For most of us, we began to self-isolate Friday, March 13th, fittingly enough. Many of you were ahead of the public pronouncements by state authorities, not to mention our laggard federal leadership. We chimed in at that time as to the urgency of establishing a circle of safety and staying rigorously within it. So today is the 4th day of Week 2 of the Covid-19 epidemic self-quarantine. What lies in store?

Circles of safety at least through April

In Massachusetts and New York and many other locales, new cases continue to escalate in dramatic fashion. The clear message of the many predictions of the course of this epidemic is that we will have expansion of infection at least through the end of April. Beyond that, it seems much more likely than not that May will also be a month of expanding infections, but with some hope of leveling off only if the public as a whole practices rigorous social distancing and if we get data about new infections.

Whether that will happen is unclear for several reasons. The most important is our still vastly inadequate testing capability for Covid-19 here in Massachusetts, as elsewhere. We simply do not now know the prevalence of infection within the community and the numbers of people incubating the disease. We still cannot get all suspiciously ill or exposed patients of ours tested promptly. You can’t predict the future without knowing the present.

And second, with our current national leader today pushing to undo social isolation strictures by Easter (April 12), the effectiveness of mutual public protection is suspect and under threat. God bless Dr. Fauci, but his tenure at the public forefront is clearly in jeopardy.

The best advice Dr. Sobel and I have for you is to prepare for continued, rigorous social isolation within your circles of safety through April and likely well into May. Plan your Easter and Passover ceremonies remotely, unless all your family are in your circle of safety. We will update this outlook regularly, and will hope for better (realistic) news.

Office procedures for continued remote care

Our Orchard Health Care office remains open its normal hours, M-F from 8:30 a.m. to 4 p.m. Our nurses, Pat Potenza and Anna Cherkassky, are in every day. They are fielding emails and phone calls and generally directing traffic so that Dr. Sobel and I can answer your questions and solve medical issues remotely by phone and electronically and try to allay your fears. Our admins, Sandra Curtin and Cathy Salvucci help them keep the medical infrastructure working, including arranging referrals (even though most in-person medical visits are on hold at other practices).

We are trying to be organized with remote visits on a schedule. The phones can be overwhelming for the two nurses during the day, so we prefer you to use email wherever possible, especially for anything non-urgent:

  1. Please transmit your concerns to us by email, using nurse@orchardhealthcare.com for any clinical issue, and adminohc@orchardhealthcare.com for any scheduling or admin issue. Include both addresses on the note if there is any uncertainty. Our email is secure.
  2. You can certainly copy your physician on those emails (drkanner@orchardhealthcare.com or drsobel@orchardhealthcare.com), but in general please include the staff so they can help follow through and arrange remote conversations. (For Dr. Sobel, you can use the Partners patient gateway as an alternative.)
  3. Please do not text to Dr. Sobel or Dr. Kanner. Such texts are not secure, not HIPAA compliant, can’t be forwarded easily to staff, and can’t be readily archived.
  4. Clearly urgent issues will be dealt with urgently by the staff and Dr. Sobel and me.
  5. Most issues will be set up as remote visits on our schedule, starting late morning. Dr. Sobel and I will then get back to you by phone or other electronic means and resolve the problem as best we can. We will be taking notes, as will the nurses, so we can keep everything straight. There is a lot of monitoring going on of people at risk, people worried, and unanswered and sometimes unanswerable questions. We will be charging insurance for any substantive remote visits, as has been approved, which means you may see copays down the road.

If you have any questions about this, please pose by email. Also please read our blog posts. We are trying to get relevant current information to you on our website and pushing to you by emails. You are welcome and encouraged to comment on the posts. That way many people can get the same (I hope accurate) information most simply.

Personal protective equipment (PPE)

Masks, gloves, and hand sanitizer remain in short supply in the hospitals and nursing homes. This of course should not be, in the U S of A. But it is. So if you are sitting on a sizeable amount of any surgical masks, protective gloves, or hand sanitizer that exceeds what you realistically need, we are trying to help get that back to the hospitals and health care facilities that truly need it today. You have heard of this. Dr. Sobel is coordinating our response. Please email to her (drsobel@orchardhealthcare.com) with details about exactly what you have and the quantity and she will work with you about how to get that to appropriate care facilities in short supply.

Using masks yourself

Several members have asked, if you have surgical face masks, sufficient for personal use, is it reasonable or necessary to wear them in public if you are out and about. Such masks mainly protect others from your exhaled air and droplets, but offer some modest protection to the wearer. An occasion to use a mask might be if you go to a supermarket for food or a pharmacy to pick up meds. But much better for all would be for you to arrange for your food to be delivered or for the pharmacy to deliver. Overall, stay at home, walk in the woods or open spaces, but minimize excursions into any commercial spaces where there are potential clusters of people.

A final word for Day 4 of Week 2

Please remember that while Covid-19 can be quite serious and cause death,  and is much more serious than influenza A, nevertheless most cases of Covid-19 are mild to moderate and treated at home. We also collectively are now 11 days into serious social distancing. The median onset (50% mark) of disease with this virus is 5.5 days, and 97.5% of disease onset occurs by 11 days, which is where we collectively are. Within another 3 days, if we have truly been self-quarantining in our circles of safety, we should be past almost all the risk of Covid-19 infection from our prior exposures.

Spring is here. We should all be optimistic. Concerned but not afraid. And also resolute to keep to our circles of safety for the next month or until we get reliable, science-based information so that we can begin to mingle more normally again. More tomorrow sometime. Have an afebrile day.

 

 

 

 

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9 Responses to Covid-19: Day 4 of Week 2, Lots More to Go

  1. Kathy Cincotta says:

    Thank you so much, Doc, for these updates. Relying on government leaders who have no clue about the medical aspects of this is dangerous and moronic. Experts are experts for a reason.

  2. Deb and Craig Cerretani says:

    Dr. Kanner, as you recall, Deb and I drove from SW Florida and picked up daughter, Kendra husband Gerardo and granddaughter, Sofia…in a stealth, 20 minute operation in NYC, last Saturday PM at 6. We then drove, with masks to Falmouth and, have been self-quarantined since. Deb and I are obviously at risk as the NYC exposure has been more intense. We are 4 days in and, everything seems ok up to this point although Kendra and Gerardo have developed very benign sore throats which we will monitor carefully. On an anecdotal note, Falmouth folks have been VERY vigilant about social distancing. Also…lots of great Americans are there for all of us at grocery stores, pharma, and take out food. We are so very proud of these as well as the first responders. Godspeed to all!! Craig and Deb Cerretani

  3. DrKanner says:

    Greetings Dr. Kanner (from Margi and Dave Doherty, posted at their request)

    Thanks for your continued updates re COVID-19. Dave and I really appreciate hearing from you.

    Two questions when you get a moment to respond: We keep hearing that people with high blood pressure are vulnerable . My questions are:

    1. If hypertension is under control, is one more vulnerable? or

    2. Is the medication that keeps hypertension under control the problem?

    Since both Dave and I take medication to keep our pressure under control, we were just wondering.

    Thanks and we hope all of your staff stays safe.

    Margi and Dave

    • DrKanner says:

      “Underlying medical conditions” is sort of code for high blood pressure, diabetes, heart disease, rheumatoid arthritis and many other conditions that much more afflict the older population than the younger. No one, including Dr. Fauci, has been explicit about what is meant, since mild, well-controlled hypertension is biologically different from uncontrolled high blood pressure inducing heart disease, kidney failure, and strokes. This lack of specificity in turn leads to worry in people who are paying attention to the details.

      My take is that any grandparent with blood pressure or cholesterol issues or mild diabetes, any or all of which have been under good control with self-care and medication, is at minimally if any incremental risk of bad outcome if infected with Covid-19. Dr. Sobel and I certainly let you know when you are well controlled (which most of you are at any time), so I would not focus any concern at this time except to continue your controlling medications.

      There have been some theoretical concerns raised that ACE medications for hypertension, and possibly the ARBs (also for hypertension), might weaken body defenses against Covid-19. The big however, however, is that we have no hard data so far that this is true or meaningful in real life, and the additional concern that stopping or reducing those exceedingly helpful medications would worsen your hypertensive control and thereby clearly worsen the outcome of an Covid-19 infection. So I would ignore any public musing on this topic, take all your meds, and keep tuned. Should any definitive evidence show up over the next month or two, Dr. Sobel and I would take direct action with each affected member to make medication modifications quite promptly.

  4. DrKanner says:

    From: afmassari30@verizon.net
    Sent: Tuesday, March 24, 2020 11:08:44 PM

    Dr Kanner, another excellent article expressed with right combo of concern and calmness to strike a perfect balance.

    Three questions I have which others may be interested in the answer: (1) if one becomes infected with the virus what is the average duration—time to recovery based on mild, moderate, severe cases?;

    (2) if infected does one build up an immunity to the virus and for how long?; and

    (3) can medical science determine at a subsequent time, if someone not tested was previously infected by the virus and at this subsequent time was either immune or again could be potentially infected by the virus. Thanks.

    God Bless. tony massari

    • DrKanner says:

      Tony, (1) the median incubation till symptoms is about 5.5 days and the 97% is 11 days. The end of realistic risk is 14 days or so, though there are, of course, scattered reports of Covid-19 infections with a longer latency. Those are consensus data widely written about, with some minor variations.

      (2) The immunity situation is not yet clear. With most viruses, one becomes immune in the process of fighting off the infection and that immunity most often lasts many years if the virus remains unchanged. Think chicken pox. However, some viruses remain mostly the same but mutate enough with each year or season that infection one year does not confer life-long immunity. Think influenza A. At this point, we don’t know the path this virus will follow, since it is “novel” and has not been seen before. The precedents, I believe, are that other coronaviruses do not evolve that rapidly and that immunity at least for a year or so is likely. That should help to establish “herd” or community immunity and eventually help to extinguish this virus in the human population. It does not appear to have animal reservoir at this time except the bats from which it was transmitted. Most people are not in contact with bats.

      (3) At some point we will be able to test human blood for antibodies to Covid-19, both the quick-arising ones (IgM) that show up within weeks and last a number of months, and the long-acting antibodies (IgG) that usually persist for years if not indefinitely. I believe there is already research identification of these antibodies, but to my knowledge there are not yet any commercially available blood antibody tests available. They will of course be useful for eventually determining who had what, who is protected, and so forth in the denouement of this epidemic.

      Good questions. Quite pertinent. I hope this helps.

      • Tony Massari says:

        Dr Kanner thank you for your candid expert responses, understanding that there is still unknowns as to how this virus will play out. One point of clarification:if infected and symptoms materialize day 5 and diagnosed as “moderate” (however so defined)and treatable from home, is there an average number of days before fully recovered from symptoms and things get back to normal (however that is defined). I gather it will vary by any pre-conditions, age etc, but is there enough data to evaluate healing process from symptom manifestation to full recovery. Thank you. God Bless. tony

        • DrKanner says:

          Tony, from multiple public sources from other countries especially, the course of “moderate” disease is likely well over a week. And in more severe Covid-19 disease, the patient gets worsening respiratory symptoms a day or two into the second week of symptoms. This is a long course of infection. I will try to provide more detail as we get more published experience.

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