April 1, 2020
Distanced, but not distant:
Thank you for the many kind offerings and support you, our patient family, have poured our way. Your messages warm our hearts, as have your offers of errands, virtual cups of tea, gloves, PPE from construction sites, technical skills, and much more.
Undoubtedly the hospital teams in the ICUs, ERs, and wards are waging the biggest battles and accepting the greatest personal risk. They deserve heaps of gratitude and admiration.
Really, all of you are on the front lines of this. Working from home with kids bouncing on your head, checking groceries of people without knowing who will sneeze next, helping Amazon fight price gouging, covering your beats as firefighters, medics, police officers, journalists, mental health providers, keeping others fed, helping to educate and look after our children.
We realize the sacrifices each of us have been asked to make in combating this virus are heavy, but we appreciate all of you for helping us brave this trial.
While the burdens social distancing has placed on our social and professional lives have been difficult, we wanted to take a moment to highlight the idea that we hope each of you may find silver linings in these trying times. We came to the conclusion that some of you may enjoy having us share how various Wise Patient team members have been finding their own silver linings, so this week we will hear from one of our Health Coaches – James.
“Over the last year, I have struggled with the protracted process of applying to graduate school. As I am sure many of you can understand, the demands of a large project can swiftly erode the time and attention we feel we have for our health. It was easy to point to the next essay as reason alone to skip out on my scheduled run, or decide to order food again. Soon I went from 10K training to squeezing in a few thousand-steps a day at work. Only recently did I emerge out of one self-imposed period of isolation to be thrust into another.
While I deeply wish we were not in this situation, I realize that this outbreak has re-focused my attention to my health, and given me the time to once again make it a priority. In the last two weeks, my running shoes have come out of retirement and I have been able to put some mileage in on my go-to scenic trail. I have also been able to get back in my kitchen and experiment with new recipes – here’s one I did you can consider trying!”
Whether it is a renewed focus on a passion, your health, your family, or your community, we hope each of you is able to find your own silver lining throughout this time.
Patient walks into the clinic with a cucumber sticking out of one ear, a banana out of the other, and a carrot coming out of their nose.
They ask the doctor, “I just don’t understand what’s wrong with me, doctor!”
Doctor replies, “You’re not eating properly.”
Current Landscape at Wise Patient:
By this point, we anticipate that many of you are starting to either settle into life at home or are starting to brave the first waves of cabin fever. We have begun to settle in to our own change in operations as we strive to continue providing high-quality care to our patients making use of telehealth tools. Our office remains open for medical needs that cannot be addressed by telemedicine, though we ask you to reach out to us prior to coming in if you need an in-office appointment. We remain here for you! Please do not hesitate to reach out if you need us.
While we realize that the current Covid-19 outbreak is at the forefront of everyone’s minds, we want to put an emphasis on making sure other aspects of your health do not fall by the wayside during this trial.
While we remain hopeful of continued advances in the testing pipeline including rapid-testing kits, expanded supplies, and the possibility of antibody screening (blood test which confirms exposure, with possible evidence of immunity against subsequent infection), our current testing capacity remains limited but available to you. Our current supply will only allow for ~15 tests until more supplies are available.
Virtual Visits for Non-Members:
We have considered our place in the community, and what we can do to help increase access to medical care for those in need throughout the Covid-19 outbreak. In accordance with this, we have elected to now offer a one-time, $75 cash telemedicine visit for non-established members. We hope this may help serve as a stopgap in addressing our community’s health care needs, as well as preventing face-to-face visits which may strain the capacity of our region’s urgent/emergent care centers and potentially expose patients.
If a patient is happy with their care, we will give them the option to use their payment for the televisit towards their first month’s membership with Dr. Naomi Lee.
We encourage any interested parties to reach out if they have questions.
The excitement about new and upcoming serology testing for SARS-CoV-2 is warranted:
Serology testing is different from the current RT-PCR tests available to detect active infection. Serology tests for the antibody response to COVID-19, which doesn’t tend to occur until several (or more) days after exposure to the virus. One class of antibodies, called IgG antibodies, tends to remain elevated for life and often provides protection against future infection. It is too early to conclude that people with COVID-19 who subsequently recover will be protected, either fully or partially, from future infection with SARS-CoV-2 or how long such protective immunity would last. Yet scientists are hopeful based on a study showing that rhesus macaque monkeys could not get reinfected after resolving their initial infection (Reinfection could not occur in SARS-CoV-2 infected rhesus macaques), and observations that the genetic material (RNA) in SARS-CoV-2 doesn’t mutate as readily as influenza (Coronavirus Mutation Rate and Vaccine Feasibility).
Currently a company called United Biomedical is working to test for antibodies to SARS-CoV-2 all 8,000 residents of San Miguel County, CO: Testing in Telluride
Here are the most exciting potential uses of antibody testing for SARS-CoV-2:
Getting a sense of where we are with herd immunity, since the current models for herd immunity are wide ranging. One analogy is a forest fire dying out after it runs out of susceptible trees. If R-naught (R0)is the average number of susceptible people infected by one person with COVID-19, once the fraction of susceptible people in a population drops below 1/R0 then one person with COVID-19 on average infects less than 1 other person and that is when we are ‘over the hump.’ Most modelers believe we are still far from that point. But how far?
We are not in any way advocating for relaxing the current shelter-in-place strategies for purposes of herd immunity. Shelter-in-place strategies are already starting to pay off and will continue to save many lives. It’s just that when a country eventually reaches some major achievement of greatly declined deaths, an argument will be waged between people who say, “We achieved this through shelter-in-place. Don’t relax shelter-in-place,” versus people who say, “We achieved this through shelter-in-place plus herd immunity, so let’s discuss which social distancing measures we can begin to relax.” Without a measurement of herd immunity, through serology testing, that argument will be uninformed by fact.
Assuming there is protective immunity, individual serologic tests may be used to guide duty delegation among healthcare workers and return-to-work decisions among wider society.
Helping identify people who could donate their antibodies for the purpose of injecting them, as treatment, into patients with severe COVID-19, or as prevention in people with ongoing high exposure in the healthcare setting (both of which are still experimental, not proven).
More accurate assessment of case-fatality rates for COVID-19 in different populations (since ‘recovered’ people who weren’t tested for active disease in the first place would be added into the denominator).
State of the state:
Early signs of success with social distancing:
New, preliminary data emerging this week has pointed to positive impacts of social distancing on the rate of spread of Covid-19. The Seattle Times reported that a survey by the Department of Health has tallied a reduction over the last week in hospital admissions for patients with fever, cough, shortness of breath.
Further analysis by the Bellevue-based Institute for Disease Modeling on mobility data (harvested from Facebook) alongside case reporting has quantified a reduction in the spread of the virus in King County after the implementation of social distancing measures – primarily the closure of schools and limiting the public gathering of persons. Given the length of the virus’ latency period, we will only be able to more accurately analyze the effects of Gov. Inslee’s most recent ‘Stay Home, Stay Healthy” policy in the coming weeks.
While IDS estimated that the effective reproductive rate (Re = R0χ, where χ is the proportion of the susceptible population) has dropped from 2.7 new cases per infected person to 1.4 from February 26th to March 18th, their message was clear — keep it up! We will only see a decline in the disease once we can get this value below one (by strategies including behavioral interventions, expanding herd immunity via vaccinations, etc).
New models for hospital resource use and deaths courtesy of IHME:
Washington reported the earliest confirmed case of Covid-19 in the United States on January 21st. Since that time, we have seen what was initially silent propagation in our community and others become a nation-wide outbreak. While we have seen many groups publish visual representations of cases of Covid-19 (ie. Johns Hopkins Coronavirus Map), new analyses are emerging which aim to represent how each state will fare. The Institute for Health Metrics & Evaluation, a local health metrics powerhouse in South Lake Union, has recently published their forecasts for Washington. You can find their models, as well as the methods behind their modeling, here. Their current projections for Washington state, given the timeline of cases and social distancing measures imposed are as follows:
Peak date of hospital resource use in 14 days on April 15th, 2020
No general bed shortages, but an expected ICU bed shortage of 93 beds on the peak date.
Deaths per day peak at 23/day from 4/15 – 4/21
Total projected deaths (through 08/04/2020) in Washington: 1,233
Similar projections can be found for other states, as well as the national projection, at the above link. These projections are updated regularly, so they are a great tool to use when examining disease burden in our state.
Access to health care and other basic needs:
If you missed the annual Washington Health Exchange enrollment period, or had a recent change in health insurance status, we want to let you know a special enrollment period is currently in effect. A news briefing from the health benefit exchange outlines the special enrollment period (SEP), which will run through April 8th for health plan enrollment.
As a reminder, enrollment for Washington Apple Health (state Medicaid plans), is open for enrollment year-round. If you are interested in enrolling in either an exchange plan or an Apple Health plan, please reach out as we will want to share important information with you about how these plans work alongside our membership model.
Additional Basic Needs Support
City of Seattle Resource Page – Many resources including food voucher program.
United Way of King County – Resources including food, utility, rental assistance, internet, & childcare.
Housing Justice Project – Legal Assistance related to eviction: 253-234-4204
Reliable Sources to Stay Updated on the COVID-19 Outbreak
- A comprehensive list of resources is available on last week’s newsletter which is available on our website: https://imwisepatient.com/week-of-3-23-2020/
If you have any questions, please contact our office at: firstname.lastname@example.org