June 17, 2020
Hello Wise Patients! Just when we “thought” we were through with it, Covid-19 rears its ugly head again like a pimple on a pristine face. Make sure to adhere to the guidelines and continue to distance yourself from others by at least 6 feet, continue to wear your facemask out in public, limiting your trips out into the public etc. If you are in need of a facemask we have a limited quantity of cloth facemasks that we can give out (thanks to a crafty Wise Patient). We can still test you for Covid-19 here at the clinic but the city of Seattle has offered free testing at two locations, one in North Seattle and the other in the South. More info can be found here.
As King County remains in Phase 1.5 and has applied to move to Phase 2, we are beginning to see restrictions be lifted and re-opening of the county begin. One of the biggest questions we see being asked as we begin re-opening is if we will see a large increase in Covid-19 infections and what we can do to prevent spikes in infections. Face masks have been shown to play a key role in reducing the spread of Covid. A journal article from The Royal Society Publishing used mathematical models to study the efficacy of face masks in reducing the spread of Covid. Through the models, the authors found that the increased use of face masks by the public significantly reduced the spread of Covid. When masks are used at all times and not just after exposures or symptoms appear, the rate of infection drops and holds even more true when we have high rates of mask compliance by the population with maximum benefits being at 100% of the population wearing a mask. The article also notes that viral infection rates also significantly decrease when the mask efficacy increases but suggests it is still reasonable to wear a homemade mask that can capture large particles which also assists in lessening the spread of the virus to others.
Through this article and other similar studies, we see that face coverings of any kind help with reducing the spread of Covid-19 and we encourage everyone that can to continue to wear masks to keep themselves and others safe while we go through this re-opening.
This Friday, June 19th, 2020, Wise Patient Internal Medicine Clinic will be closed to observe the Juneteenth holiday. Juneteenth is the holiday that celebrates when Black people in the United States were finally free from slavery. It is important to note that the date itself, June 19th, wasn’t the exact day they were freed but the day they were told they were free. Abraham Lincoln, signed the Emancipation Proclamation and had it go into law January 1, 1863, but for Black slaves living in the southern states (Louisiana, Texas, Alabama, Mississippi etc.) they didn’t receive the news of their freedom until 1865. Since then, Black people around the country have recognized June 19th as the date for the holiday and have celebrated since.
However, although considered legally free, there are still so many setbacks that Black people have received in this country. Being enslaved for 400 plus years in this country has led to different forms of racism with eras of slavery, segregation, Jim Crow, and modern Trumpism. Each era continues to inflict great damage onto the Black psyche with their devastating effects hurting past, present and future generations. At this point in time, it would be remiss of us as healthcare workers to deny racism not affecting the health of Black people. The social determinants of health with Black individuals is steeped and embedded in racism from housing, the environment, education, employment etc. This year we’re already seeing Black people die from COVID-19 at higher rates than other races in the United States. Black individuals, gay, bisexual, transwomen, have been diagnosed and affected by HIV, more than any other group in the nation. In this article from Vox, it highlights and discusses the effects grief, discrimination and images of Black death on Black mothers and how that can cause an enormous amount of stress which can effect blood pressure, increase inflammatory markers, and worsen sleep patterns.
In King County, it was declared that racism is a public health crisis. Dismantling racist institutions and practices definitely can’t happen overnight, but getting people to acknowledge how institutions that have benefited white people for centuries at the expense of Black bodies is an unfortunate start. So for this year’s Juneteenth, examine your privilege. What is it that you can do today to advocate for those who haven’t been afforded the same challenges to you? To those who’ve pulled themselves up from their bootstraps, will you recognize that Black people weren’t even given boots to even change an ounce of their lives? Educate yourself, whether it’s through reading books, watching documentaries or even marching for Black lives. Know that in order for there to be considerable progress, justice, justice for Black lives, be it Henrietta Lacks, Emmett Till, Trayvon Martin, Tamir Rice, Sandra Bland, Charleena Lyles, Ahmaud Arbery, Manuel Ellis, Breonna Taylor, George Floyd and countless others who’ve been victimized by the effects of racism needs to occur.
COVID-19: Asymptomatic Transmission
As we move in the direction of “opening up” with less restrictions on being together in public space, we need to keep in mind what we know about the transmission of the virus. The topic of asymptomatic transmission is an area that is evolving and important to keep in mind, especially as we contemplate hugging our dads and grads this weekend. On June 8th, Dr. Maria van Kerkhove, the technical lead for COVID-19 at the WHO said that asymptomatic transmission was “very rare”. The following day, she took it back saying that some modeling studies estimate that as many as 40% of SARS-CoV-2 transmissions may be from asymptomatic cases. Given that asymptomatic people are much less likely to be tested, it’s easy to see why it’s hard to say.
Some of the information that we have about asymptomatic transmission comes from studies where there was wide spread testing in certain populations. We reviewed the study of women presenting to the labor and delivery ward in New York City in a past newsletter. This week, in a letter to the editor of the New England Journal of Medicine, there is an analysis of the passengers from the Diamond Princess cruise ship that docked in Japan on February 19th after an outbreak of COVID-19 was discovered on board.
Of the the 3711 passengers and crew members on board the Diamond Princess, 712 people were found to be infected with SARS-CoV-2 at the time of screening. Of those with a positive test, 410 (58%) were asymptomatic. Some of those asymptomatic patients (96) and some of their cabinmates (32) who tested negative on the ship were transferred from the Diamond Princess to a hospital in central Japan between February 19 and February 26 for continued observation. Of the 96 asymptomatic patients with a positive test, 11 went on to develop symptoms at a median time of 4 days from the positive PCR. So these patients were basically pre-symptomatic instead of asymptomatic. Of the 32 who were asymptomatic and tested negative, 8 went on to have positive test within 72 hours, but all remained asymptomatic. The patients were followed with serial PCR tests to see when the infection resolved. It was considered resolved with two consecutive negative PCR tests. In all, there were 90 patients who initially tested positive for SARS-CoV-2 infection and remained asymptomatic until resolution of infection. The researchers described the characteristics of the patients who remained asymptomatic as having a median age of 59.5. Coexisting medical conditions were present in 27% of them, including hypertension (in 20%) and diabetes (9%). The younger the patient was, the more likely they were to clear the infection quickly, but 90% had cleared it by 15 days.
This shows that asymptomatic infection is not all that rare and that even older patients with comorbidities can be among the asymptomatic. It is hard to say for sure how many of these patients transmitted the virus to others, but the fact that 8 of the 32 cabinmates turned positive suggests that transmission did occur (they had been quarantined in their cabins).
So, stay home if you are sick, but please continue to behave as though you or anyone you come in contact with could be infected with SARS-Cov-2 even in the absence of symptoms. Wear a mask in public, wash hands frequently. If you spend time with dads and grads this weekend, remember that gathering outdoors with 6 feet between you is the best way to reduce risk while getting together.
Blood Type and COVID19 Susceptibility
Observational data has been mounting for an association between blood types and susceptibility to COVID19. The New England Journal of Medicine released an article today confirming this. Blood group A was associated with a 45% increased risk for COVID-19 respiratory failure, while blood group O was associated with a 35% lower risk, relative to other blood groups.
Why? It has to do with the glycosylated proteins that type A and B blood cells have, but type O doesn’t. From the Journal of Chemical and Engineering news: “SARS-CoV-2 can replicate in cells that express blood type antigens, says Jacques Le Pendu, a glycobiologist at the University of Nantes. So when an infected person coughs or sneezes, they possibly release viral particles coated in their blood type antigens. That means if a person with type A blood transmits the virus to a person with type O blood, the type O person will have antibodies that can fight the virus. However, if the person inhaling the particles is also type A, they won’t have those antibodies. ”
Blood type is not the only factor for infection with COVID19 and the severity of disease, however. For example, O is the dominant blood type in the Black population in the US, but COVID19 has disproportionately hit the Black community. If your blood type was the only factor for severe infection, this would not be the case. As Dr. Laura Cooling, director of immunohematology at the University of Michigan states, “It’s what your blood type is, relative to the other person who exposed you, relative to all the other genetic and acquired health conditions you have.” We also know that the burden of infection (ie how many virus particles you inhale) makes a significant difference in your chance of infection and severe disease.
We’ve fielded calls from some of you wanting to know what your blood type is. For most of you, we don’t have that data, since blood typing is typically only done during a first pregnancy, or in anticipation of a surgery where you may need a transfusion. Typically, most people find out their blood type when they donate blood (which, if you decide to go that route, is free, and helps BloodWorks Northwest with their life-saving supply!).
I would caution those of you who may know that you’re type O from letting down your guard, since people who are type O still can get severely ill and die from COVID19. Similarly, we don’t have any different treatment for people depending on blood type. So we’re all still in this together. We all need to continue to do our part to prevent the spread of this virus, which will also help prevent each of us from getting it as well.
How Far I’ll Goooo
Today in pet entertainment. Lucan and his favorite movie, Moana
Renzo is setting sail, maybe to follow in Moana’s footsteps?
WPIM Book Recommendations
We asked and you responded. Here are just a few of the titles that you’ve dusted off your physical or digital bookshelves. If you have any novels you’d like to share, let us know!
- How to be an Antiracist by Ibram X. Kendi
- Farewell to Manzanar by Jeanne Wakatsuki Houston & James D. Houston
- The Half Has Never Been Told by Edward Baptist
- The Prime of Miss Jean Brodie by Muriel Spark
- Spillover: Animal Infections and the Next Human Pandemic by David Quammen