By Dr. Chris Magryta
Rowan Pediatric Associates

Latest numbers show that, on balance, COVID-19 incidence is rising rapidly in certain parts of the nation while declining to minimal counts in formerly hard-hit areas. The death rate is not tracking as fast as the average age at infection has dropped by more than 10 years from the previous month’s data. The death rate is also likely lower because of effective quarantining of at-risk individuals in nursing homes and at home. Urban centers remain the areas with greatest mortality and infectious risk.

As with the first newsletter on this topic, keep solace with the fact that there is a 99+% chance of survival for all of us.

Something is amiss. Why are we not seeing a resurgence of cases in the previously hard-hit Northeast? Could they have hit a disease break point? They are clearly not at herd immunity by the studies to date. This issue will be answered in the next month or so. Do Florida, Texas and California follow a similar path? Spike, plateau and calm after the storm.

1. Lockdowns continue to paint a curious picture. We know without a shadow of a doubt that they cause unbelievable economic damage and human mental stress. No question there. Do they work? Let us look at the numbers. Sweden with a population of 10.2 million played an interesting game with pursuing a social program of voluntary social distancing, hand washing, self isolation if symptoms develop, and other soft changes while avoiding a total lockdown. Belgium and Germany with populations of 11.5 million and 83 million pursued aggressive lockdown measures. One would expect that if lockdowns are the direct cause of death prevention, there would be a dramatic death avoidance in Germany and Belgium over Sweden. What happened? As of July 17, per the Johns Hopkins COVID-19 website, Germany had 9,088, Belgium had 9,795 and Sweden had 5,619. Clearly something is amiss. Sweden should have exploded. It did not. (Kamerlin et. al. 2020) Germany faired better while Spain, France, Italy and the United Kingdom all had significantly higher death rates for various reasons. However, the belief that a total lockdown is the answer to a pandemic is seriously underwater. Other Nordic countries including Iceland, Finland and Norway have had minimal cases to date, giving many the impression that locking down is a winner. Sweden is likely to have faired better because of population level decisions to remain in quarantine when ill and by protecting the elderly early on. Further analysis to come in time, however, for now the data paints a far better picture then the media has tried to portray of Sweden’s decisions including the now infamous July 7 New York Times cautionary tale piece. Or, this week’s USA Today opinion piece, which cherry picks data to support their predawn conclusion. These articles are yet further reasons for us all to follow the data and not journalistic opinion/spin.

We need to continue to follow the data and make conclusions based on it. For now, I do not believe that complete lockdowns are the answer. Avoiding large crowds, avoiding crowded indoor spaces, wearing a mask, social distancing, taking care of self through nutrition, exercise and stress reduction, quarantining the at-risk population all make great sense and have stronger data and mechanistic plausibility. There is a lot more to Sweden’s brave story to unfold. I plan to follow it very closely.

2) The American College of Cardiology has written a nice algorithm for a post COVID-19 return to sports plan. Their thoughts are:
a) one must be symptom-free for 14 days
b) for teenagers and college students that had moderate disease (prolonged fever and bedrest), they should consider getting an EKG, echocardiogram and troponin I. These tests can rule out COVID damage that could result in a negative outcome with an acute change in metabolic demand that follows a return to competitive sports. Younger children need not have any intervention unless they had multi inflammatory syndrome.
c) for anyone with severe disease (hospitalized, abnormal cardiac testing) they should not proceed until cleared by a specialist (Dean et. al. 2020)

3) Two out of the 831 patients under the age of 39 and zero of those less than 19 had critical COVID disease based on an Italian study. Under the age of 19, a full 82% of positive SARS2 patients had no symptoms. More than 77% were asymptomatic in those below age 39. (Poletti et. al. 2020) Unless something big changes, children will not be a significant part of this pandemic from a death or morbidity perspective.

4) A mutation in the spike protein of the SARS2 virus has increased infectivity through increased viral loads but not changed mortality. (Korber et. al. 2020)

5) If you missed it last week, Dr. Jeffrey Bland has written a fascinating article entitled “COVID19 — A Pandemic Within a Pandemic.” It is a must-read for all of us as it lays bare the reality of future risk with COVID-19 or the next non-infectious or infectious trigger.

6) An interesting perspective written in JAMA Network on total lives lost versus just COVID places a stark divide between the myopic view that COVID is all that we as a society should pay attention to versus all issues related to a pandemic. (VanderWeele T. 2020) I cannot tell you how much we are likely to rue the lack of attention paid to children in poor environments that were before and will be left home this fall as schools avoid in-person education. Mental health will need to be high on all of our lists moving forward.

7) Moderna’s vaccine has shown promise in the first 45 people tested during a phase I safety study by demonstrating antibody response. While this is good news, it is far from the end. So far, many studies have shown that the human antibody response to COVID infection wanes within weeks to months after an infection. Does the vaccine follow this same course? If so, then it will be a no go. Second issue came up that after a two-dose series separated by 30 days, 21% of the recipients experienced significant non-life threatening symptoms. (Jackson et. al. 2020)

8) Abstract: Coronavirus disease 2019 (COVID-19) is characterized by distinct patterns of disease progression suggesting diverse host immune responses. We performed an integrated immune analysis on a cohort of 50 COVID-19 patients with various disease severity. A unique phenotype was observed in severe and critical patients, consisting of a highly impaired interferon (IFN) type I response (characterized by no IFN-β and low IFN-α production and activity), associated with a persistent blood viral load and an exacerbated inflammatory response. Inflammation was partially driven by the transcriptional factor NF-κB and characterized by increased tumor necrosis factor (TNF)-α and interleukin (IL)-6 production and signaling. These data suggest that type-I IFN deficiency in the blood could be a hallmark of severe COVID-19 and provide a rationale for combined therapeutic approaches. (Hadjadj et. al. 2020)

What this new article in Science is showing us is that host viral immune surveillance and then rapid innate immune response is critical to survival. If you keep your immune system powered up to surveil, find and kill, then you are in good shape. This is also where viral load and exposure play a huge role in risk and outcome.

Imagine that you are mildly sleep deprived and stressed from work. You generally have not been eating nutritiously nor exercising. These lifestyle issues are immune suppressing and inflammation promoting. If you now happen to run into SARS2 by standing next to an asymptomatic “spreader” for 20 minutes in conversation. You are sitting in a perfect storm to overwhelm the surveillance and killing mechanisms of our immunity. This is the place where prevention and understanding meet disease risk avoidance.

Wearing a mask may help slow this progression. Sleeping, eating nutritiously, moving, relaxing and generally taking care of self will reverse these risks.

9) Asthma not associated with increased risk in those without metabolic diseases like hypertension, diabetes and cardiovascular disease. This is great news for those with asthma who do not have the associated co-morbidities. (Panettieri et. al. 2020)

10) Young adult smokers and vapers are at increased risk for negative morbidity from COVID-19. While this is not surprising, it is relevant to discuss. Smoking and vaping promotes reactive oxygen species damage in the lung tissue which causes secondary inflammation. This is a perfect breeding ground for a pathological viral disease. (Adams et. al. 2020)

11) Masks definitely seem to be beneficial. “Researchers in Australia used high-speed cameras to photograph light scattered by aerosols and respiratory droplets that were expelled during speaking, coughing, and sneezing when a volunteer wore different masks. A three-layer surgical mask was the most effective at limiting droplet spread. A two-layer cloth cotton mask was more effective during coughing and sneezing than one made from a single layer, but even the single-layer mask was better than no mask. The authors write in Thorax: “Guidelines on home-made cloth masks should stipulate multiple layers (at least three). (NEJM Journal Watch).

“This study is the first randomized control trial of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Further research is needed to inform the widespread use of cloth masks globally. However, as a precautionary measure, cloth masks should not be recommended for health care workers, particularly in high-risk situations, and guidelines need to be updated.” (Macintyre et. al. 2020)

For now, using a mask of the surgical type appears to be a great idea to prevent spread.

Dr. Chris Magryta is a physician at Salisbury Pediatric Associates. Email him at newsletter@salisburypediatrics.com .