It is week 27 of the COVID restrictions in the Commonwealth of Pennsylvania. We are definitely seeing another surge now that fall has arrived.

We’ve actually set a record number of new cases per day with 2200 new Pennsylvania “cases” on 23 October compared to the Spring peak in mid-April at about 1700 cases per day. Happily, at this new peak, hospitalizations are only 37% of their peak in the spring. The death curve remains flat.

Around here we are seeing some activity, including in my own hospital, but so far it is not overwhelming. And we have tons of potential ICU capacity based on our reshuffling of beds earlier this year.

A little perspective however is in order. According to the most recent data on the Pennsylvania COVID 19 dashboard, the test positivity rate for the state is still around 5%, and the overall percentage of ER visits for “COVID like illness” is .8%. There is considerable variation among the counties.

Other states are surging also. States like Minnesota, Wisconsin, and Ohio are having what one might say is their first big peak, with an accompanying admission peak, more commensurate to what we saw in April.

Governor Wolf has so far resisted the temptation to re-impose our Spring restrictions. I’m hoping he realizes that for many businesses, another shutdown would be fatal to their existence. This virus is apparently going to be persistent, at some level we are going to have to figure a “workaround “.

It should be a hopeful sign, that President Trump, and his affected staff, have emerged from their infections essentially unscathed. I do recognize there are people reading this that may have wished for another outcome. I also note that he was by current practice rather aggressively treated. When you compare his disease course to that of Boris Johnson, who became ill in the spring there is a symbolic cause for optimism.

Mr. Johnson is you may recall in early April, contracted the virus. He became rather seriously ill to a point of needing an ICU, and by contemporary accounts required considerable supplemental oxygen. Much like his American counterpart, I am sure he received the maximum therapy available through the National Health Service of Britain at the time. But now we have Remdesivir, antibody cocktails, anticoagulation, and dexamethasone. 5 months later, our head of state, despite being older, had a much milder illness and quickly returned to a rather vigorous schedule.

If I keep writing these articles on a 2-week schedule, the next one will be after the election. It is been fashionable to accuse our Democratic Governors of playing politics with the virus, I myself have been guilty of this. At times, like in mid-July when restrictions were reimposed while cases were still flat, it seemed likely.

There are those who find the current case surges in swing states suspicious. They note that many democrats have already voted by mail, whereas Republicans tend to wait to cast their votes directly. They suggest that these case “surges” are manufactured to discourage Republicans from in-person voting. I might have been open to this concept except as mentioned above, there appears to be real illness associated with the increasing case numbers, at least in our commonwealth. Still, with masks and distancing, I have no fear of the polling stations.

in response to these articles in the past, I have been criticized, particularly on Facebook, for what some people feel is a cavalier approach to this outbreak. I think I’ve been fairly consistent, suggesting that we not react merely to the number of positive tests, but to factors such as hospital utilization, and of course deaths, to decide public policy regarding COVID 19. Given what been going on in the last week, I think it is time to be more careful now. We need to go back to more frequent handwashing, the wearing of masks (for what it’s worth) social distancing, and protection of the vulnerable. We need to carefully balance our understandable desire to socialize, with the risks of gatherings indoors.

There is some reason for cautious optimism. Obviously, with every new case that is either asymptomatic or recovers, that’s one less person who can transmit the virus. With over 5000 positive tests for instance in Luzerne County, if you factor in the asymptomatic’s that were never tested, you may have a lot of immune people in the region.

We also note that the virus is thought to be getting less virulent as time goes on, which is predictable. So far it seems to be the case, that in regions that are having their second or third peak, hospitalizations and death are far lower than when the virus first appeared.

Also, according to Dr. Fauci, we are perhaps 3-4 months from when a vaccine will be available. It is my hope that we can all find safe ways to patronize our small businesses to keep them afloat until the end of the pandemic but still avoid unnecessary spread. We need to come out of this, intact and healthy both as individuals and as a society.

We need to be not fearful, just careful.

As always, I would be honored if you would share this post.

Header image: Witch Hazel (Fujifilm X100V, TCL X100)

We have officially hit week 31 of curve flattening, infection prevention, disease curing, bizarro world. With the weather growing colder here in Pennsylvania there has been an uptick in positive coronavirus “cases”, meaning positive PCR tests. There has been a small increase in hospitalizations, but the death curve is so far flat.

Remember that the New York Times reported that by the current method of PCR testing, up to 90% of people who are PCR positive may be noninfectious. My fear about the rising case numbers is that our governor and health secretary will use the occasion to increase the restrictions upon us. Remember the severe “red phase” lockdowns in spring. All that misery and lots of people still got sick.

Of course, the big news in the last week was the fact that President Trump and a significant number of White House staff have tested positive for coronavirus. Although there have been allegations, that the president was cavalier about masking, the bottom line was that he has been tested frequently if not every day, along with apparently anyone who was in contact with him in the White House. This clearly was an extraordinary effort to protect him from the virus. Yet it failed. It did so for one reason: this virus is ubiquitous in the environment.

He was admitted to Walter Reed Hospital, not so much because he met the criteria for admission, but because he is the president. Though apparently never requiring oxygen, or getting particularly sick, he was treated with a very aggressive regimen of medications including the antibody preparation from Regeneron which is clearly experimental. After a 2 day admission, he was discharged.

Apparently, he is testing negative for coronavirus now and has been deemed “noncontagious”. The other “infected” staffers, including the first lady, have all done well. As I understand it, no one else was hospitalized.

The Pennsylvania new “case“ numbers are impressive. On October 7 there were roughly 1400 cases reported, roughly the same number, as were reported on April 23 for instance. The difference is that on October 7 there were roughly 700 patients admitted to the hospital with COVID, versus 2700 in April. Whether these patients are actually sick from the virus, or merely PCR positive is anyone’s guess.

It’s also was noting there was far less testing being done in the spring. Clearly, either the tests are oversensitive, or the virus has changed. Maybe it’s a little bit of both.

The search for a vaccine apparently is continuing at a rapid pace. Apparently, the Johnson & Johnson candidate may have provoked some unusual symptoms in one of its test subjects and for now hold has been placed on their efforts.

So now we have increasing cases and so far, God willing, little morbidity. Given the availability of more sophisticated care for those to become ill, I continue to believe that continued numbers of asymptomatic and mildly symptomatic COVID infections is actually good news about our journey to a helpful degree of herd immunity.

Remdesivir is also in the news. On October 8 a study comparing the drug to placebo in ICU patient’s revealed that the median time to recovery, defined by the study as either discharged from the hospital or to a custodial situation was 10 days in the treatment arm and 15 days in the placebo arm. This is a fairly significant result suggesting the drug is a useful part of our growing options for the treatment of COVID 19.

I continue to believe that given the persistence of the virus, it’s declining virulence, the improvements in treatment, that we should relax the regulations killing specific industries and small businesses. We need to react, not to PCR tests, but to actual illness, hospitalizations, and death from COVID, not PCR positives with other acute medical problems.

Finally this week, the World Health Organization seems to change its mind on the advisability of lockdowns. In an interview, Dr. David Nabarro, the WHO’s Special Envoy on Covid-19, warned against using lockdowns as the primary control method for the coronavirus, for fears that global poverty and malnutrition may ultimately result. He expressed concern that for instance, the suppression of the tourist industry has impacted many destination countries severely.

In other words… after eight months of masks and misery, people continue to be exposed to this virus. Time for plan “B”.

Hopefully, Governor Wolf is listening.

As always, I’d be delighted if you’d share this with your friends.

Header image: Maple in the Glen (Fujifilm X100V, TCL X100 II)

We are now in week 29 of what is apparently an endless state of behavior control by our omnipotent masters: the executive branch of Pennsylvania government. Once again, another legislative effort to loosen up the restrictions, in this case on the restaurant industry, has been vetoed by the governor. This is despite the fact that while we are seeing modest numbers of positive PCR tests, there is very little actual illness resulting.

I remind myself that when I posted my first “viral” article back in mid-March, I assume naïvely that this topic would die out by midsummer. That my cover image for this edition now features autumn foliage, is quite discouraging.

Meanwhile, our governor, in a conversation with Rep. Wendy Ullman of Bucks County, is caught on an open mike discussing the concept that for our elected elites, wearing masks in public is “political theatre”. Good to know.

In Pennsylvania, the small peak of cases we had over the summer is waning. The number of hospitalizations, ventilated patients are all decreasing from already modest levels and the percentage of emergency room visits devoted to COVID-like symptoms is well below 1%.

I think we know this anecdotally. Other than a few patients whom I have attended, I know perhaps 3 people who tested positive for this illness. One of them had a fairly severe flu-like illness from which she recovered. Another had a short period of mild respiratory symptoms. The third was absolutely asymptomatic and was retested in 4-5 days and found to be negative. Most people I talk to have similar impressions. I understand that I didn’t live or work in NYC or similar hotspots. I’m referring to Pa. and I think, most of the rest of the country.

One of the things I have been pondering about is the disparity I have noted between my liberal and conservative friends, and their attitude towards the pandemic. In general, my liberal friends tend to be much more concerned about the possibility of contracting the illness and are much more careful about human contact. My more conservative friends seem more willing to interact, and in general, are more casual about their behavior. In my mind, this crosses all intelligence levels in both political persuasions. While this disparity is not absolute, to me it seems pretty consistent.

Let me say that I am excluding from this discussion the more militant “anti-maskers” from this as #1 I don’t know anyone who is a complete nonconformist to the rules, and #2 given their lack of courtesy, I would tend to discount their opinions.

I don’t see anything innate in one’s political leanings that should lead to this effect. I refuse to believe for instance, that all my liberal friends, want to keep us shut down to affect the upcoming elections.

 I am left to believe that it is the media that we consume that forms our attitudes. It is clear to me that conservative media is more willing to entertain a certain skeptical approach to the pandemic through their pundits. The liberal media tends to emphasize the case numbers and the strains on the healthcare system where they occur. If there is a political motivation for this, I think it exists within the media and their allies in the political parties. This is a potentially dangerous game as it inhibits a purely rational approach to this outbreak.

So I shall once again restate my current thinking.  Yes, there is/was a pandemic. Each of the states has had different peaks depending on travel patterns and other factors. There has been an “excess of deaths” throughout the country, though the numbers don’t precisely match the COVID death numbers. There is a reasonable case to be made that some of the additional deaths may be consequences of the lockdown, particularly suicides, addiction, and the fear of hospitals by people who required medical attention.

Currently, I believe that per a number of sources including the New York Times article, that PCR testing is oversensitive and maybe creating a lot of false positive “cases”. I believe that rather than worry about the numbers of additional positive tests, we should scale our precautions based on actual disease burden which for now is modest at best.

I look at the pandemic the way I would look at a critically ill patient during my years as an intensivist. Let’s say a patient is admitted to the intensive care unit, with sepsis and low blood pressure. We would intervene in this, often by giving a large amount of IV fluid, plus drugs that can compress the blood vessels, raising the pressure. These modalities though, have long-term side effects that can be life-threatening, so in these situations, we are constantly testing. If the patient’s blood pressure appears to stabilize, we begin to withdraw the interventions. If the patient deteriorates then we may need to re-increase the therapy, but ultimately the goal is to discontinue these measures before they do the patient more harm.

This experience informs my attitude towards the current status of COVID in most of the country. The measures we took back in March, were certainly appropriate then, but they have been continued in situations where the “patient” seems to have stabilized. The problem is that prolonged intervention has done a lot of damage to large and small businesses that are now either crippled or deceased.

The goal of therapy needs to be the return of the “patient” to normal life as soon as possible. I suspect we would be doing this more aggressively if governor Wolf was not a “lame duck”, and if a presidential election were not imminent.

It’s now Autumn. Time to end the political theatre.

As always, we would be honored if you would share.

Header Image : Scene Along Glenside Road (Fujifilm X100V)