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.

Many thanks to a good friend, and to the remarkable Dr. Atul Gawande, a Youngstown native, and now internationally valued medical journalist, for this extraordinary update on COVID-19- I recommend everyone read it carefully, it informs much of what follows, except the update on vaping and vaccines:

https://www.newyorker.com/science/medical-dispatch/we-can-solve-the-coronavirus-test-mess-now-if-we-want-to 

Spreadability

From Dr. Gawande, we now know that science has pinned down some curious properties of how the SARS-CoV-2 virus spreads:

• First point- it spreads.  It spreads well, we know that because the US is closing in on the virus killing 200,000 of us, and the world will soon count 1 million of us dead, all in less than a year.  The infection has spread widely too, literally around the entire planet.
• We know that COVID-19 is caught most effectively in sustained, indoor, close contact.  The place it spreads best is one’s home- nowhere else do numbers of people spend hours in close contact together.  Second places include other sites of prolonged, indoor gathering, such as churches, synagogues, concerts, and likely, schools.
• Contagion only happens of course if you get infected.  And one gets infected with only a few hundred SARS-CoV-2 viruses landing in your eyes, nose, mouth, or throat
• Once the virus lands, it may or may not infect, but if it does, then by day 5 of contact and infection, you are breathing out millions of SARS-CoV-2 viruses EVERY HOUR
• Once infected, the virus rapidly divides, the peak as noted, of viral load is day 5 and that is when symptoms most typically appear.
• On day one after contact AND infection, almost no one has enough virus to be contagious, about 100% of those infected on the first day after infection will be negative.
• On day four after contact AND infection, only 33% of people will be contagious, about 67% of those infected, four days after contact, will have a negative COVID-19 test.
• Contagion for those who never require oxygen ends typically around 7 days of symptoms, hence the cautionary rule to be in isolation for 10 full days of symptoms, coming out of isolation on Day 11 of symptoms.
• A key property of this virus’ spreadability is how HIT-AND-MISS it is.
• Even in the intense exposure of one’s home, about 60-90% of those exposed to a known positive family member in the house, never get infected.
• Across this whole pandemic, it is estimated that 80% of all COVID-19 cases were caused by only 10% of those infected ever!  This is the super-spreader effect.  That is, most exposures do not lead to contagion, but some really do, and no one knows why person A may not spread it much while person B does. Or situation A leads to few cases and situation B does.

Severity

COVID-19 infection clearly affects the lung.  And so we have all felt that smoking would only make COVID-19 worse.

Now we know that is true, and is also VERY true for plain vaping, anything.

This report from the Times, tells all.   https://www.nytimes.com/2020/09/04/health/covid-vaping-smoking.html

The impact is extraordinary:  smoking cigarettes will double your chance of your COVID-19 landing you on oxygen in the hospital.  And as for vaping, doing this increases your chance of coming down with COVID-19 five-fold!

Diagnosis

Dr. Atul Gawande’s essay gives us the latest on diagnostic tests for current infection (antibody tests to show past infection remain unreliable).  Remember the two main tests look for traces of the viral genes (RNA PCR tests) OR for traces of the viral proteins (antigen tests).  Here is the latest on both:

RNA PCR Tests

These are the swabs currently being used everywhere.  Here is how they perform:

• If your swab PCR test is positive you can be very, very confident you have COVID-19 infection or recovering from one.
• If your swab PCR test is negative, there is an overall 20% chance you actually do have the infection.
• If your swab PCR test is negative, and you are in the 20% who are infected but have a negative swab PCR test, you are almost certainly not contagious at that moment.
• The chance of someone infected with the SARS-CoV-2 virus having a negative swab PCR test goes way up the earlier in the course of the infection you are swabbed, as noted above.  The first day after contact and the first day of infection, these swab tests are almost 100% negative, in those infected.  
• Of course, that means if you are 5 days after your contact that made you infected, and are therefore at the peak of your contagion, and your swab PCR test is negative, your are less than 20% likely to be infected actually.

Antigen tests

These are the mouth swabs being developed for very rapid, even at home, testing with a simple test strip, like a pregnancy test.

Here is the latest on these tests:

• As noted above, the RNA PCR test has few false positives, if you are positive you can be confident you have COVID-19 or are in recent recovery.
• But, the antigen tests all turn up positive in about 2-3% of those who are NOT infected.  Since most people are not infected with SARS-CoV-2 virus, that means the majority of those who test positive with current antigen testing technology will turn out NOT to have this infection.
• The Abbott antigen test that requires a machine to process is only approved for symptomatic people.  In asymptomatic people, the test is less likely to find those with an infection, and return a negative result even if you are infected.
• A rapid antigen test is being developed for home, with the same level of problems of too many false positives.

CRISPR tests

Many months away is the use of very precise technologies that snip bits of genetic code and analyze the bits created, it is called CRISPR.  The CRISPR accuracy may sharply reduce the false positive mess of antigen testing.  One group at MIT is actually looking at a face mask that will turn a strip color if you get infected, using CRISPR technology.

Treatment

Vaccine Update

The most important point in this update on the progress on vaccines is this: many candidates are being looked at, many developed, many studied, but as of this moment, there are NO vaccines that can reliably be used, or about to be used in practice in the US.  

Three vaccines in the world are in use and in wide practice, but two are only in China and one only in Russia, and all three were released to wide use without completing full safety studies.

In the US, it is very important to know that the pharmaceutical industry has gathered its leadership together to push all such companies to agree not to break ranks and release a vaccine for use prior to completion of all reasonable safety and efficacy studies.

We all know the issues big pharma has had over the years in marketing products, but the hope is that so much is riding on getting this right, that this push to complete all studies will be truly honored.

A really great guide to the huge number of vaccines in process can be seen here- https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html

This guide makes clear that 128 different vaccines are under development, here is the breakdown of where we stand on them all:

• 91 vaccines are being tested to see if they work and if they are safe, in animals
• 37 vaccines have proven they work safely in animals, and are now being tested in humanity
  • 24 are in Phase One testing- a handful of human volunteers to check out if they create protection by blood test measures and overall safety.
  • 14 are in Phase Two testing- now given to hundreds of volunteers of various, specific groups.
  • 9 are in Phase Three testing- a vaccine can only reach this phase if the research creates strong confidence it will work and is safe.  That confidence is tested across a very large number of volunteers, typically 30,000
  • 3 are in use before Phase Three testing on a large scale was completed, two in China and one in Russia

The range of technologies is quite a range, too, and includes:

• Protein vaccines- Inject the protein of the virus, the only type of vaccine in use in all our non-live vaccines for all other illnesses, such as polio and measles.
• Genetic vaccines- Inject a bit of viral genetic material to get the body to make the viral protein which induces immunity.  The leading genetic vaccines require a storage freezer of -80 degrees, far colder than any regular doctor’s office would have
• Viral vector vaccine- Inject a bit of harmless virus, containing a bit of the COVID-19 genetic material to get your own body to make the viral protein, which induces immunity.
• Whole virus vaccines- Inject the whole SARS-CoV-2 virus.  Still, like all the others, this is a dead vaccine, and obviously includes the proteins on the virus that induce immunity.
• Repurposed vaccines- Take an already proven safe vaccine and see if it protects against COVID-19.  For example, one company is taking the BCG vaccine for TB and seeing if it stops COVID-19.

Typically, when there are 128 candidate vaccines, and 9 are already promising enough to reach Phase Three testing, we usually end up with a vaccine.

BUT, not always.

AND, the progress to date makes it clear, IT MAKES NO SENSE to expect a working, proven, safe vaccine, distributed and available by Election Day.  Period.  Any claims otherwise are all about the Election not the Pandemic.

BOTTOM LINES

1. Once again, we are reminded, COVID-19 spreads.  And despite recent lulls, it continues to spread right here.  We are fast approaching 200,000 American killed by this virus, an entirely unacceptable failure.
2. We know where it spreads best (home) and second best (sustained, indoor places, like churches and schools), and it can spread outdoors too (soccer, football teams).
3. It hits peak contagion five days after exposure, which is usually Day 1 of infection, and contagion is often over by Day  7 of infection, to be sure, stay isolated until Day 11 of infection.
4. Cases cluster, who knows if you are infected if you will infect no one, or dozens, of how sick those you infect will get.
5. Smoking doubles your chance of the deadly severe level of infection.
6. Vaping increases your chance of coming down with COVID-19 FIVE TIMES.
7. Current swab tests (RNA PCR technology) if positive almost always mean you have it.
8. A negative current swab test means little the day after contact, means the most 5 days after contact onward.  Overall a negative swab test carries a 20% error rate.
9. If your swab test is negative, infected or not, you are very likely not contagious.
10. New technologies will make testing easier and cheaper.  Current test strip technologies will find 2-3% of all those uninfected to be positive on the test, so most of these positive tests will be false.
11. Dozens, over 100, vaccines are being developed.  Nine show real promise.  NONE ARE PROVEN TO BE SAFE AND EFFECTIVE FOR GENERAL USE.
12. There is NO WAY a vaccine will be available for me to give to anyone by Election Day.  Period.  Beware of any promises otherwise.

We are learning a lot.

But one thing remains true, this is a deadly virus, it spreads well, we must continue to act as though our lives, the lives of those we love, depend on it.

To your health,
Dr. Arthur Lavin