is planning to reduce the period of quarantines.  Has this happened yet?

         A: Not yet.  On November 24, many major news outlets reported that the CDC was considering this action, but it has not yet happened.  As Reuters reported, “a top official” at the CDC said the agency “may soon shorten the length of the recommended self-quarantine period after potential exposure to the coronavirus.”  Health authorities currently recommend a 14-day quarantine, but there is some evidence that the period could be shortened if testing is done during the quarantine.  “Let me confirm that we are constantly reviewing the evidence and we are starting to have evidence that a shorter quarantine complemented by testing might be able to shorten that quarantine period from 14 days to a shorter (number of) days,” a top U.S. health official said.

No change in the 14-day recommendation has yet been made.

[1] FAQ #152

Frequently Asked Questions About COVID-19

  “Shared expectations lead to predictability.”

155. Holiday gatherings revisited

         Q.Family gatherings over the holidays – what’s the latest?

         A:  The COVID-19 pandemic is explosively expanding throughout the US and Connecticut.  The risk of contracting the disease is now greatly increased.  Indoor meetings are especially at risk.  There has been a flood of recent public information cautioning people to limit family gatherings to just people living in their household.

  • Thanksgiving Day and weekend:
    • If you have followed the prolific advice and are having your celebration with just those with whom you daily eat, watch TV, and say goodnight every day, but yet you still feel a bit guilty, remember the adage, “We isolate so that when we gather later, no one will be missing,”
    • If you have decided to take the risk anyway, and are meeting with one or more friends and remote family members, there are a few things to consider to reduce a bit more the risks you are assuming;
      • Wear masks inside except when eating. If you can blow out a candle while wearing your mask, it is not an effective barrier.
      • Open windows and use a fan to exchange air and ventilate indoor space.
      • Eat outdoors if you can.
      • Consider using straws with a mask when socially drinking.
      • Space chairs more than 6 feet apart around a table. This may result in using several extra tables, maybe in different rooms.
    • Make contingency plans in advance so you will know what to do if someone comes down with a fever after they arrive, or tells you they had been in contact with another person who tested positive a few days earlier.
    • Review again the CDC guidelines about celebrating Thanksgiving to pick up other suggestions to reduce your risk.[1]

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/holidays/thanksgiving.html

  • Christmas and New Year’s Eve
    • If you are planning to celebrate with just those in your household, BRAVO!
    • If you are even considering going out to meet or party with others, look over the CDC guidelines given above just one more time, substituting the words “Christmas” or “New Year’s Eve” for the word “Thanksgiving.”.1

 156. Vaccinations are around the corner, but not right away.

          Q: When can we get vaccinated?

          A:  One vaccine, produced by Pfizer, has applied to the FDA for authority to ship the vaccine to the states to vaccinate people.  Another company, Moderna, is anticipating it will seek similar approval in the near future.  AstraZeneca has also announced it will soon seek approval.  But there are a few remaining steps that must be followed.

  • An independent board of scientists must review the data collected from the Phase 3 clinical trial for each applicant to verify its safety and effectiveness.
  • After the FDA reviews the independent board’s findings and issued its Emergency Use Authorization (EUA), the White House has to activate its “Operation Warp Speed” distribution system. Planned to be carried out by the military, doses that are already manufactured will be shipped to a location in each state.  The state will then repackage the number of doses for each local “point of delivery” (“POD”) site where they will continue to be held until they are injected.  The logistics for this process may take some time.
    • For Pfizer, the vaccine must be stored in super-cold storage (minus 94 degrees F).  A continuous resupply of dry ice will be needed to store the vaccine in each of its locations in Connecticut before it is given.
    • There will need to be staffing available to receive, repackage and transport the doses throughout Connecticut.
    • Recordkeeping is needed for timely reminders to be sent out alerting each person to come back to receive their second dose.
    • The transportation and staffing costs for this effort was anticipated to be provided by the federal government. As of last week, there is no money authorized to pay for this.  Further delays can be expected.
  • Priority vaccination of essential health care workers and first responders are expected to take place by January 2021. People at risk due to health conditions or over the age 0f 65 will follow – probably in late winter into spring of next year.  The general public should then expect to begin their vaccinations by next summer into next fall.  Over time, more accurate target dates can be expected.
  • Patience will be required! It has to be remembered that until at least three-quarters of the public receive the vaccination, people will still be contracting COVID-19 disease.  Wearing of masks and social distancing will need to continue by everyone for many months to come.  Even some of those vaccinated will be at risk. If the vaccine is 90% effective, 100 people out every 1,000 receiving the vaccine will not be protected by it.

157.  Eli Lilly’s monoclonal therapeutic is granted an EUA for general use

          Q:  What’s the latest in treatment for COVID-19?

          A: Early in October, president Trump was admitted to Walter Reed Army Medical Center to be treated for COVID-19.  While there, he was given an “antiviral cocktail” drug being tested by Regeneron Pharmaceuticals.[2]  This was a new medication still undergoing clinical trials.  Initial data showed it had a positive effect in suppressing advancement of the disease if taken early in its progression.  Using this and other approved medications, Trump recovered.  Among other pharmaceutical companies testing similar drugs, Eli Lilly on November 9th was granted an Emergency Use Authorization (EUA) approval for its version called “Bamlanivimab,” a monoclonal antibody.

It is now available for people over age 65 or with underlying health conditions.  Monoclonal antibodies are synthetic antibodies that are given intravenously to block the virus from spreading the infection within the body.  It works on patients with mild to moderate symptoms and serves to reduce the risk of later hospitalization.  This creates a dilemma – IV Infusions are usually given in hospitals but eligible patients will not be hospitalized.  The logistics on where people go to receive this medication are being worked out nationally.

It is not for everyone, officials warn.  In addition to the limitations placed on its use by the FDA, the number of initially available doses is quite limited.  Connecticut is now receiving its initial allotment of 1,050 doses.  The federal government has agreed to purchase 300,000 doses which will be delivered to all 50 states during 2021.

Regeneron’s drug that was used to treat president Trump was granted an EUA just last Saturday.  That approval is for a combination (or cocktail) of its two drugs “Casirivimab” and “Imdevimab.”  This approval is for the same treatment protocols as Eli Lilly’s’ Bamlanivimab.

[1] To open this website, copy the entire URL (“https://…..”.) from the text, and copy it into the search window on your web browser and hit enter.

[2] See FAQ #126

Frequently Asked Questions About COVID-19

  “Shared expectations lead to predictability.”

  1. Risk assessment: a functional way to plan for the future – and the holidays…  

          Q. I’m confused matching CDC and state guidelines to actions needed during the current COVID-19 surge. Can someone help?

          A.  If you haven’t recently watched TV or read the newspapers, the number of COVID-19 cases has been dramatically increasing!  Here are some recent Connecticut headlines:

  • “Experts: Surge could last at least another month”1
  • “As surge increases, hospital cases spike”1
  • “UConn places entire Storrs campus under quarantine”[1]
  • “Virus case sends state’s top Dems into isolation”1
  • “Outbreaks stem from dining, worship, homes”1

 

There really is surge in cases, and each day the number of new cases increases exponentially.  Over time, the risk of contracting COVID-19 is rapidly growing.

But what do we do about it?  Guidelines exist from the CDC, and the State of Connecticut:

  • Three basic actions are advised when outside and people other than within your household are present:
    • Keep socially distant – at least 6 feet away from other people.
    • Wear a cloth face covering – a mask.
    • Wash hands frequently for 20 or more seconds or when this isn’t possible, use hand sanitizer.
  • Indoor gatherings have guidelines that limit the number of people present. For example, here are a few: 
    • Commercial venues for meetings, parties, – 25 people.
    • Private residences – 10 people.
    • Religious gatherings – 50% of capacity up to 100 people.
    • Fairs &, festivals – maximum = 25% of previous year.

These guidelines are based on the situations where people gather, and primarily serve to assist sponsors of events and investigating agencies to determine compliance.  But they are conflicting and confusing for individuals trying to remember as they move from location to location.  And they change as each sequential phase is reached.

When someone rationally decides to go to their church service with 90 people present and no one there becomes infected, it is easy to consider going to a banquet hall for a 50th wedding anniversary party with 50 people attending, which guidelines indicate is “unsafe.”  Who can remember what the limits are for each kind of event?

Risk management recognizes that risk is variable.  There is no interaction with another person that is 100% COVID-19 safe.  Likewise, there is no way that one can predict with certainty that they will become infected.  Between these extremes, risk can increase or decrease depending on the actions one takes.

If risk is variable, then risk management should not be based on a memorized list of dozens of different situations.  Instead, safe procedures should be based on a foundation of habitual actions, like always putting on a seat belt when getting into a car.  Then vigilance is needed to adapt to different circumstances.  While driving wearing a seatbelt, one slows down when an erratic driver is spotted ahead, or when the roads are icy.  Regarding coronavirus-19, a person becomes infected when a concentration of virus enters their mouth, nose or eyes.  The three basic measures – social distancing, mask wearing and hand hygiene – should become habitual whenever one is outside of the home.  Vigilance over the surroundings can then  lead to additional adaptive behavior.  With an upsurge in the number of cases, the chance of contacting someone with the disease increases.  One can then be more vigilant reducing the number of people that are present in various activities.  For upcoming holiday celebrations, limiting the number of friends and families who come will not only consider the increased risk of loved ones becoming infected, it also reduces the possibility that the one person who is infectious without showing symptoms will not be there.  If continued vigilance shows that community surge presents a greater risk, one can take other actions, remembering to always use the three basic habits whenever possible: masks, social distancing and hand hygiene.

  • Provide for air exchange allowing outside air to flow in:
    • Open windows and use fans to exchange air
    • Use a tent with side flaps open enough to allow air exchange
  • Using Plexiglas shields where people are required to be less than 6 feet apart
    • Serving food or tending a bar
  • Purchasing an air purifier with a HEPA filter.
    • Must have a High-Efficiency Particulate Absorbing (HEPA) filter
    • Ultraviolet light systems are not deemed as effective
    • Different levels of room sizes are available
    • Check for the frequency of complete room air exchange over time
  • Limiting attendance to members of the household living at the site

Perhaps we’re not really having “pandemic fatigue,” but rather “vigilance fatigue.”

  1. WREN Laboratory based in Branford Connecticut has a new saliva-based test.

          Q: Is there a COVID-19 test that I can use at home?

          A:  WREN Laboratory has just received an Emergency Use Authorization (EUA) for its self-administered PCR diagnostic saliva test. This is the first approved test of its kind that provides a collection system, a color coding indicating the collection has been completed and stabilized, and then does the actual analysis.  It takes about a teaspoonful equivalent of saliva spit into a tube.  This does not require medical worker assistance.   It is being marketed to schools, sports teams and other groups that need continuous testing.  It has a reported accuracy of 99%, and is designed to stay “on a shelf” for up to 12 months.  The test results are usually available electronically within 24 hours.  The cost is reported to be $150 per test.  Further information is available at https://www.wrenlaboratories.com

154. Commercial mink farms are hit hard because COVID-19 infects this animal.

          Q:  Is there any more information about pets and other animals contracting COVID-19?

          A: There are about a dozen mink farms in the US, mostly in Utah, Wisconsin, Michigan and Pennsylvania.  Approximately 15,000 of the furry creatures have been killed by COVID-19, including 10,700 mink at just 9 American farms.  Research has shown that the mink probably had been infected initially by a human being.  Mink are raised in farms where the animals are in very close contact with each other causing the disease to spread rapidly.  Workers have then become infected by contact with the animals.  The problem is not limited to the U.S.  A study conducted in the Netherlands showed that 68% of the workers and their close associates on mink farms became infected.  Fear had been expressed over the possibility of mutations of the virus in the mink population and that this may have caused a surge in the number of human cases. However, it was later found that the disease has not yet spread this way.  Large scale mink farming also exists in Denmark.  The Danish government had announced it would kill all of its 17 million animals to help curtail a potential surge in human COVID-19 cases. The economic impact of this led to a very strong reaction.  Denmark later retracted this idea and research continues.

+++++++++++++++

 Ideas for future bumper stickers:

“We isolate now so when we gather again, no one will be missing.” 

“If vigilance becomes a habit, it will be easy to remember good actions.”

“It is better to be patient than to be a patient.”

 

[1] Hartford Courant, November 11-15, 2020