Dr. Gerald’s Weekly COVID Analysis

Here is Dr. Gerald’s most recent update on the COVID-19 outbreak. From Dr. Gerald… “While university campuses are improving, broader trends in the general community continue to slowly worsen. For what it is worth, test positivity for traditional PCR, saliva and antigen testing have converged around 4 – 6%.”  

While it is difficult to understand the validity of the IHME metric regarding adherence to face mask recommendations, this week’s news is disappointing as Arizona ranks at the bottom of the 50 states. Overall, we are currently in a relatively good spot but complacency is becoming an ever greater concern with the worst case scenario being low adherence to mitigation efforts during peak viral respiratory season.”

What’s the Treatment Plan for the President?

By now, all of you know that the president has been diagnosed with COVID-19. Reports are that his symptoms were moderate to severe on Friday but have since improved. His symptoms have included cough, fever and low oxygen saturation levels (less than 94% on room air).

His treatment plan includes administering a course of treatment of remdesivir, a drug that slows the replication of of the virus. This medication has been shown to improve outcomes in some patients when administered early. A clinical trial found that the drug accelerated recovery among patients that had advanced disease. It was a randomized, controlled trial involving 1063 patients.

The study found that patients who got remdesivir recovered 31% faster than the people that got the placebo (p<0.001). The median time to recovery was 11 days for patients treated with remdesivir compared with 15 days for those who got the placebo. Results also suggested a survival benefit, with a mortality rate of 8.0% for the group receiving remdesivir versus 11.6% for the placebo group (p=0.059).

A few months ago the FDA issued an Emergency Use Authorization for remdesivir to treat COVID. That means doc’s can now prescribe for patients without enrolling them in a clinical trial or getting compassionate use approval.

The patient is also being treated with dexamethazone, a steroid. This medication is used in COVID patients that have low oxygen saturation on room air. It tamps down inflammation and has been shown to improve clinical outcomes in patients that have lowered blood oxygen levels. He received supplemental oxygen on Friday (2/L per minute).

The patient’s treatment team also administered monoclonal antibodies produced by Regeneron. This experimental monoclonal antibody treatment is still in clinical trials (it is an investigational new drug) and is available “for compassionate use” outside of clinical trials if approved by the FDA. The FDA issued such an approval Friday.

The Regeneron CEO has made statements suggesting that the drug is quite effective, but no data (that I could find) establishes this as the case. Here’s more about the investigational new drug process from a previous blog.

The patient’s treatment plan also includes zinc, vitamin D, an antacid called famotidine, melatonin and aspirin. None of these require a prescription and none have been proven to be effective against COVID-19. 

Statistically, a 74 year-old male in reasonably good health has a 3% chance of dying from COVID19. Patients in that range have symptoms bad enough to be hospitalized in about 10-15% of cases.

Persons with other underlying medical conditions (like obesity) are more likely to have a worse outcome.

On the other hand, these statistics include patients that were infected in the Spring and Summer of 2020 when less was known about effective treatment for the infection. Treatment for this illness has improved significantly in recent weeks and I expect outcomes to continue to improve as more is learned about effective therapies.

Journal Articles of the Week

Prevalence of SARS-CoV-2 antibodies in a large nationwide sample of patients on dialysis in the USA: a cross-sectional study The Lancet DOI:https://doi.org/10.1016/S0140-6736(20)32009-2

For this cross-sectional study, in partnership with a central laboratory that receives samples from approximately 1300 dialysis facilities across the USA, we tested the remainder plasma of 28 503 randomly selected adult patients receiving dialysis in July, 2020.

Seroprevalence of SARS-CoV-2 was 8·0% (95% CI 7·7–8·4) in the sample, 8·3% (8·0–8·6) when standardised to the US dialysis population, and 9·3% (8·8–9·9) when standardised to the US adult population. When standardised to the US dialysis population, seroprevalence ranged from 3·5% (3·1–3·9) in the west to 27·2% (25·9–28·5) in the northeast. (0·4 [0·3–0·5]) when compared with a reduction of less than 5%.

During the first wave of the COVID-19 pandemic, fewer than 10% of the US adult population formed antibodies against SARS-CoV-2, and fewer than 10% of those with antibodies were diagnosed. Public health efforts to limit SARS-CoV-2 spread need to especially target racial and ethnic minority and densely populated communities.

MMWR: Changing Age Distribution of the COVID-19 Pandemic

The CDC released an MMWR describing the changing age distribution of COVID-19 infections in the United States from May-August 2020. During the first months of the pandemic, COVID-19 incidence was highest among older adults, but between June-August, COVID-19 incidence was highest in persons aged 20–29 years. This report provides preliminary evidence that younger adults contributed to community transmission of COVID-19 to older adults

New Visitation Policies for Long Term Care

Visitation policies for long term care facilities are in the process of changing, thanks to the lower level of community spread that resulted from interventions by cities and counties to require face coverings, the several week suspension of bars and nightclubs, and the better (but not great) business and bar compliance with recommended CDC mitigation measures.

Family members or friends of folks living in assisted living or skilled nursing (and designated caregivers) will be given access to the facilities during normal pre-COVID visitation hours if they meet certain conditions, like providing a negative COVID test result within the last week. Here’s a description of the policy changes.    

AzPHA Wins the National APHA Vision Award for Excellence in Health Policy

Below is an e-ail that we received notifying us that AzPHA will be receiving APHA’s Vision Award for Excellence in Health Policy Award this year:

Congratulations! On behalf of the APHA Community Health Planning and Policy Development (CHPPD) section of the American Public Health Association, we are honored to present you with the Vision Award for Excellence in Health Policy.

We were inspired to read about your work promoting public health policy and equity in Arizona through advocacy, research, teaching, and health communication. 

We plan to present the award at the CHPPD awards assembly at the APHA Annual Meeting, which will be virtual this year. The event will be on October 25 from 6-8 pm Mountain Time. If you are unable to attend, you are also welcome to submit a short video (5 minutes or less) describing a few key lessons you’ve learned through your experience or advice you would give to other public health professionals. Please let us know which option would be more convenient for you.

We will mail the physical award to your address. Please let us know what address you would like us to mail the award to and how you would like your name and credentials to appear on the award. We will make every effort to present the information as you would like. Could you please also send a photo that we could use to share in our social media?   

Congratulations again, and please let us know if you have any questions.

FDA Authorizes First Point-of-Care Antibody Test for COVID-19

FDA issued an emergency use authorization for the first antibody point-of-care test for COVID-19. The “Assure COVID-19 IgG/IgM Rapid Test Device” was given emergency use authorization in July to help identify individuals with antibodies to SARS-CoV-2. The EUA was reissued this week authorizing the test using the fingerstick method.  The press release is here.

Rapid antibody tests that also include a specific test for IgM antibodies can sometimes be useful to identify newly infected people. That’s because the very first antibodies that your immune system makes are IgM (these are your emergency response antibodies).

The presence of IgM indicates a very recent COVID infection- as opposed to the presence of IgG antibodies- which indicates a historic infection. Still- it’s better to rely on an antigen test than an IgM antibody test to identify newly infected people when you need a rapid test result. 

Does Barrett’s Past Writing Shed Light on How She Might See the California v. Texas Case?

Soon to be Associate Justice Barrett wrote an article for the Notre Dame Law Scholarship Law Journal in 2017 that sheds some light on how she might think through the California v. Texas case. In the article, entitled “Countering the Majoritarian Difficulty“, Barrett seems to quite deferential to the executive and legislative branches. That may be a good thing for the ACA’s fate as restraint would tend to make her reluctant to overturn laws like the ACA.

However, on pages 80-84 of the article, she specifically suggests that Roberts’ majority opinion interpreting the penalty for not having health insurance a tax was flat out wrong – implying that she may believe that the ACA should be overturned on that basis:

In NFIB v. Sebelius… Chief Justice Roberts pushed the Affordable Care Act beyond its plausible meaning to save the statute. He construed the penalty imposed on those without health insurance as a tax, which permitted him to sustain the statute as a valid exercise of the taxing power; had he treated the payment as the statute did—as a penalty—he would have had to invalidate the statute as lying beyond Congress’s commerce power.

Barrett’s doesn’t opine on whether the ACA should have been considered constitutional based on congress’ authority to regulate interstate commerce… although that’s irrelevant because that’s not a question in front of the court in Texas v. California.

The fate of the ACA will soon rest with 9 appointed people.