July 1, 2020
COVID-19 Updates
Summer Cleaning… for your Colon?
Many of us have been in “survival mode” over the past several months as COVID-19 has swept across the globe. Our newsletters have reviewed ways to stay healthy related to COVID-19 (wear a mask!), and we want to focus some attention on other ways that we maintain health as individuals and as a society. We realize that decision making about the risks and benefits of “when/where/what for” to seek medical care has shifted. In earlier newsletters we wrote about people who were delaying care for heart attacks and appendicitis out of fear about going to the ED. Here we want to focus some attention on something that might be easier to put off than a heart attack or appendicitis, but is still important: age appropriate cancer screening.
Colorectal cancer is the second leading cause of cancer-related death. Screening for colorectal cancer typically starts for average risk people at age 50. Colonoscopy is the most sensitive and specific screening tool for colorectal cancer and has the benefit of being able to deliver a therapeutic intervention at the time of screening (removal of polyps). However, the best screening test is also said to be one which an individual is willing to do. While we believe that going for your colonoscopy is safe (there are screening and other safety procedures in place in colonoscopy suites), we also want to highlight an alternative method for colon cancer screening for people who assess the risks and benefits of their screening colonoscopy and decide not to go in for it.
The Multitarget stool DNA testing (MT-sDNA, also known as FIT-DNA, called Cologuard in the United States) is a good test that you can do at home. A kit gets mailed to you, you collect a sample in a container provided and then send it back. It does not require any dietary changes prior to doing the test. It works by assessing for the presence of DNA changes present in malignant cells that are shed into the stool. The USPSTF reported that the sensitivity of FIT plus sDNA for detecting CRC was 92% (CI, 84% to 97%) and specificity was 84% (CI, 84% to 85%). If the result is positive, a follow up colonoscopy is required. If it is negative, repeat screening is recommended after three years. We continue to be here to work with you on disease prevention and health promotion. If you are due for colon cancer screening this year and might want to pursue this instead of a colonoscopy, reach out to us.
This is a Mask Only Zone
The effect of mask wearing on daily deaths in the United States, as modeled by The Institute for Health Metrics and Evaluation (IHME) at University of Washington: https://covid19.healthdata.org/united-states-of-america.
The solid line is observed data (ie, through today). The dotted lines are mathematically projected. The green dotted line represents a “universal masks” scenario that assumes mask wearing will reach 95% in 7 days, and social distancing mandates will continue to ease, but will be re-imposed for six weeks in areas where daily death rates rise above 8 per million.
Last week we discussed the decisional challenges we all face trying to navigate our individual and family risk tolerances for extending our social contacts, even within the reopening rules and guidelines created for us by government and public health officials. As we do what we can to de-risk our social interactions (wear a mask!), reviewing the fundamentals of COVID-19 transmission should help us. To this end we cherry-picked an outstanding compilation of covid science curated and maintained by the Hospitalist team at Swedish on First Hill: https://tinyurl.com/y8yb7q83. One of those Hospitalists, Kailey Bolles, shared this “Frontline Covid-19 Guide” with us early on in the pandemic and we return to it often, and gratefully, to help our own decision making at Wise Patient.
Incubation period: most estimates between 4-7 days with 98% within 14 days (Lauer et al, Tian et al, Zhang et al, Park et al, Sanche et al)
Transmission: droplet, contact (fomites up to 7hrs on some surfaces), likely airborne (1hr half life of aerosolized virus), likely fecal-oral (RNA and infectious virus found), and possibly maternal-fetal (van Doremalen et al, Xiao et al, Santarpia et al, Chen et al, Zeng et al, Leung et al, Wölfel et al, Guo et al, Liu et al, Xiao et al [different paper])
Asymptomatic & presymptomatic transmission occurs and viral loads appear highest around time of symptom onset (Bai et al, Du et al, Qian et al, Kimball et al, Wei et al, Lavezzo et al, He et al, Chow et al).
While some have theorized that transmission will decrease as weather warms, relatively rapid infection rates in warm West Africa argue against this theory (Martinez-Alvarez et al), as does recent spread within the sunbelt of the U.S.
Viral shedding: can be present 1-3 days prior to onset of symptoms, median duration 20 days with durations up to 6 weeks in recovered patients (Zhou et al, Kai-Wang To et al, Zou et al, Lan et al, Xiao et al) but it is unclear how much this represents live virus capable of causing infection versus inactive viral debris.
High risk populations: elderly; residents of nursing homes (McMichael et al), assisted living facilities (Roxby et al), shelters (Tobolowsky et al, Mosites et al, Baggett et al), and psychiatric facilities (Yao et al); healthcare workers (Wu & McGoogan, CDC though possibly lower risk in US as seen in Mani et al); immunosuppressed patients (Haberman et al, Pereira et al, Akalin et al); refugees (Kluge et al); prisoners (Kinner et al); minority & poor populations (Johnson & Buford, Grantz et al, Lancet, ICNARC, Martinez et al, Emeruwa et al, Alsan et al); family members of infected patients (Rosenberg et al, Li et al)
Immunity: seroconversion appears to occur between day 7-14 but levels appear to vary significantly person-to-person; appear to neutralize SARS-CoV-2 in a small human study and in animal studies (Zhao et al, Bao et al, Wölfel et al, Wu et al, Long et al, Qu et al, Wajnberg et al, Ni et al) Level and persistence of antibodies may be related to severity of illness (Long et al). Not all recovered patients show detectable antibody levels in early testing (Wu et al)
If immunity develops, it is unclear how long it will last — immunity to other coronaviruses appears to wane after 1-2 years (Memish et al, Li & Xu, Kirkaldy et al). There may also be a coronavirus-specific T-cell response, which could be more durable than the antibody response alone (Ni et al), may be cross-reactive with other coronaviruses (Grifoni et al)
Social determinants of health: pre-existing conditions disproportionately impact racial and ethnic minorities and poorer patients due to large pre-existing healthcare disparities, putting them at much greater risk of complications and mortality (Johnson & Buford, Khullar & Chokshi, Grantz et al, Wadhera et al, Eldieb et al, ICNARC); these communities are also likely to have much lower access to care and insurance and some face major language & cultural barriers (Alsan et al). Poorer & working-class communities are more likely to be exposed as they are less likely to be able to use telecommuting/working from home to socially distance (Yancy, Wise). Health department data shows huge disparities by race/ethnicity, with disproportionately high minority mortality (esp. black, Hispanic, Native American patients); the Navajo Nation has more confirmed cases per capita than almost every U.S. state (NYC, Louisiana, Michigan, Yancy, Miller)
Surgical procedures: surgery on asymptomatic/presymptomatic patients associated with high rates of ICU admission (44%) and mortality (21%) (Lei et al)
Thank you, Swedish Hospitalist team!
To the Fig Tree on 9th and Christian
Tumbling through the
city in my
mind without once
looking up
the racket in
the lugwork probably
rehearsing some
stupid thing I
said or did
some crime or
other the city they
say is a lonely
place until yes
the sound of sweeping
and a woman
yes with a
broom beneath
which you are now
too the canopy
of a fig its
arms pulling the
September sun to it
and she
has a hose too
and so works hard
rinsing and scrubbing
the walk
lest some poor sod
slip on the silk
of a fig
and break his hip
and not probably
reach over to gobble up
the perpetrator
the light catches
the veins in her hands
when I ask about
the tree they
flutter in the air and
she says take
as much as
you can
help me
so I load my
pockets and mouth
and she points
to the step-ladder against
the wall to
mean more but
I was without a
sack so my meager
plunder would have to
suffice and an old woman
whom gravity
was pulling into
the earth loosed one
from a low slung
branch and its eye
wept like hers
which she dabbed
with a kerchief as she
cleaved the fig with
what remained of her
teeth and soon there were
eight or nine
people gathered beneath
the tree looking into
it like a constellation pointing
do you see it
and I am tall and so
good for these things
and a bald man even
told me so
when I grabbed three
or four for
him reaching into the
giddy throngs of
wasps sugar
stoned which he only
pointed to smiling and
rubbing his stomach
I mean he was really rubbing his stomach
it was hot his
head shone while he
offered recipes to the
group using words which
I couldn’t understand and besides
I was a little
tipsy on the dance
of the velvety heart rolling
in my mouth
pulling me down and
down into the
oldest countries of my
body where I ate my first fig
from the hand of a man who escaped his country
by swimming through the night
and maybe
never said more than
five words to me
at once but gave me
figs and a man on his way
to work hops twice
to reach at last his
fig which he smiles at and calls
baby, c’mere baby,
he says and blows a kiss
to the tree which everyone knows
cannot grow this far north
being Mediterranean
and favoring the rocky, sun-baked soils
of Jordan and Sicily
but no one told the fig tree
or the immigrants
there is a way
the fig tree grows
in groves it wants,
it seems, to hold us,
yes I am anthropomorphizing
goddammit I have twice
in the last thirty seconds
rubbed my sweaty
forearm into someone else’s
sweaty shoulder
gleeful eating out of each other’s hands
on Christian St.
in Philadelphia a city like most
which has murdered its own
people
this is true
we are feeding each other
from a tree
at the corner of Christian and 9th
strangers maybe
never again.
Ross Gay
Depart with Doge