COVID Fatigue?

Polarization over the coronavirus pandemic that has gripped the nation has divided people according to their political (and thus media) alliances and influences. It has become evident that the church – even CMC, to which this is specifically addressed – has fallen right along with the world, dividing us as well, largely by the same political/media polarizations. There tend to be strong opinions on both sides, unwittingly so, but still opinion: opinions often planted and cultivated by politics and the media, right or left. This ever-increasing political identity and fixation more than threatens our spiritual and ideological identities and bonds. This suggests (more likely indicates) that we are allowing the idolatry of nationalism to infiltrate our body of Christ, rather than going forth as ambassadors to the nation(s).

We have become a house divided.

I see that there seems to be confusion. What is real? What is not? This confusion significantly contributes to the polarization. As a physician, I have access to the medical information that is continuously coming out of the experience and study of this disease, having the benefit of seeing it before it is painted either red or blue, and spewed out by the media. I thus offer this as the tool to direct our thoughts about, and approach to, COVID-19. While this medical information is coming from a more direct source than from the media and should be more “right,” we must also recognize that this is still a young disease; information is incomplete and will be modulated as more data is obtained. Therefore, we should extend some grace to the scientific community who works so diligently to solve the puzzle, and to the medical community, who goes to the front lines to fight the war against this disease and who face fatigue and burnout, and currently, shortage of staff, supplies, and testing reagents. Medical personnel have higher rates of COVID-19 illness and death than the population at large.

Near the end of 2019, a novel (‘new’) coronavirus was identified in Wuhan, China. Since that tiny spark, its fires have produced nearly 55,000,000 known cases to date, with huge morbidity associated with the illness. More than 1.3 million deaths have been attributed directly to the disease, with many more indirect deaths (suicide in particular) and domestic violence (thought to result from the consequences of lockdowns such as isolation, close quarters, and financial stresses) taking their toll. From March to August 2020, about 225,000 more deaths have occurred than would usually be expected in the United States— indicating that, no, COVID-19 did not just kill people who would have died anyway.  

Many more known and as-of-yet undiscovered sequelae in survivors, including brain and mental health problems, kidney failure, cardiac issues, vascular effects, and clotting disorders, are being found.

The death rate overall is about 2% of known cases, with death rates significantly rising with age, from about 0.1% at age 40, to about 5% of those over 80 years of age. (The real rates will be somewhat lower since there is an unknown number of positive cases that are not included in the denominator.) Many people who died had concurrent medical problems, but on the other hand, young healthy people do on occasion die, as do children, although severity and death incidence is much lower in children.

Symptoms significantly overlap those of the common cold and flu, with fever being common (but not ubiquitous), loss of taste and smell being more specific, and diarrhea may also be present. 

Incubation, which is the time from exposure to infection, is typically 2.5 days, but may be as short as  24 hours, or as late as nearly two weeks, hence the two-week quarantine.

Symptoms typically appear at about five days post-exposure, but may be delayed as well. This gap between contagion and symptoms creates a window in which a person may be contagious before they are even aware of infection, so spread can happen before symptoms are evident. In addition, many people have minimal or no symptoms, further contributing to its stealth.

Testing is not as accurate as we would wish. There are few false positives, but false negatives may be as high as 15% for various reasons, including sampling errors. The science is not perfect.

Treatment
Regimens are still developing, and include oxygen support as needed; steroids; remdesivir (which has been approved and shows some promise of benefit); and plasma antibody body infusions (from blood taken from recovered patients and currently of unknown utility). Hydroxychloroquine has not been approved—its studies being somewhat conflicting and not having shown benefit. Because of the vascular effects of the virus, increase in toxicity has been associated with hydroxycholoroquine.

Vaccines
As of this writing – mid-November – two vaccines from two separate companies are showing promise. Vaccines typically take years to develop, but in this case, have been rapidly and unusually fast-tracked. Efficacy and safety must be established prior to distribution. Once these have been established, it is hoped that herd immunity will be achievable, as has been done with many other diseases. As of now, the vaccines look to be 90-plus percent effective. That is very good! Safety profile information is still pending.

How long the antibodies will last is currently unknown. How long will I be protected? Can I get a second illness? There is some indication that antibodies from the disease itself may only last, in some people at least, three or so months. More study is necessary.

Risk Factors for Contracting the Disease:

• Proximity of encounter with an infected person
• Duration of encounter with an infected person/people
• Indoor vs. outdoor contact
• Number of people in a space

Mitigating Factors (i.e. reduction of the inoculating load):

• Masks: transmission of articles and oxygen flow through masks has been studied. Oxygen flow is not significantly inhibited. Studies indicate that the aerosol particles from the nose and mouth are restricted, but not fully stopped, by a mask. Masks must be worn properly, with as little leak as possible. Beards are not so good. Cloth masks are not so good. Viral particles on their own could easily slip through the mask, however, the virus is carried on small aerosol particles, and this causes a lessening of viral load in the surrounding air. Proper masking does not cause increased infection in the wearer. Proper masking means — no longer than two days per mask, (cloth masks, not as good) and need for thorough washing, if cloth. Avoid touching the mask while in place and allow to dry between uses. Masking is largely for the benefit of others, although it does provide some self-protection. Singing, coughing, and sneezing increase viral load in the surrounding air.
• Distancing: obvious.  While six feet is not a magic number, from aerosolization studies, at six feet the concentration of particles diminishes, so six feet is deemed to be a good distance.
• Hand washing, cleanliness: the virus can survive on skin surfaces up to about nine hours.

These parameters, i.e., risk and mitigating factors, are largely from epidemiological studies, such as  transmission studies, proximity habits, contact tracking, etc, rather than randomized control trials (RCT’s) which would be the gold standard in determining the science. It would be quite difficult to set up RCT’s; would it even be ethical?  Could an RCT get through a review board?

Questions arise concerning reimbursement. It has been alleged that hospitals/doctors get an extra chunk of my money for each COVID diagnosis, and that non-COVIDs are coded COVID to fatten up reimbursements. There likely have been some few cases of presumed diagnoses early on, but test specificity has improved. To misdiagnose is fraud and carries significant penalties. There are no “presumptive” COVID diagnoses in the hospital system where I work (Parkview), but are coded as such only with a positive test.

Hospitals do get reimbursed for taking care of COVID patients—as it should be. As in other diagnoses, there is a code for COVID-19, which dictates the reimbursement level. For example, appendicitis has a code, and gets reimbursed according to its own code.

How long is one contagious after infection, i.e., how soon can I mingle again? The current guideline is ten days after onset of symptoms, resolution of symptoms, and no fever for 24 hours. (I personally think this is a bit liberal, but these are current.)

Well, I suspect there will be many questions, and likely some push back. I have attempted to be a-political, basing this from medical information that has not been painted either red or blue. It is my hope and prayer that this will provide some baseline information with which to facilitate how we think about it, how to  approach this disease, and that it will facilitate a commonality that will supersede political affiliation and media influence. We must not allow such as this to drive a wedge into community!

If you have other data to add, or that may contradict what I have put here, please feel free to contact me at the link below. All this is developing information, and helpful information is welcome. I can provide links to medical information if desired.

lorenjhelmuth@gmail.com