Hi, I’m back as Robin-Schoenthaler-the-Boston-cancer-doctor-who-writes-about-Covid.

(And its okay with me if you want to share.)

Today I’m going to talk about why rates in Massachusetts and other states are going up, and what we can learn from White House events about self-protection. This is being written on Oct 4, 2020 around midmorning.  I’m including this because it may well be out of date in less than a day.  Things move so quickly here!

Big picture:  Massachusetts’ numbers have begun to rise again. There was a hint of this two weeks ago, the start of an upturn last week and this week it is beyond question.  There are more cases — 500-700/day — and it looks like more hospitalizations.

Why the rise?  It’s because we have more people having contact with more people.  More People with Mouths and Noses. 

People With Mouths and Noses are the single biggest risk factor we face. 

More People with Mouths and Noses means there’s more live contagious viruses with the opportunity to head your way.  Especially if either of you or god forbid both of you are unmasked.

What is NOT causing the increase in cases and hospitalizations?

  • This is not school reopening yet — it will take several weeks to see that impact
  • This is not protests.  Multiple studies have shown outdoor masked protests are not associated with spikes
  • This is not colleges in Boston.  The universities in the Commonwealth have performed over ONE MILLION tests and there have been only 918 positive people (students, staff and faculty).

Why is this happening?

This is happening because people are getting together with unmasked People With Mouths and Noses.

So right now in Massachusetts we see a rise in the case number and the hospitalizations, but not the deaths.  Because it’s too soon, or, maybe we’ll get lucky and it won’t happen.

I say this because in many parts of Europe the cases and hospitalizations have been going up for some time, but there has not been a big rise in deaths. 

It is possible (this is a theory) that this is because the hugest rise in cases is among young people.  The case rates are going up because young people are out and about, going back to work, serving our food at our newly opened cafes, teaching our children. 

But young people have MUCH lower death rates.  Not none — it’s still a dangerous disease for some young people — but statistically, we are not seeing the same six-weeks-later-rise-in-death-rates in Europe. 

So there you have your good-news-for-the-day. Let us hope it lasts.

What can we learn from President Trump’s journey?

  1. Never go anywhere where there are unmasked People With Mouths and Noses
  2. Do not go to indoor events
  3. Don’t get close to people indoors or out

         Don’t shake hands

         Don’t hug

         Don’t kiss

Don’t take pictures with your arms around each other without masks

  1. Do not spend unmasked time in small spaces like airplanes and conference rooms
  2. The second you are ill, stay home. 
  3. The second you are ill after a known exposure, tell everyone you had contact with to get tested
  4. The second you get tested, stay home.
  5. The second you hear you’re positive, stay home
  6. The second you are home, plan to stay home and stay away from all people for 14 days or ten days after symptoms
  7. The second you hear you’re positive, tell everyone you have had contact with to get tested and stay home

What can we learn from the White House illnesses?

  1. Most people get sick around five days after exposure
  2. If you have a real exposure (>15 minutes, <6 feet) to someone who is positive, you need to get tested AND stay home for 14 days.  This is the official guideline. Don’t go to parties, don’t go to the store, don’t get on an airplane.
  3. A test can be negative in the morning and positive at night as the viral load inside your nose builds up. Many people are negative on Day One after exposure but positive on Day Five.
  4. People can be contagious when asymptomatic
  5. People can be very contagious when symptomatic — especially coughing and sneezing
  6. Once positive, many people have mild or no symptoms and stay home and do fine
  7. People go into the hospital when they have low oxygen or look like they’re getting sicker. Insurance doesn’t let you go in as a “precautionary” measure.  You don’t “check yourself in” like it’s a Holiday Inn.  You get “admitted” by a doctor who is worried about your health.
  8. Covid is a slower illness than the flu.  The second week is usually when real badness happens. Not the next few days.  Next week.

What is there to learn about his treatments?

  1. He got an antiviral drug, Remdesivir, which has been approved for people who are hospitalized
  2. He got a “new” drug— a monoclonal antibody combo called REGN-COV2 — which is not an approved drug. However, it has some good preliminary science behind it and years of using other monoclonal antibodies to help us feel reasonably confident it’s reasonably safe.
  3. Very ill hospitalized people are often given “corticosteroids,” often referred to as “steroids” — in this case 6 mg dexamethasone (Decadron).  This is approximately 40 mg prednisone, the kind of steroid dose you might get with an asthma attack or really bad poison ivy.  (These are not “anabolic steroids” like athletes use.) Treatment guidelines say you only give steroids if patients are sick enough to require oxygen. It isn’t clear he has received steroids.  (ETA: he did)
  4. These kinds of steroids can cause a number of side effects when taken for a while including stomach upset and psychological impacts ranging from insomnia to feeling super speedy (cleaning the linen closet in the middle of the night) to getting emotionally unstable (what I call “crying in the middle of a sentence”) to “steroid psychosis”
  5. He has also been given or was taking zinc, melatonin, Vitamin D, Pepcid and aspirin.  None of these have scientific studies supporting their use.  Vitamin D is the most interesting from a theoretical standpoint.
  6. One of the best treatments at this point is “proning” where people lay on their stomachs as much as possible.  This hasn’t been mentioned. (ETA: apparently he didn’t)
  7. In my experience, VIP patients often get over-treatment and sometimes under-treatment. It can be a challenge for a physician to find the perfect Goldilocks position of “just right.”

How will he do? 
Most people recover from Covid whether at home (the vast majority) or in the hospital (most people). 

His risk factors for severe disease are his age, his reported weight (BMI>30), and the fact that he is male. 

Other risk factors for bad disease that he is said to NOT have have include cancer, chronic kidney disease, history of organ transplant, serious heart disease, sickle cell disease and type 2 diabetes. 

Statistics say he will recover and go home from the hospital. But one of my most common lines as a cancer doc is “Statistics apply to groups.  For any individual person, survival is either 100% or 0%.” 

Next week will tell the tale.

What can we do to avoid his fate?

So much! 

  • mask
  • wash hands whenever not home
  • stay home when sick
  • stay physically distanced (don’t hug or kiss)
  • stay outside
  • stay out of crowds (don’t go to indoor bars or restaurants)

And most of all, stay away from unmasked People With Mouths. 

Again, People With Mouths and Noses are the single biggest risk factor we face.  Especially people with unmasked big mouths.