Covid-19 Update

Hello everyone,
 
We would like to update you all further regarding Covid19!

It’s been a number of weeks since the last update, and while things were fairly stable for a time, it is beginning to change once more, and it’s important for all of us to review now what the current situation is, and what we need to do moving forward.
 
As usual, the key points are next, followed for those who are interested by a more in-depth discussion below. 

1. The pandemic is *not* over. It is now clear that unfortunately it likely won’t be over for some time to come. So it remains important to *persist* in your efforts to maintain physical distancing from those not in your household, wear a non-medical mask if you cannot avoid this, and wash your hands. This. Must. Not. Stop.
2. If you are sick, please tell us ASAP. We are often testing people with even slight symptoms. This is really important to stop the disease from spreading. It’s what we would have wanted to do in March but couldn’t at the time. Now we can, we should, and we will. If you are sick, we want to know. If you are not sure, but are worried you are bothering us, you are not. ‘Bother’ us. Please. 
3. A second wave here in BC is a very significant concern. In fact, it’s unfortunately highly likely. Numerous other countries employing similar measures to us have experienced second waves, often worse than the first, and we need to be prepared for this reality. Cases are already rising here again. More details below.
4. Due to the above, we will continue doing video/phone consults the majority of the time, with in-office visits reserved for when a physical exam is *needed*. All care starts with a video/phone consult first though. 
5. We ARE currently seeing patients in the office 1-2 days per week, but *ALL* in-office visits must be approved by the physician as necessary. More in-office time will be added in the future, but probably not until later this year. We remain available the rest of the time by video and phone (video preferred for most people).
6. Certain routine care such as pap tests have resumed, and we are clearing a backlog first. You will be called if you are due or overdue. If you are not sure, feel free to check with us, but perhaps wait 2-3 more weeks to see if you are called. 
7. Physical exams can resume but with modification. There will be a video consult first (20 min), followed on another day by an in-office visit for the physical exam itself (10 min). This is the same total time spent previously on physical exams/health reviews. The intent is to keep the in-office component focused on the physical exam itself, with any further discussion and review to occur by video again afterwards as needed. We want to seriously limit the in-office time. Most covid transmissions take 10-15 minutes of close contact. We want to keep as many face-to-face interactions below that time as possible.

 
The Details
 
The pandemic has been hard on everyone. We all want it to be over. We wish we could tell you it will be soon, but we also know you want a realistic assessment of what is likely to happen. This bug is really bad. The majority of people recover, just like we previously told you. It is definitely much less dangerous for kids than adults over age 60. But it spread far and wide and fast. 19 million people have had it worldwide as of today. 700 000 plus have died. There are likely millions who recovered but now have ongoing serious health consequences. In BC we have taken extraordinary steps to contain this, and have been far more successful than many other places. What did we do right? The lockdown was necessary at first for a variety of reasons, but hopefully can be avoided again, even if a second wave occurs. At the least, it can probably be more focused on specific regions, or types of activities/jobs. Other locations, including Australia, and Hong Kong, *have* had to resume aggressive lockdowns. Physical distancing is unquestionably effective. Hand-washing is effective. Masks are almost certainly effective.
 
Combining physical distancing with hand-washing and masks could in theory eliminate the virus. Wait, what?? The virus typically spreads from 1 infected person to about 3-5 others (although perhaps much more in indoor settings). The three measures above are likely to reduce viral spread from 1 infected person to less than 1 other person. So, if those measures were used in combination, by most people, for a number of months, this could then potentially dwindle cases down to zero. It is however challenging to physically distance at times, there is unfortunately a lot of (ludicrous) pushback against simple measures like masks, and there is understandable pandemic-fatigue that has set in, and so people become less careful. If you want to help yourself and everyone else, these are the three key steps.
 
Where are people getting it?
 
We know the virus is transmitted mainly indoors. The most common scenario by far, is where someone gets it while they are out in some congested area, or at work, and brings it home. Most people in the house then get it. Conferences are a huge problem. Anywhere people are singing is a huge problem. Bars are a very huge problem. Outbreaks from home parties are a major risk. On the other hand, outdoors tend to be fairly safe. There are no known/proven cases of people out exercising, or walking along the street and getting it from a passerby. Typically, when someone gets the infection, it’s because they were in the presence of a sick person for about 10-15 minutes or more. This all comes down to ‘viral load’. Your body will probably fight off the virus if you only get exposed to a little bit. When you breath in someone’s air repeatedly in close quarters for 15 minutes though, it gets to be too much. Going briefly into a store is probably fairly safe, but wearing a mask will reduce your risk, and reduce the likelihood you put others at risk.
 
As the pandemic is clearly not ending any time soon, we must continue to conduct most medical care by video (or phone if necessary), and avoid unnecessary in-office visits. We are gradually resuming some of the routine care such as pap tests, and routine checkups, but with some modifications. The most critical one is to minimize the time spent in office, to keep it below that 10-15 minute exposure time above. This is why we are insisting on video consults first, so we can assess if the in-office visit is really necessary, and to conduct most of the discussion that way, followed by a very brief in-office visit that is highly focused on getting the physical exam part done. There really shouldn’t be any further discussion in the office. If there are leftover questions to be answered, this should occur in another video (or phone) call later. 
 
In general, we are strongly in favor of video appointments over phone calls when possible, as we get a much clearer sense of how you are doing when we can see you. It makes a difference.
  
What are we (your doctors) doing to protect ourselves when we go out?

• We are exercising outdoors essentially as usual. We keep 6 feet away from others, even outside. If we anticipate touching anything then we have hand gel with us. 
• We are wearing a mask whenever we go indoors anywhere, even if it’s very brief (arguably this is not that necessary for a quick stop into a store, but again, it’s more about protecting everyone else than yourself). This is most important for busier places that you may have to spend more time in, like grocery stores and pharmacies.
• Hand gel goes with us everywhere.
• We do NOT wear gloves when we go out anywhere. It’s better to just be sure to clean your hands, and avoid touching your face. The hand gel comes into the store in our pockets, and we stop and clean them right after we exit, before we get back in a car for example. Gloves will not protect you if you end up touching your face with them. We try to think of our hands as ‘dirty’ when we are in a store.
• We do not wipe down groceries, rather we put them away and then clean our hands.
• If we order-in food from a restaurant, we ensure non-contact delivery.
• We have extremely limited contact with anyone from outside our households. You should certainly feel free to socialize, but you should very strongly favor outdoor settings **WITH** maintaining 6 foot distancing.

 
Does this virus transmit from surfaces?
 
It’s a bit frustrating that we don’t have a clear answer for this yet. Studies had come out a couple of months ago, showing that virus could be found on exposed surfaces up to 3 days later. BUT, that was after exposing those surfaces to massive doses of the virus, far beyond what even a very sick very contagious person would be shedding into their environment. What is clear, is that handwashing is the most important way to prevent yourself from being exposed to a virus that may be on a surface you touched.
 
I keep hearing that kids don’t transmit this, is that true?
 
This will be a dicey subject. The public health office here seems to be of the opinion, based on current evidence, that kids are not major drivers of the pandemic. Their interpretation of the data is that kids don’t get it as easily, and don’t transmit it much either. While there can be severe cases, and they can get very sick and even die, this is very rare, and not something to be too panicked about (as difficult as that may be). We are concerned however that more recent studies are showing that kids do in fact get and transmit the virus, perhaps as much as adults. Thankfully, the vast majority of them still do not get very ill. The problem is that this can still put teachers, and family members back home (or within their social ‘bubble’) at serious risk. Further research will be needed. School has already started up in many other parts of the world, including some parts of the USA where there is very poor control of the pandemic. It will likely become clear over the next 4-6 weeks just how much school-age kids transmit this. There is already fairly solid evidence that teens transmit it as much as adults do.
 
So how are schools going to open?
 
Despite the above, we are reasonably confident it *is* possible to open schools. How? First, we are doing far better than many other parts of the world. We do know that in areas where the case counts are low in first place (currently all of BC, despite the recent rise), and where some measures are taken in the schools to limit spread, the likelihood of a school outbreak is fairly low. This is why it’s so important for everyone to do our part to keep those counts down in the community. A number of steps have been planned to make adjustments here in BC to enable them to open safely.
  
We must also continue to learn from others. Some countries, notably South Korea, have been managing all this fairly well, with schools open, and case counts remaining stable and low. They are one of the few countries that has not had a second wave (so far). What steps have they been taking? Kids there *are* wearing masks in schools, they eat *very* spaced out, and the classrooms have been adjusted carefully to seriously limit how close they are to each other. Everyone gets a temperature check on arrival. Teachers are well-equipped. They were quite thorough.
 
Even if schools do open, things may be difficult at times. Kids (and teachers, and all the rest of us) will get sick from other viruses from time to time, and unlike in the past, no one can go to school (or work, or anywhere really) if they are even slightly unwell. Families with more than 1-2 kids will be challenged due to increased likelihood that someone in the house is sick (from something, not necessarily covid19) and stuck at home. Families will be wondering if someone at home is shedding virus but not showing signs of illness yet. There must be schooling and work back-up plans in place both for individuals and communities. This is a really challenging situation. *But*, it has been done elsewhere. So it can be done. We all have to have a lot of patience and understanding.
 
When can we test our immunity/antibody levels?
 
Just about every single place in the world can do this except for BC. There are a number of reasons for the hold-up that we won’t get into here. A number of you were ill, and couldn’t be tested with a nasal swab, and are wondering about getting this blood test now instead. It may be a moot point now anyways. It’s not clear how long antibodies to COVID19 remain elevated after infection, and some studies have suggested it may only be a few months. A significant number of people with confirmed COVID19, and who had high antibody levels, have been shown to have a large drop in their antibody levels after 6-8 weeks. Even if one has antibodies, that still doesn’t mean they are actually immune though. Also, it’s possible to have no antibodies, but have what are called memory T-cells (that no one has a test for other than research labs), and actually have immunity. So the test may not be quite as helpful as we thought it would be. I’ll let you all know when there is an update on this, but don’t expect any mass antibody testing here in the next couple of months.
 
How about a vaccine?
 
Vaccine research is progressing fast. I hesitate to use terms others have, like ‘warp speed’, as I think this is an inaccurate way to describe what is occurring. The research itself is happening at about the exact same speed as always, it’s mainly the ‘red tape’ that is being cut through much faster. Generally there is a long line up to have something ‘reviewed’ and ‘approved’ for the next stage, and vaccine research now gets immediately to the front of the line. No short cuts in the actual clinical research and evaluation itself are being taken. The studies are being done very methodically and carefully.
 
If we are very very lucky, a safe and effective vaccine will be available perhaps by early next year. More likely we are looking at middle to end of next year. Note that the manufacturers are planning to make about 1 billion doses by the end of next year. That is around 7-14 billion doses short of what the world needs (it may be a 2-dose series). So even if the first vaccine out of the gate is ‘perfect’, this pandemic is unfortunately *not* stopping yet. I suspect the first groups vaccinated will be medical staff, followed by (or at the same time as) people in care homes, then everyone over age 65 with health conditions, then everyone at any age with health conditions, then everyone over 65 and healthy, then everyone over 50, then if the pandemic has not wound down, everyone else. If certain groups (like kids) are found to be driving the pandemic, they might be vaccinated much earlier, even though they are not typically getting very sick from the virus. By the time the vaccine is available, we will know all this.
 
Will life go back to normal?
 
We are reasonably confident, one way or another, that it will. This does depend somewhat on how long we stay immune for if we get the virus though. If people who had it are immune for about 5 years, this will almost certainly dwindle down over roughly that time. If immunity is short lived though, we do face the possibility that the virus just circulates around and around indefinitely. That’s a gloomy prospect for sure. This is why a vaccine may be critical. We suspect immunity does in fact last some time, as we are still not seeing clear cut cases of recurrence in the same individuals. It will take until at least late this year to be more confident about that. 
 
There are a couple of treatments for in-hospital patients that provide some limited benefit, but every bit helps. There is also a growing list of other possible treatments, and some of them do show some promise. These treatments are generally directed at those who get sick enough to need a hospital admission, not those who are recovering at home. There will be results for those new treatments probably in another 2-3 months. An effective treatment (without a vaccine), may enable us to manage this without worrying quite as much about it’s spread, just like we take some measured steps to prevent things like strep throat infections, but we have an effective treatment for it when it does occur.
 
Some things won’t go completely back to the way they were, and that may be a good thing. The days of people going to work while sick are essentially done, for good, and we consider that a plus. Medical care has become much more available by video and other means, and that is likely to remain that way forever. We are learning new ways to connect with each other.
 
It’s not easy, but we will put the work in, and find ways to adapt, and make the best of our situation. This isn’t the only virus humanity has faced. We beat the others. We’ll beat this one too.
 
Keep well,
Your North Shore Medical Group Physicians