Glossary

• Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
• Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
• SARS-CoV-2– the specific name of the new coronavirus
• COVID-19-the name of the illness that the new coronavirus is causing
• Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic– a sudden burst of an illness that comes and goes over a limited time
• Pandemic– an epidemic that bursts across the world not just one region
• Spreadability– how contagious is the disease, how many people will end up infected
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
  • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
  • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
• Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
• Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
• Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
• Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.
• Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
• Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.
• Vaccine Terms
  • Vaccine or Immunization– a dose of a substance that activates your immune system, as if you have the actual infection you are hoping to prevent, leaving you in fact protected from having that infection.
  • Efficacy– the percentage of people immunized with a particular vaccine who will not get infected if exposed to the target infection.  For example, a COVID-19 vaccine will be said to be 95% effective if 95% of people immunized with that particular COVID-19 vaccine will not get COVID-19 if exposed to COVID-19
  • mRNA– DNA works by dictating exactly which proteins your cell will make.  The message on how to construct each protein is delivered to the cell machinery that makes proteins by a piece of genetic material called messenger RNA, or mRNA
  • mRNA vaccine– an mRNA vaccine places a small bit of mRNA code that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected
  • Viral vector vaccine– a viral vector vaccine takes a harmless virus that is known to infect people reliably and places that weakened virus in a person where that virus will in fact infect the person.  The virus is not only weakened, but also attached to a set of genes  that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected.

Christmas in France-  Stories from Around the World

This Christmas season, we have been so blessed to hear stories from families who have friends and family quite literally around the world.

Most years, the stories we get to hear warm our hearts in ways familiar, no matter where we live, we are all people after all, right?

But this year is different.  Yes, all the houses are lit up in our neighborhoods like any other Christmas, and you can feel the Holiday season is here.  Most people will be off work this and next Friday here in Cleveland, around the nation, and across Europe.

At the same time it does feel different.  Nearly everyone I talk to tells me that in some way, the pandemic has changed this Christmas, no matter if you are staying safe at home or risking all to travel.

Three stories told me three different stories of Christmas and the Holidays this year.

Three stories from around the world.

We start in France.

France

This story was a gift from a family from France.  And the story is very simple.

I am told that France adores Christmas.  The holiday, its shopping, its meal times together, its celebrations, are central to the life of the people across all of France.

The COVID-19 pandemic has some power, but nothing like the power of Christmas, and so the people of France are out shopping.   Restaurants, even some schools may close, but not the shops which are packed.  Parties and meals together are filling up.

France has voted with its feet, and the people of France have voted to follow Christmas over COVID.

It’s not even Christmas yet, but we have some idea of how this will turn out.  First, we know everyone is going to have a great time this week.

Second, we know as a result of all this holiday cheer, a large number of people will die, just a few days, weeks, or months before they could have received the vaccine and lived.

France had a severe outbreak in the Spring, and then the people, and government, of France decided, it was better to live, and essentially stopped the spread of SARS-CoV-2.  It wasn’t complicated, everyone planned and implemented well, with good testing, tracing, and isolation of the infected.  It worked!  National death numbers plummeted below 100 a day by the end of May and hit less than 20 in the summer.  They started to climb above 100 in October, and now that everyone is getting together for Christmas, 500 people across France die every day, with the expectation that this number will only climb as the holiday fun intensifies.

There was no Thanksgiving surge in France, because Thanksgiving is not celebrated there, so no flocking together took place then, but it is happening now, and we already are seeing cases and deaths begin to rise.

China

This story is via good friends of people here, who live in a town in mainland China, a city of several million people, like so many in China.

Many have observed how unreliable data are from the People’s Republic, but this story shares the real life experiences of a good friend of the family, so I find the story very credible.

In this city, the friend reports that life is totally normal.  Everyone can go to school and work, to sports games and movies, shop and play together, as much as they ever did, and no one gets sick or dies of COVID.  Hospitals are open too, with people joining family members who need care as if COVID never happened.

The big difference between this town and the one in France, or even our city, is that China monitors for the appearance of any case of COVID-19 very closely.  One case is considered a major event in China, in any town or village.  Because testing is so easy to do, is so constant for really any reason, people with COVID-19 in China are discovered long before they spread it to thousands of people.

And China actually stops its spread once discovered.  When a case of COVID-19 is found in a city, the friends in China report that the entire city goes into quarantine for 2 weeks.  Those infected and those in contact with those infected are isolated outside their home for 2 weeks.

The result?

Lives are saved.  Epidemics ceased early in 2020.  In return for 2 weeks of total quarantine whenever a case is discovered, a city gets months and now a year of totally normal life.  Almost no one has died from COVID since this regimen was adopted.

Lives saved, work saved, schools and education saved, normality returned.  Sounds like a good holiday season, even without Christmas there.

Here at home

The story here at home is told by so many families as we all find our way through the Christmas season.

The story told by families here at home is more like France than China.  It it told by people of all faiths, and it is a story of small groups gathering, despite the danger, to just simply be together during the holiday season.  Every day we are told of people making reservations to fly, of people planning to drive, of young and old getting to see each other after a dreadful year apart.

What I hear more than anything, is how the yearning of the soul to be together with those we love surmounts all pleas to stay apart, to keep the killer virus from reaping more tragedy, just as the vaccine is being shipped to stop death’s progress and end our nightmare.

With likely just a few more months to go, the holiday season is pulling so many to walk outside the safety of their own home, to gather, to see each other, to be together, and just as certainly, to fan the flames of this dread pandemic.

The evidence is overwhelming, gather now, and you risk serious disease.

We saw this happen right here over the summer, when getting together left traces of packed hospitals and mounting loss of life.  We saw it in churches that decided to meet.  We saw it in indoor dining that decided to open.  We saw it following large rallies.

We have seen it happen right here in our practice community.  We diagnose a child with COVID-19 every day now, and have for months since schools opened.   We see cases routinely following a family getting together for one dinner with friends after weeks of careful care and avoidance of infection.  We see it over and over and over again in kids whose schools insist on keeping sports open.   We see it after small trips families take to see just a few family members.

And now we see the fury of the virus roar following a rather striking abandon to travel and gather after Thanksgiving.  The pace of catastrophe is hard to truly comprehend.   We now are losing over 3,000 deaths a day, even if everyone gets the vaccine when it becomes available, our current losses are now estimated to top 500,000 of us gone before the vaccine ends the nightmare.

Gatherings around Thanksgiving created a burst of death in Ohio too, which thankfully has calmed, but we anticipate another set of people losing their lives to holiday cheer once again this holiday.

Our friend Dr. Vin Gupta, an ICU doc in Seattle, tells us that just this week, he has seen many folks arrive in his ICU, deadly ill, clearly because they threw caution to the wind and decided to get together with a few friends or family this Thanksgiving.  Even though they wore a mask, even though they kept their distance.

The virus is simply soaking the air to thickly to be able to gather safely.  Period.

Do New  Mutations Weaken the Vaccine?  Not So Far.

Most of us have heard that the SARS-CoV-2 virus is changing somehow.  The biggest news is from Great Britain, where reports prove that some genes in the virus have changed, or mutated.  The changes have proven to cause the virus to spread more rapidly.

How does this happen?  What does it mean?  To understand this development, we review a couple of basics.

What is a Virus Made of?

To change, a virus must change items that it is made of.  All viruses are made up of two basic pieces: genetic material and proteins.   They serve each other.  The protein delivers the genetic material to the target cell.  The genetic material forces the cell to make zillions of copies of the viral genes and proteins.  And on it goes.

The virus of COVID-19 is no different.   Everything this virus does is defined by exactly what proteins and genes it holds.

Change the genes and proteins enough and you have a whole new virus, not even COVID anymore.

But no one is seeing major changes like this even close to happening.

At the same time, tiny changes have been happening all along.

Some basics on the genes of SARS-CoV-2

The genes of the SARS-CoV-2 virus are all made out of RNA, not DNA like our genes.  RNA and DNA are almost exactly alike.  Both are long strands of just 4 chemicals whose sequence create a code that defines creation of proteins.   For RNA those chemicals go by their initials, C, G, T and U.

Every three letters tells a cell which amino acid to link next in a chain.  The SARS-CoV-2 RNA has about 30,000 of these letters in a long chain, that allow for about 5-6 proteins to be constructed.  Remember, every protein in all forms of life is a long, long chain of amino acids, whose sequence is defined by the letters of the RNA.

So now you know, if you change any of the letters of the viral RNA, you could change which amino acid gets linked next, which in turn changes the protein the virus makes.

Viral Mutations- what do they mean

With all this in mind, let’s see what changes mean for our health.

Viruses are far, far more sloppy copy machines than we are.  If you scrape your knee, your skin copies your own genes to make new proteins to make new cells, to make new skin, a process we call healing.  Human cell copying is extremely precise.  The DNA of the new skin cell will be excruciatingly exactly like the old cell.  We have many mechanisms to detect errors and fix them.  This is why you can go back millions of years in the life of a species and see that they may look just the same as today.

Not so with viruses.   They just have to copy well enough for some of the zillions of copies able to infect a new cell and make zillions more.  Also, they only make a handful of proteins, so they have no mechanisms to monitor for errors.

So viruses typically have errors in their copies.  That means the SARS-CoV-2 virus that infected my cell on say December 1 at 10:15AM, will almost certainly have copies that burst out of my infected cell at 11:15 AM that have slightly different sequence of letters in its RNA.

This can be detected because labs can take any virus and figure out the sequence of its C, G, A, U letters, and see changes over time.

The question is, if a virus mistakenly puts an A where a C was, how different will the resulting protein be?  Maybe not at all.  Or maybe the protein will be detectably different but still will work exactly the same way.  Or maybe the protein will be different and behave very differently.

Those three outcome possibilities open the door to three different outcomes in future experience with the virus:

1. No change in the proteins of course means COVID-19 does not change.
2. Change in the proteins but no change in their function means COVID-19 does not change.
3. Change in the proteins and some change in their function means the illness changes.  Those changes can be trivial, noticeable, or huge.

How much does the SARS-CoV-2 change as it travels through millions of us?

Not much.

It does change.  Most infections and all the zillions of copies of virus that happen each infection, lead to very trivial changes.  Maybe a letter of viral RNA here or there, with essentially no impact on the function of the resulting viral proteins.

These tiny changes allow labs to trace the path of this virus.  It was tiny changes in the virus when it copied through so many people in Europe that allowed labs to prove the huge outbreaks in NY this spring came from people infected in Europe, not China.  But all those viruses infected people the same way, at the same rate, and caused the same illness and risk of death.  No changes there.

Now, what about the British mutation?

The SARS-CoV-2 virus has changed in Britain, and several other places, including South Africa, more than a trivial amount.  A total of 4 significant mutations have happened: in the Spring in Italy, this summer in mink farms in Denmark and America without clear spread to humans, this October the one in South Africa which increases contagion.  This one might spread more in young adults and make young adults sicker.    The British mutation first appeared in September.

We know exactly what letters in the viral RNA are different in the new British strain.   We also know it has changed the handful of proteins of the virus enough to make it more contagious.  And we also know that we can be confident the virus remains same enough for the vaccines in use to work against it plenty well.

We know it is more contagious because it is replacing the old version rapidly, right now in Britain close to half of the new COVID-19 cases are with the new mutation version.  It spreads about 70% better than the old version.

So far, it does not seem that patterns of illness, like how sick people are likely to get, is any different.  So the new version appears to cause the same COVID-19 we have seen for a year.

But some questions remain:

1. Will this new version enhance the ability of children to spread COVID-19?  Some think yes.  If this turns out to be true, then schools will become hotbeds of COVID-19 spreading far more than now.  We do not know if this is happening, so stay tuned.
2. Will this new version of the virus change who gets sick, and how sick and sick in different ways?  The current patterns in the UK of this illness, even with the new version, seem about the same, so first indications are that no, this new version will leave current patterns of illness alone, but it is too early to be sure of that.
3. What does a boost of 70% in contagion mean?  That would mean we could see numbers of cases and deaths, even if the actual infection severity does not change, go up perhaps significantly.
4. What does this new strain mean for the vaccine, will the current vaccines still work?  All indicators are that the current vaccines in use will protect all of us from this new version, but not enough immunized people have been exposed to this new version in real life to be sure.  Still, scientists are confident the vaccine should work just as well.
5. If you change the genes of the virus, will tests for COVID-19 detect the virus if they work by finding the RNA of the old version?  Apparently some labs only look at tiny parts of the viral RNA in their test.   These will miss the new version.  Other labs sample a larger part of the viral RNA and will detect this new mutation.  Labs need to determine if their PCR nasal/oral swabs detect the RNA of this UK version.

Influenza Update

Here is some good news, there are no indications of the 2020-2021 influenza epidemic starting, yet.

Bottom Lines

1. COVID-19 in the United States continues to worsen.  The pandemic is once again causing catastrophe to go beyond our worst fears.  THIS IS A DANGEROUS TIME.
2. When virus spreads as thoroughly as this one has, it becomes far far far easier to catch it, even if you take precautions.  We are seeing this happen, the virus goes from small get togethers and fans across the broader community.  This is really happening!
3. This is why every doctor and expert is PLEADING for everyone to avoid gathering.  TO BE CLEAR, THIS MEANS WE URGE EVERYONE RIGHT NOW:
   1. DO NOT TRAVEL
   2. DO NOT GATHER
   3. IF YOU MUST LEAVE HOME- WEAR A MASK, STAY 6 FEET APART
4. This virus is like all others, it changes as it infects (copies itself).  Four large mutations have already occurred.  The one in the UK does make it more contagious and may cause more harm, we will see.  The current vaccine appears to protect against this well too, but more information is needed to be sure.
5. No influenza virus epidemics are evident in the US at last count.
6. When your group is informed you can be immunized for COVID-19, please do so ASAP.  All those working at Advanced Pediatrics have been informed we are due to be immunized and we all said yes immediately.  We anticipate being immunized in January.  This is the only path open to us ending this nightmare, let’s all take it!  Lives literally depend on all of us doing this.

My Takeaway – In One Sentence:

This is the week of Christmas, let us honor the holiday, the holiday season, our care for each other, and stay at home to keep as many of us alive as possible for the next holiday season!

Happy Holidays, to your health, and may we all make it to the vaccine,
Dr. Arthur Lavin