Take Stock of Where we are
MEDICAL AND MENTAL HEALTH UPDATE
Giddy up, it’s 2021.
As we stare down the barrel of the New Year with a still-raging pandemic, it’s easy to feel hopeless and afraid. Yet it’s important to realize how much we’ve learned over the last year about COVID-19. We know a LOT more than we did in March.
Now that 2020 is behind us, where the hell are we?
Today we’ll take stock of WHAT WE KNOW TO DATE about prevention and treatment of COVID-19—from vitamin D to vaccines, masks to monoclonal antibodies, steroids to self-care.
In honor of my anxiety, we’ll start with the worst case scenario.
What do we know about the treatment of SEVERE COVID-19 (moderate-to-severely ill patients requiring hospitalization)?
If people end up needing hospitalization, it’s typically in the second week of symptoms that they end up there.
We currently have four mainstays of treatment for hospitalized patients:
Supplemental oxygen. A low oxygen level at home is usually the reason for admission to the hospital. Our sickest patients require mechanical ventilation and “proning”—a face-down position to optimize oxygen delivery to damaged lungs. A large subset of these patients die..
Dexamethasone. This steroid has been shown in robust studies to reduce mortality in our critically ill patients by 30%. It works by tamping down our body’s hyperactive immune response that drives the second phase of illness.
Remdesivir. This is an antiviral medicine that is given intravenously to hospitalized patients requiring oxygen within the first 14 days of illness. It is generally considered safe, however its universal efficacy for all hospitalized patients with COVID-19 is being re-evaluated in ongoing trials.
Blood thinning. Data supports administering daily aspirin (or other blood thinners depending on the clinical situation) because COVID-19 can cause clotting in any organ system.
What do we know about the treatment of EARLY COVID-19 (mild to moderate symptoms with a positive COVID test)?
It’s important to note that 80-90% of patients can be managed at home and never need hospitalization, particularly if they are in close communication with their physician.
For my COVID patients at home, we monitor symptoms and their oxygen levels with a portable pulse oximeter (with a goal of remaining at 94% or above). I also typically recommend:
Acetaminophen or Ibuprofen for sore throat, body aches, fever
Vitamin D 1000 IU and zinc 25 mg daily as some studies suggest these help and almost certainly cannot hurt (though it’s best to know your blood levels and to consult with your own doctor)
Rest (and Melatonin at bedtime if needed for sleep)
Aggressive hydration with Pedialyte, Gatorade, or broth
Time (most people recover fully after a week, though certainly we are seeing a lot of long-haulers whose symptoms can last weeks or months)
Isolation for ten days (this goes without saying but still...), with no test needed afterwards. Really.
There is only ONE evidence-based treatment of early COVID-19 (despite massive amounts of misinformation floating around online). This is monoclonal antibodies, a one-time intravenous infusion of laboratory-created antibodies modeled on antibodies from patients who have successfully recovered from COVID-19. It’s designed for COVID patients at home—and only is useful in the first 7-10 days after symptoms onset—in order to prevent hospitalization. I just ordered this very safe and under-utilized treatment over the weekend for two patients. Both are at higher risk for severe COVID due to their age and underlying health conditions, and both are doing well today after receiving treatment.
In early (week one of) COVID, I definitely DO NOT recommend steroids, Hydroxychloroquine, Ivermectin, Azithromycin or other antibiotics. Despite what you read on the internet, currently there is no role for any of these treatments in patients with mild to moderate COVID symptoms. They can even do harm. (Bring on the hate mail!)
What do we know about post-exposure prevention of COVID-19 (e.g. you’ve been exposed, what to do next)?
Recall that a high-risk exposure is one where you are less than six feet apart for a total of 15 minutes over 24 hours from an infected person. Being unmasked and/or indoors is higher risk than being masked and/or outdoors. Infected people are most contagious starting two days prior to the onset of symptoms and usually for 4-5 days after the onset of symptoms (but can be contagious for up to 10 days after onset of symptoms).
After a potential exposure, you need to quarantine for 10 days per CDC guidelines (it used to be 14 days), with the understanding that you can become infected at any point up to 14 days after an exposure (however the chances of testing positive or developing symptoms at day 11 through 14 is very low). The CDC also allows for a 7-day quarantine if accompanied by a negative test at or around day 7, but you should consult your own physician and/or your local health department when considering this shorter quarantine.
What do we know about general prevention of COVID-19 for everyone?
The short story is this: my handy-dandy MOSHPIT acronym still stands! To review:
Masks. There is abundant evidence that masks protect other people and the wearer from coronavirus. Masks are arguably the most effective public health measure we’ve got.
Outdoors. It’s twenty times safer to see other people outside rather than inside. When indoors, good ventilation is critical to reduce transmission via smaller aerosolized virus-containing particles.
Social distancing. The further apart we stand from one another, the lower the risk of transmission. Why? Because the primary mode of transmission is person-to-person via respiratory droplets. Limiting the size of gatherings also reduces the risk.
Handwashing. The virus is extremely wimpy against soap and water and hand sanitizer. Use it early and often! Surface transmission of the virus is not a main contributor to cases, but it’s not impossible.
Personal and public responsibility. Adopting an attitude of “I will protect others like I protect myself” is critical for public health and crushing COVID-19. Until we achieve herd immunity, not getting on that airplane and not hosting that indoor gathering protects you and other people. Even if YOU are at low risk for severe illness, you can easily—and invisibly—be a link in the chain of transmission that can kill someone else. A little selflessness goes a long way these days!
Information and knowledge. Follow facts. Trust science. Know where to find the truth. This includes knowing your own COVID status. Get tested frequently, even in the absence of symptoms. Increasing data supports that testing asymptomatic people saves lives. (Recall that approximately 40% of people infected with coronavirus do not have symptoms yet are able to transmit it to other people.) In the current testing landscape, I only recommend PCR testing for asymptomatic people; the antigen tests aren’t reliable unless administered frequently and in the proper setting.
Talk to your doctor. Schedule your physical. Know your personal health risks. Discuss with your doctor how to protect your unique body from illness. Take stock of your mental and physical health in tandem. Addressing anxiety, mood, trauma, and grief is as important as managing your weight, cholesterol, and blood pressure. Optimizing your underlying health—specifically prioritizing sleep, exercise, healthy eating, stress management, and self-care—is the best way to prevent COVID-19 and bad outcomes from it. Moreover, a healthy body and mind only sets you up for success in everyday life!
Like slices of swiss cheese, these MOSHPIT risk mitigation measures must be layered on top of each other to prevent holes in the system—to optimally prevent coronavirus from slipping through one layer. In other words, masks alone aren’t enough.
Take, for example, my patient who developed COVID-19 at a masked, outdoor gathering, sitting three feet away from a friend who was unaware that she had asymptomatic COVID at the time. My patient got sick five days later. Had they distanced six feet, my patient might have been okay. Particularly with a more transmissible variant of the virus in circulation, layering risk mitigation elements has never been more critical. MOSHPIT works; we just need to use it.
How else can we prevent COVID-19?
Widespread vaccination! We now have two wonderful, safe, and highly effective vaccines. They are nothing short of a miracle. Yesterday I had dose #2 of the Pfizer-BioNTech vaccine. Aside from a slightly sore arm, I feel great. I’m hopeful and extraordinarily grateful to soon be immune to this beast.
However, I am acutely aware of the desperate need for widespread vaccination before anyone can relax. We have a long way to go before we achieve herd immunity. We also don’t yet know if vaccination prevents asymptomatic carriage and transmission of the virus. So: while I’m confident I won’t get sick from COVID-19, I can’t take off my mask, hug my parents, or feel comfortable at an indoor gathering until we are ALL immunized. When will that day come? If I had to guess, I’m picturing a much better summer and a near-normal fall of 2021. Will normal ever include handshakes, unmasked airline travel, and packed concerts with REAL mosh pits? Who knows! I’ll simply be happy with a few hugs, a family trip, and laugh-out-loud dinners with friends in 2021.
For more vaccine info, I recently wrote two blog posts on vaccines and frequently asked questions. Click here and here to read! I also did a live Q & A on Instagram last night.
I will check in later this week. Until then, be well.