April 22, 2020
Inadvertently Celebrating Earth Day
April 22, 2020 marks the 50th Earth Day anniversary. Like many other holidays, birthdays, and milestones this year, celebration will look different in 2020. But in the case of Earth Day, different is positive.
According to data collected by Swiss researchers at IQAir, current global carbon emissions since the COVID-19 outbreak are as low as they’ve been since the 2008-2009 financial crisis. Some models project that if shelter-in-place is observed for a few more months 2020 could see the lowest rates of carbon emissions in the last century. Decreased carbon emissions have meant visible, positive changes in air quality across the globe. For example, residents of highly urban cities such as New Dehli, Los Angeles, and Beijing are breathing higher quality air than they’ve had in years. Clearer skies in these same cities yield stunning views that are usually indiscernible.
This news, while positive at face value, comes at a high price no one wanted to pay — decreased carbon emissions via pandemic-induced, global economic shutdowns, and extensive social distancing.
After sifting through the budding research and mixed opinions, here are the salient takeaways we wanted to share to about these environmental changes:
- Trends observed during shelter-in-place offer insight about how the Earth responds to decreased carbonization. Specifically, the current positive changes anecdotally imply the Earth’s resilient and responsive to decreased carbon emission.
- The current air quality improvements can be quickly reversed if carbon emissions escalate again; post-covid economic policy will be very influential. Environmental scientists are advocating to use current trends as momentum for prioritizing environmental-conscious policy (focused on decreasing carbonization) as economies reopen after COVID-19 is contained.
- From an infectious disease perspective, the health of our planet plays a role in the spread of zoonotic diseases. Around 75 percent of new and infectious diseases are zoonotic and, in fact, about 1 billion cases of illness and millions of deaths occur every year from these diseases.
In conclusion, this Earth Day, consider taking an extra moment to notice changes in your environment. For civic engagement opportunities check out Earth Challenge 2020. We recommend enjoying clean air and clear skies in a safe, socially-distant way to celebrate Earth Day!
References for this article:
–NPR Updates on Pollution in India
–COVID-19 as a factor influencing air pollution?
–Coronavirus pandemic leading to huge drop in air pollution
-Images courtesy of NASA, CNN, Getty, Reuters, Business Insider
Your Access to Antibody Testing at Wise Patient:
See last week’s newsletter for a discussion about potential accuracy pitfalls in early antibody testing owed to the FDA laxing their standards for these tests to come to market. Still, it stands to figure that at least some of the 90+ companies selling tests will be shown to have gotten it right, through confirmatory testing from academic centers and agencies (FDA, CDC, and NIH). In fact, the University of Washington virology lab recently reported exceptional accuracy of Abbott’s antibody test: sensitivity of 100% and specificity of 99.6%. The fair warning remains that there is no guarantee of protection, partial or complete, against re-infection if you are antibody positive.
At Wise Patient, we are optimistic for those people who end up being IgG antibody positive for SARS-CoV-2, but we know optimism can burn us occasionally. We expect widespread availability of antibody testing within the upcoming weeks, not only from UW but also the major private labs. Additionally, we are avidly looking into several rapid antibody test kits that we could use to test you here in clinic using a finger prick blood sample. Our first priority for you is accuracy, so it may well end up that the most accurate testing will be our sending your blood sample to UW, Labcorp, or Quest. Like the case was for the RT-PCR nasal/throat swab that tests for active COVID-19 infection, the earliest samples we send to any location for antibody testing may be the ones with the most frustrating turn-around times.
Lower-than-predicted case-fatality rate for COVID-19
Two preliminary reports of population-based antibody testing in California, one performed by Stanford researchers for Santa Clara County and the other by USC researchers for L.A County, suggest more ‘recovered’ cases of COVID-19 than were previously estimated for these locations through modeling based on PCR testing for active infection. If the preliminary numbers in these reports stand the test of time and more global antibody studies, the case fatality rate of COVID-19 may end up closer to 0.1-0.2%, only somewhat more deadly than a typical influenza season. While this would be great news compared to prior estimates, everybody with their eyes open, and especially those who work in the intensive care units of urban centers, can see that COVID-19 in the time we have known it is worse than influenza. Here are ways that 2 viruses with similar case-fatality rates can have dramatically different impacts on health and death:
- One of those viruses can infect many more people overall than the other, leading to many more deaths.
- One of those viruses can be more transmissible than the other, leading to more deaths within a fixed time period.
- One of those viruses can cause more severe and prolonged illness among the people who eventually survive it, burdening the healthcare system, especially intensive care units.
COVID-19 seems to fit all three of these criteria. Related to #2 above, here’s a telling graph of new COVID-19 deaths per capita reported weekly compared to average weekly deaths (in different years/seasons) from other familiar causes, with data sources for each line listed below it:
Covid-19, starting from February 17. (Covid Tracking Project)
- The 2017-18 flu season: This was the deadliest recent flu season. The chart shows one line for deaths attributed directly to flu, and another for deaths attributed to either flu or pneumonia. The smaller line is an undercount of flu-caused deaths, the larger is an overcount, with the real number lying somewhere in between. The data begin on October 1, 2017, which the CDC considered the first week of that flu season. (CDC)
- Heart disease and cancer: The first and second leading causes of death in the United States. The chart shows total 2017 deaths averaged per week. (CDC)
- Car crashes: Weekly deaths beginning from January 1, 2018. (National Highway Traffic Safety Administration)
- 1957-58 Asian flu pandemic: Weekly influenza and pneumonia deaths beginning from August 24, 1957. These data come from a contemporary CDC program that surveilled 108 American cities with a total population of about 50 million people. We have used that figure, rather than the total U.S. population at the time, to calculate deaths per million. (CDC)
The Clinical Spectrum of COVID-19
The spectrum of clinical disease caused by the SARS-CoV-2 virus is diverse, ranging from asymptomatic to critically ill. For example, while Covid-19 is primarily understood to be a respiratory illness causing fever, shortness of breath, and cough, other case reports include milder symptoms of diarrhea and abdominal pain. It is hard to know the extent and spectrum of the less severe disease. Two recent publications studied specific populations who received more widespread testing than the general population. Observations from these studies yield additional insight into the range of symptoms (or lack thereof) experienced by patients with SARS-CoV-2.
The first was a study of obstetric patients in New York City. After diagnosing COVID-19 in two obstetrics patients admitted to the hospital for delivery (one of whom was asymptomatic on admission), two hospitals started universal screening of all obstetrics patients being admitted for delivery. Screening was done with a nasopharyngeal swab and quantitative PCR. There were 215 patients screened from March 22 – April 2. There were 4 women with fever or other symptoms consistent with COVID-19 on admission and all 4 tested positive. Of the 211 women who did not have symptoms, 210 were tested and 29 (13.7%) tested positive for SARS-CoV-2. This means that 87.9% of the patients who tested positive for SARS-CoV-2 were asymptomatic on admission. Three of these women went on to develop symptoms. In addition, one of the patients who initially had a negative swab later developed symptoms and subsequently had a positive PCR. It is important to note that this was in two hospitals in New York city where there was a high rate of community transmission and that pregnant women near their delivery date are likely to have been visiting healthcare facilities within the two weeks prior to delivery (in addition to being somewhat immunosuppressed). So, it could be expected that rates of infection were higher in this population than the general population. However, the fact that such a high percentage of patients testing positive had been asymptomatic is very interesting.
The second was a retrospective study of health care workers who tested positive for SARS-CoV-2. It sought to refine criteria for testing in health care workers, who if infected with SARS-CoV-2 are at high risk of transmitting it to vulnerable populations. The healthcare workers worked at different institutions in King County who all had different criteria for testing. No asymptomatic patients were tested. The study found that if only fever, cough and shortness of breath were used as screening criteria, it would have missed 17% of the cases. If myalgias and chills were added, it still would have missed 10% of the cases. The other symptoms reported at symptoms onset included nausea/vomiting, abdominal pain, watery eyes, headaches, chills, hoarse voice, and decreased appetite. This was based on data and interviews from 48 healthcare workers who tested positive for SARS-CoV-2 in King County, This is a small sample, but demonstrates the wide spectrum of symptoms caused by infection with SARS-CoV-2.
In light of these and other studies, we are leaning more towards a “universal precaution” protocol rather than a symptom driven one. When you arrive at the clinic, you will find us wearing masks during patient care and requesting that you do the same. We still want to know about it ahead of time if you are experiencing symptoms possibly consistent with COVID-19.
Wise Patient Spotlight:
We’ve been inspired by the creative ways our patients have chosen to cope in these unprecedented times: running with dogs, Zoom birthday parties, painting, tipsy yoga, mask making and more. One of you was kind enough to share personal reflections from this time. Gardening and group meditation via Zoom have helped this patient adjust. She kindly shared photos of her newly planted seeds. In her own words: “That is it for now. Plenty of other projects to do but since Covid, I like to do things more slowly instead of freaking out. I’ll get to this and that.” May we all also continue to be patient with ourselves as we learn and grow from this time.
Baking in Quarantine: Cream Puffs and Cheese Puffs!
Confession time: the Beda house is treating quarantine anxiety with carbs. And running. Each makes the other necessary. Since yeast is the new toilet paper, we are baking things that don’t have to rise, like pasta and cookies. Last weekend we leveled up by making pâte à choux which bakes into cream puffs (plain, fill with cream) or if you add shredded cheese, bakes into fancy cheese puffs (gougeres). They were crazy good. Here’s the recipe (courtesy of New York Times Cooking. If you have an account, check it out there!)
Pâte à choux for Cheese Puffs and Cream Puffs:
- 1 stick unsalted butter (8 tablespoons, or 1/4 pound), in 1-inch chunks
- ½ teaspoon salt
- 1 cup all-purpose flour (135 grams)
- 4 whole eggs, and 1 egg lightly beaten for glaze
- Pinch cayenne
- Pinch freshly grated nutmeg
- Black pepper, to taste
- 4 ounces grated cheese, like Comté or Gruyère
- Put butter and salt in medium saucepan with 1 cup water, and bring to a boil. Add flour, and stir with wooden spoon or sturdy whisk until mixture comes together, about 1 minute. Lower heat and cook for 1 minute more.
- Transfer dough to bowl of stand mixer fitted with paddle attachment. Mix at medium speed to cool mixture slightly. Increase speed and begin to add eggs, one at a time. Make sure each egg is fully incorporated before adding the next. After fourth egg has been added, beat for a minute more, until dough is smooth and glossy. Stop machine, add cayenne, nutmeg, pepper and grated cheese, then mix briefly to combine. (If you don’t have a mixer, you can also beat the dough vigorously by hand.) Scrape down sides of bowl and remix, then put mixture in pastry bag.
- Heat oven to 425 degrees. Line two 12-by-18-inch baking sheets with parchment. On each sheet, pipe six rows of 1 1/2-inch-round mounds of dough, five to a row, with at least 1 inch of space between them. (If you prefer, use two soup spoons to put the dough on the sheet.) Brush each mound with beaten egg, smoothing the tops with a finger if not quite round.
- Bake for 10 minutes, then reduce heat to 375 degrees. Continue baking for about 25 minutes, turning baking sheets as necessary, until mounds are puffed, golden and crisp. Serve immediately or cool on a rack and reheat later.
- For cream puffs, reduce salt to 1/4 teaspoon and omit cayenne, nutmeg, pepper and cheese. Bake puffs according to directions and cool on a rack. Split and fill with a teaspoon of lightly sweetened whipped cream, then dust tops with powdered sugar. Serve immediately. If puffs are baked ahead, reheat to crisp, then cool before filling. You can also make larger puffs. Increase baking time by about 10 minutes.
Reliable Sources to Stay Updated on the COVID-19 Outbreak
- A comprehensive list of resources is available on this 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: email@example.com