We have Flattened the Curve

We Have Flattened the Curve

Dear JCP Families:

Thank you for the opportunity to keep you informed and aware of the facts and not the fear about COVID-19.  We welcome questions and concerns.

Congratulations!  Our extreme social distancing is working.  We have flattened the curve.  Data continues to show declining rates of infection and ICU admissions among Georgians and in much of the United States.  While data models predicted a peak of cases in late April in Georgia, the numbers indicate that our peak occurred in early April.  Models are models and data is data.  We are not out of the woods yet, and by no means should let down our guard.  Our high-risk populations continue to see significant disease, particularly the elderly and nursing homes.  But it is time to move into the next phase of pandemic management.  

We have learned much about this unseen enemy SARS CoV-2, the virus that causes COVID-19.  

How it is spread:  This virus behaves similarly to other respiratory viruses such as influenza.  The predominant means of spread is via respiratory droplets.  These droplets are expelled with an uncovered cough or a sneeze that propels infected virus particles for up to about 6 feet for a very brief time (about 20 minutes).  These nasty little bundles of RNA rapidly sink to nearby surfaces, where they may be detected for some time (hours to days) but are unlikely to be contagious after a short time (hours).  Virus particles are also found in much tinier aerosolized particles that linger in the air for a much longer time and can be produced by asymptomatic or mildly symptomatic people with normal talking and especially with singing.  While these tinier particles may be contagious, it appears that it takes prolonged close contact, such as in a home setting or other group settings involving hugging, hand shaking, kissing and sharing food.  
So, in public, we are worried about the more difficult to spread respiratory droplets.  At home or in social settings particularly groups of 10 or more, we are concerned with both respiratory droplets and aerosolized particles.  To prevent viruses that are spread through respiratory droplets (think influenza, cold viruses) we practice droplet precautions.  These are

•Cover mouth and nose with inner elbow with cough and sneeze.
•Stay home when sick.
•Wash hands often, preferred soap, water and friction.  Hand sanitizer is an option if soap and water are not available.
•Don’t touch your face.
•Stay 6 feet away from anyone overtly ill.  And for COVID-19, I am going to add on wear a mask in public in case you have asymptomatic infection to protect others, or you unexpectedly come closer than 6 feet to someone to protect yourself.

At home
•Do all the above, except no mask needed.
•If you are ill, self-isolate from other household members, especially those at higher risk of illness.  Stay home.  Call your doctor if your symptoms are concerning to you.

Symptoms of illness and transmission:
Typical symptoms of illness are fever, dry cough and chest pain or difficulty breathing.  Symptoms usually worsen several days into the illness.  The illness lasts about a week.  Virus particles can be found from several days prior to symptom onset to 2-3 weeks from symptom onset.  Contagious particles are thought to be present from about a day prior to symptom onset to 7 days after symptom onset and when fever has resolved, and cough and chest pain are significantly improved. Remember that these tests are PCR (polymerase chain reaction) technology which amplifies the presence of the viral genetic material and therefore detects very tiny amounts of virus that may not be contagious.  

Like ALL viruses, manifestations can be different in different people.  COVID-19 can cause minimal illness in some and SARS (Severe Acute Respiratory Distress Syndrome) especially in older adults and in people with chronic health problems.  This syndrome is the result of an overactive immune system unleashing inflammatory changes in the lungs that cause fluid to leak into the lungs and severe respiratory disease.  ICU admission and fatality are high in this small sub population.   Yes, the rare young person in good health can also get serious disease.  Other symptoms can also occur such as sore throat, chills, headaches, nausea, vomiting and diarrhea.  Again, this myriad of manifestation of severity and type of symptoms is typical for viruses.

Recent reports talk about risk of sudden stroke in otherwise healthy young people.  Keep in mind that there are a few case reports amid millions of cases.  More study is needed to determine cause and effect, who is at risk and why.
While there are still clinical features of the disease that we are learning about, our knowledge has advanced significantly in the last 2 months.

Questions that remain:

•Effective treatment.  In medicine and science, it is essential to study treatments in terms of safety and efficacy before presenting them as recommended therapies.  We have always had compassionate use medications in which we attempt to try everything for someone severely ill, pulling out all the stops to save a life, and an unproven treatment may be tried.  Researchers continue to study cholorquine, hydroxychloroquine, azithromycin, remdesivir (an antiviral) and hyperimmune globulin to name a few.  These drugs are being used in investigational and compassionate use protocols at this time and are not routinely recommended.

•Testing.  Testing is not widely available in Georgia, especially for children.  At this time, since children are NOT getting severe COVID-19, the only ones we are testing are hospitalized, severely ill children, and they are few, thankfully.  There are questions about reliability of the commercially available tests with estimates of up to 30% false negative rates.  That means, you have the virus but the test is negative.  Therefore, testing is NOT necessary unless you have severe illness.  Exceptions to this rule of testing include health care workers and perhaps family members who have at risk people in the home.  If you are sick, but not sick enough to need a doctor or emergency room visit, assume you have COVID-19, stay home, self-isolate until your fever has resolved for 72 hours and you are feeling better.  If you have risk factors, difficulty breathing or other symptoms that worry you, call your doctor (or us!).
•Immunity, Antibodies and Vaccination.  How many of us had infection and never knew it?  Could many of us be immune?  What level of antibodies is protective?  How long do protective antibodies last?  Are vaccinations under study now safe?  Effective in producing protective antibody?  How long lasting is that protection?  WE HAVE NO IDEA.  All these areas are under investigation and are fast tracking to get information.  While commercial labs have antibody tests available, they are not FDA approved.  We do not know how to interpret the results.  We do not recommend routine antibody testing YET.  We will keep you aware of changes.

As you know, our governor has opened our state and our shelter in place order expires on May 1. We are in a public health emergency through May 1st and people over 65 and with chronic medical conditions have shelter in place orders through May 15th.  These orders can be renewed, so we will see what happens.  
Editorial by Dr. Dewling:  While the news media tried to portray us as country bumpkins intent on going bowling, the truth is that it is time to restart our economy.  As one parent put it, “My job is essential.  It is how I feed my family.”  The relaxation of the shelter in place order allows hospitals to begin performing “non-essential procedures.”  Our practice has several patients waiting for these procedures that are rapidly becoming more essential, including ear tube procedures, sinus surgeries, and even heart procedures.  CHOA is now beginning to perform these necessary procedures.  Why doesn’t the media report this benefit?   They love to create drama, conflict and fear.  Let us stick to the facts.
Our economy is suffering.  CARES Act funding gives a temporary respite to those small businesses fortunate enough to procure funds.  However, if we do not start returning to frequenting those businesses, they will ultimately fail and this money will be wasted.

We are seeing increasing emotional impact to children and adults as shelter in place orders limit our enjoyment of life.  Anxiety occurs when we watch excessive amounts of sensationalized news and news that is partial truth with opinion “spun” in.

We do not worry about going about life during cold and flu season.  For healthy young people, the risk is likely on the same order as the risk of influenza if you are not vaccinated.  Now that we have flattened the curve, it is time to gradually and with an eye on possible resurgence start getting back out there.

A harmful side effect of fear of COVID-19 infection involves delaying necessary medical visits.  Emergency rooms and hospitals are seeing patients with traumatic injuries that delayed seeking care due to fear of catching the virus.  People are fearful of seeking care for appendicitis and are coming in with progressed symptoms that have potential for much worse outcome.  Patients are skipping needed wellness visits that address mental and physical wellness.  Importantly, vaccination rates have decreased.  We do not want to set up the next public health crisis of a resurgence of vaccine preventable diseases like measles, chicken pox, and meningitis.  

Our emergency rooms and hospitals are safe.  Our office is safe.  Infection control policies are in place, staff is well trained, patients are not sitting in waiting rooms.  PLEASE do not put off seeking medical care that is important.  Our facilities are not busy and social distancing is easy.  We are extremely comfortable with the idea of respiratory droplet precautions and have always practiced them.  Yes, they are more robust now than ever.  We are calling patients who are due in the coming weeks to get you scheduled.  Please care for your child and trust us to keep you safe.
Our Practice Policies:  We are scheduling sick visits in the afternoon at Johns Creek only.  We see very few sick children each day and they are being seen in a designated space with designated staff.  They continue to use the rear door/employee entrance.  We will be scheduling well checks in the morning and afternoon at both Johns Creek and Cumming.  Again, we will use a separate part of the office for sick children in the afternoon in Johns Creek.  If you prefer to avoid the office when sick children are there, we can accommodate that in the morning at Johns Creek and all day at Cumming.

We are frequently sanitizing exam rooms between patients and high touch surfaces throughout the office.  Our staff are screened for illness each day and are masked.  We ask patients to limit the number of people coming to the office to essential caregiver(s) and patient only when possible. We understand siblings may need to come along.  Our waiting room is closed, and waiting is in car (preferably not at all!).   And all registration is done online We understand siblings may need to come along.  If you have masks, please wear them while in the office.  We have hand sanitizer and soap and water throughout the office.  

We continue to offer virtual visits through telemedicine.  We can do procedures such as strep tests, lab tests and ear checks, lung checks in the parking lot, curbside.  And importantly, we are always here for you to help with questions and concerns.  Call us!  

We look forward to seeing everyone in the coming weeks.

Dr. Dewling

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