Covid-19 Update

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In an article published on October 5th, the Oklahoma State Department of Health updated their recommendations for quarantine and isolation guidelines and for testing for Covid-19.

Viral testing that detects the SARS-CoV-2 (Covid-19) RNA is recommended to diagnose acute infection.  The specimen is obtained by nasal swab and results are usually available in about 24 hours.

Antibody testing, performed on blood specimens including finger stick tests, is not FDA-approved for the diagnosis of acute infection.  These tests provide little information to the individual tested, but when results are available from a large number of people, antibody tests provide public health officials with important information for assessing transmission rates in the general population.

Viral testing is recommended for:

  • Individuals with signs or symptoms consistent with Covid-19

  • Asymptomatic individuals with recent known or suspected exposure to SARS-CoV-19

  • Individuals being tested for purposes of public health surveillance for SARS-CoV-19.  

Exposed individuals should complete a 14-day quarantine period following their last 

potential exposure.  A negative test obtained during the quarantine period does NOT mean that the individual will not develop illness later in the quarantine period.

Individuals exposed to Covid-19 should wait a minimum of 2 days following their first exposure before getting their first test.  If the first test is negative, serial, or repeated tests can be helpful, as recommended by the individual’s physician.

Individuals testing positive for Covid-19 and found to have mild to moderate symptoms should immediately begin isolation and remain in isolation for 10 days after the first onset of symptoms.  A test-based strategy for ending isolation is no longer recommended.

For more information: https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html

Why Herd Immunity Alone Is NOT a Viable Option for Eradicating COVID-19

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As discussed in an earlier blog, herd immunity occurs when enough people become immune to an infectious disease, either through infection or a vaccine.   A virus will die out once uninfected individuals are rarely in contact with those that are contagious.  But achieving herd immunity by natural transmission and without a vaccine is gained at the cost of many lives.

In August, the World Health Organization’s Michael Ryan warned journalists, “We are nowhere close to the levels of immunity required to stop this disease transmitting.  We need to focus on what we can actually do now to suppress transmission and not live in hope of herd immunity being our salvation.”

Experts believe that 60-70% of Americans will need to become immune before our country reaches herd immunity.  But, according to Dr. Dale Bratzler, OU Medicine enterprise chief quality officer, “Getting to herd immunity through infection is not the direction Oklahoma wants to go right now.”   To get there, nearly 2.4 million Oklahomans would have to contract COVID-19.  Using the lowest available estimate of case fatality rate of 0.3%, this would mean more than 7,000 Oklahomans (more than ten times the current total) would die, while using the state’s current 1.27% death rate means that more than 30,000 people would die.

It is believed that, even in the absence of a vaccine, the Brazilian city of Manaus has reached herd immunity.  As of August, researchers estimated that 66% of the population had been infected.  In that city of over 2 million people, 4,000 people have died so far, a high death toll for a city where only 6% of the population is over 60.  This experience reveals “that an unmitigated outbreak will lead to very significant levels of illness and mortality,” says Bill Hanage, an epidemiologist at Harvard University, “which is what we’ve been saying since February.”

So, the consensus opinion of experts, with which I also concur, is that we do need to achieve herd immunity against COVID-19 through a combination of natural immunity due to infection AND an aggressive vaccine program.  And, while awaiting the arrival of COVID-19 vaccines, we all need to continue to wear masks, wash our hands, avoid touching our faces and maintain social distancing when appropriate.  Frequent testing and contact tracing are also needed for those who have been exposed to COVID-19.  If we do these things we will save thousands if not millions of lives.

For more information check these links

https://www.thelancet.com/journals/lancet/article/PIIS0140-67362031924-3/fulltext

https://www.inquirer.com/health/coronavirus/covid-coronavirus-herd-immunity-vaccine-20200924.html

COVID-19 in Children, Teens and Young Adults

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Children and teens can get COVID-19.  While most have mild symptoms or none at all, these groups can spread the virus that causes COVID-19 to others, including older adults,  who may be more susceptible to its effects.  And children can get severely ill, and may require hospitalization, intensive care or even the use of a ventilator.  

Who’s most at risk of acquiring the infection?  The highest risk of infection is in communities with a sizable outbreak, when people spend long amounts of time in closed, unventilated spaces where other people close by are talking or otherwise emitting virus-laden vapor, and  where people aren’t wearing masks. 

Severe illness from COVID-19 is more likely if affected youth and young adults have:

  • Asthma

  • Diabetes

  • Genetic, neurologic conditions

  • Heart disease since birth

  • Immunosuppression (weakened immune system due to certain medical conditions or being on medications that weaken the immune system)

  • Medical complexity (the presence of multiple chronic conditions that affect many parts of the body and require technology and other significant supports for daily life)

  • Obesity

Infants and young children can develop a serious condition known as multisystem inflammatory syndrome that can affect the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs.

Young adults age 18-34, in whom the numbers of COVID-19 cases have been rising rapidly, are also at risk for complications from COVID-19, especially if they fall into one or more of the groups detailed above.  When young adults are hospitalized due to symptoms of the infection, 21% require ICU admission, 10% require mechanical ventilation (the use of a ventilator) and 2.7% die.

Young adults are also more likely than children or adults 65 and older to develop prolonged, post COVID-19 infection symptoms.  Termed “long-haulers,” these patients can suffer from a diabolical grab bag of symptoms, including chronic fatigue, shortness of breath, unrelenting fevers, gastrointestinal problems, lost sense of smell, hallucinations, short-term-memory loss, bulging veins, bruising, gynecological problems, and erratic heartbeat. 

Symptoms of Covid-19 are similar in all age groups and include:

  • Fever

  • Cough

  • Shortness of breath or difficulty breathing

  • Fatigue (tiredness)

  • Sore throat

  • Runny or stuffy nose

  • Muscle pain or body aches

  • Headache

  • Vomiting and/or diarrhea.

  • Significant loss of taste and/or smell

If you think you might be infected with COVID-19 seek medical advice about testing and treatment.

COVID-19 affects all age groups, can be mild or deadly at any age, and can cause prolonged symptoms even after recovery from the acute illness.  Our best current protections are to wear masks when appropriate, avoid crowds, wash our hands frequently, avoid touching our faces and maintain social distancing in public.  The use of vaccines that will become available in the coming months will greatly help to further mitigate the spread of this disease.

For more information: 

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/symptoms.html

What’s new about the Flu?

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As in previous years, the Centers for Disease Control and Prevention (CDC) recommend that everyone 6 months of age and older, and who do not have a contraindication, should receive the annual flu vaccine.  A person’s age, health (current and past) and relevant allergies may be reasons to not receive the vaccine.  Check with your doctor to determine if the flu shot is right for you.

This year the CDC has suggested that the flu vaccine be given earlier than usual, due to currently circulating Covid-19 pandemic virus and the similarities between the flu and Covid-19.   Based upon symptoms, it is hard to tell the difference between the flu and Covid-19, since both diseases frequently cause: 

  • Fever

  • Cough

  • Shortness of breath or difficulty breathing

  • Fatigue (tiredness)

  • Sore throat

  • Runny or stuffy nose

  • Muscle pain or body aches

  • Headache

  • Vomiting and/or diarrhea.

By getting the flu vaccine now, you can help avoid the possibility of getting the flu and Covid-19 at the same time. And, if you have received your flu shot and then become ill, it will be easier to determine which disease may be causing your symptoms and which treatment(s) will be best.  Flu shots given in September and October should last throughout the 2010-2021 flu season.

Check this link for more information about seasonal influenza.

https://www.cdc.gov/flu/about/keyfacts.htm

Osteoporosis in Men

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While low bone mass, or osteoporosis, is less common in men than in women, over 8 million men in the US are affected by it. The mortality rate in hip and spine fractures is higher in men than women, furthermore, due to the older age and the greater number of chronic diseases present in men at the time of fracture.

There is no routine recommendation for screening of men for osteoporosis.  DEXA scanning is suggested when fragility fractures occur and if men have high risk conditions as outlined below.  Once osteoporosis is identified, regular DEXA screening every 2 years is recommended.

The treatment of osteoporosis in men is composed of lifestyle measures, hormonal therapy, and/or non-hormonal drug therapy.

Lifestyle measures:

  • Practicing a weight-bearing exercise regimen

  • Tobacco cessation

  • Avoidance of excessive alcohol use

  • Maintaining a daily calcium intake of 1000-1200 mg per day.  

  • Measuring Vitamin D levels and adding supplementary Vitamin D3 if indicated

Hormonal therapy 

  • A Low testosterone level (LowT) is among the most common causes of osteoporosis in men.  Replacement therapy with testosterone provides skeletal benefits by increasing bone mineral density (BMD) and thereby reducing osteoporosis and the risk of fractures.   Men with LowT should also be treated with a bisphosphonate if fracture risk remains high.  There is no known benefit from taking testosterone if baseline testosterone levels are normal.  

  • Glucocorticoids, also known as steroids, can induce bone loss.  The doses of these medications should be reduced to the lowest effective dose, and stopped if possible.  Glucocorticoid-induced bone loss should be treated aggressively.

  • Androgen-deprivation therapy, administered to men with prostate cancer, increases the risk of clinical fractures by lowering testosterone levels.  If BMD is diminished, as soon as justified, this hormonal therapy should be discontinued.

  • Gastrointestinal disorders can contribute to osteoporosis due to malabsorption of Vitamin D, resulting at times in severely low Vitamin D levels.  Most often, providing adequate Vitamin D replacement and supplemental calcium can lead to marked increases in BMD.

Non-hormonal medical therapy

  • Men with normal testosterone levels

  1. In men with a history of osteoporosis (fragility fracture and/or t-score <-2.5), bisphosphonates are indicated.

  2. Men > age 50 with t-scores of -1.0 to -2.5 and at high risk of fracture, bisphosphonates are indicated.

  • In men with low testosterone levels

  1. Testosterone replacement is recommended unless a contraindication is present.

  2. Bisphosphonates are recommended if the patient also:

  • Takes high-dose glucocorticoids

  • Has frequent falls

  • Has had a recent fragility fracture

  • Has a t-score below -3.0

  • Has a t-score less than 2.5 two years after having received adequate testosterone replacement therapy.

As with women, there is no consensus on low long men should continue medication for osteoporosis.  Some experts recommend discontinuing bisphosphonates after 5 years’ use.

For men with contraindications to the use of oral bisphosphonates, Intravenous bisphosphonates and Reclast can be used, as well as Prolia and Forteo/Tymlos.  There is no reason to combine any two non-hormonal therapies.

Osteoporosis in Women

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Your bones are in a constant state of renewal, with new bone forming while old bone is being recycled by your body.  Before the age of 30, your body makes new bone faster than old, but as you age bone mass is usually lost faster than it is created.  This imbalance can weaken your bones.

Osteoporosis, which occurs when the formation of new bone doesn’t keep up with the loss of old bone, can cause bones to be brittle and can often lead to fractures after falls and such simple actions as coughing and bending over.  

Osteoporosis is usually asymptomatic in its early stages, so you may not know that there is a problem.  As the disease progresses symptoms such as back pain, height loss, stooped posture and bone fractures that occur more easily than expected can all occur.

Factors that increase the risk of osteoporosis in females include:

  • Female sex

  • Age—the older you are the greater the risk, especially after age 65

  • White and Asian race

  • Positive family history, if osteoporosis is present in either parents or any siblings

  • Small body frame

  • Certain abnormal hormone levels

  1. Lowered sex hormones

  2. Elevated thyroid hormone levels

  3. Overactive adrenal and parathyroid glands

  • Diet issues

  1. Low calcium intake

  2. Eating disorders, such as anorexia

  3. Previous gastrointestinal surgery, especially gastric by-pass

  • Certain medications

  1. Steroids

  2. Some anti-seizure drugs

  3. Proton-pumps inhibitors (e.g. Prilosec) used for heartburn and reflux

  4. Anti-cancer drugs

  5. Drugs to prevent transplant rejection

  • Certain medical conditions

  1. Inflammatory bowel disease

  2. Celiac disease

  3. Kidney and liver diseases

  4. Cancer 

  5. Lupus

  6. Multiple myeloma

  7. Rheumatoid arthritis

  • Lifestyle choices

  1. Sedentary lifestyle

  2. Tobacco use

  3. Excessive alcohol consumption

Osteoporosis Diagnosis and Treatment for Women

Lifestyle measures that should be adopted by every woman include:

  • Adequate calcium and Vitamin D

  • Regular weight-bearing exercise

  • Smoking cessation

  • Avoidance of excessive alcohol

  • Counseling for fall prevention, including advice on balance training

At age 65 in usual-risk women, and sooner if high-risk conditions are present, dual-energy xray assessment, or DEXA, scan should be performed to establish a baseline.  This test measures bone density at the spine and hip, producing a t-score value that is the most accurate assessment of bone density.  Normal t-score is -1.0 to 0.0, osteopenia (some thinning of bones) is defined as a t-score of -2.5 to 1.0 and osteoporosis (significant thinning of bones) is present when the t-score is < -2.5.  A t-score above 0.0 indicates stronger-than-usual bones.

The probabilty of fracture can be estimated by calculating the FRAX score, which utilizes the t-score and history of osteoporosis risk factors.  Most DEXA reports include a FRAX score.

Medication is indicated for women who have a history of fragility fracture and/or whose bone density measurements via DEXA show a t-score that is less than -2.5.  Medication is also appropriate for women whose t-score is -1.0 to 2.5 and who have a 10-year fracture risk assessment risk of > 3 at the hip or 20% overall as calculated using the FRAX.

The choice of drug is patient-specific.  The bisphosphonates alendronate (Fosamax) and risendronate (Actonel) are the drugs of choice for most patients, unless there is a history of esophageal disorders, chronic kidney disease and/or some types of weight loss surgery.  

Prolia, a drug injected twice a year, or Reclast, given by intravenous infusion once a year, are indicated for osteoporosis patients if bisphosphates should not be used.  Patients at very high risk should receive either Forteo or Tymlos.  However, these two drugs must be injected just beneath the skin every day and are very expensive.

Once diagnosed, osteoporosis and osteopenia should be monitored for progression by performing a DEXA scan every two years, regardless of what treatment has been started.

There is controversy about the length of treatment, but many authorities suggest a drug holiday after 5 years of bisphosphonate use and 3 years of Reclast infusions, and the drugs can be discontinued indefinitely if the t-score is stable and there have been no fractures.  Patients at very high risk should probably continue bisphosphonates for 10 years.  Forteo and Tymlos must be stopped after 2 years, when bisphosphonates can then be substituted.  There is no time limit for Prolia.