Gonna have a little extra fun with the music selections today and do this Jeopardy! style in honor of Alex Trebek who passed away today after a long fight with pancreatic cancer.  The answer to today’s Final Jeopardy question is “I am the drummer of this band.”  The video above is a tune entitled Disco Suicide by Brand X.  This song is unrelated to Disco Demolition Night which occurred two years later thanks to Bill Veeck.   The remaining tunes today will provide hints to assist you at asking the correct question to be presented at the conclusion of today’s blog.  We will start tangentially before hitting you with the Sledgehammer.

The Future Starts Today

It’s been an eventful week, and there is a lot of ground to cover.  As always, we will start with presenting the current COVID data through various lenses.  There are some updates on vaccines and therapeutics this week.  We will also try to speculate as to what the next several weeks may hold for all of us.  So grab some of the kids Halloween candy, turn your speakers up, and settle in, cause here we go…..

Fun With Numbers

The Broad View

Starting with the more panoramic view, we will progressively focus until we arrive at the local situation.  The situation in Europe is still in the category of disastrous.  At this point in time we are still seeing massive fatalities.  But there may be a silver lining emerging there of sorts.  Last week we had reported that several countries in Europe chose to reinstitute restrictions due to the increased cases, hospitalizations, and deaths that were occurring.  It appears that they are starting to show some benefit.  Below are two graphs, one for number of cases (left), the other for number of deaths (right).  If you look at the curve for case number, it seems to be starting to flatten rather than continue to spike.  The curve for deaths in Europe however is still spiking, but always remember that this is a lagging indicator for any action taken.  The hope is that in 2-3 weeks the hospital burden and death rate in Europe will again start to diminish.  While these nations closed non-essential businesses, schools are still open.

The National Vantage Point

The situation nationally is currently not favorable.  There are many other phrases that come to mind to describe it, but will spare the profanity today.  The number of cases in the US is rising rapidly and has set multiple new records this week.  As you can see in the upper panel of the chart below we are on the upslope still.  There is no indication of flattening on the horizon.  Hospitalizations have been increasing markedly, with 16 states reporting record numbers of hospitalizations, and some states reporting strain on capacity.  We are also starting to see increased deaths again on a national level (lower panel).  So far this effect continues to be subtle, but we are again over 1000 deaths per day in this country.  We can expect this number to continue to increase over the next several weeks.  Until we begin to see some flattening of the new case curve, we can further expect this to be the rule, not the exception.  How well we are managing those that do fall ill should become evident shortly.  The best case scenario is that the death rate stays in line with the increase seen in August.  The worst case?  Let’s not go there.

View from Our Backyard

So far, we are not feeling much difference locally.  That being said, the numbers are getting quite concerning around these parts as well.  Data for this section captured from the Newsday COVID tracker site.  Starting off by looking at the new case rate in Suffolk County (left panel below) we can see a definitive trend in the wrong direction.  From July through September we were seeing roughly 60 new cases per day.  Come early October this number increased to roughly 80 per day.  For the last couple of weeks that number is now in the 140 case per day rate.  Not surprisingly, we are now starting to see the effects of the recent increase in case rate in the hospitals.  The average number of individuals hospitalized in Suffolk County (right panel below) has nearly doubled over the last few weeks.  We are not seeing strain on hospitals here as in other parts of the country, but a further increase of hospitalizations is not welcome.  Over the last couple of weeks there have been two deaths in Suffolk County.

A Quick Break

A couple of clues to the drummer’s identity from our introductory clip.  First clue is Peter Gabriel.  Video below is for a tune name “Red Rain,” and my personal favorite among his solo work.  Second clue is Mike + the Mechanics, a band formed in the 1980’s as a side project for bassist Mike Rutherford.  The song “Silent Running” was among their best known.

A Little Direction

What should we be doing now?

Likely due to the election related news deluge the last week or so, there has been little discussion as to how we are managing this increase in case load.  Some parts of the country, such as El Paso in Texas have issued “Stay at Home” orders.  New York City has also utilized targeted restriction to stem surges in certain neighborhoods.  Some of these regions already have improved and are beginning to have the restrictions again eased.  Provided the surge in overall numbers is manageable with targeted increases in restrictions, we may have established a method to navigate this.

What would further assist is individuals deciding on their own to be a bit more proactive than reactive.  We all understand that the further out of hand a situation gets, the more extreme the response required to tame it.  There is a lot of data being collected to monitor the situation as you have certainly noted by this time.  There are cutoffs on some matrices by which there are plans to formally institute restrictions.  My appeal to all is to look at the picture and don’t wait for a third party to mandate a plan of action.  We are now entering prime coronavirus season on a typical year.  This is not the time to try to “max out” on what is considered permitted. What I find worrisome is that while I know we are entering the prime season, I see many that are simply tired of dealing with the situation and are choosing now to let their guard down.

At this time, do I think we need to institute a “lockdown?”  The answer is no.  Do I think you should think twice about meeting up with three families in your house for playdates and dinner?  Yes.  Do I think you need to have all your household goods shipped to you?  No.  Would I consider trying to shop at times where the store tends to be less crowded?  Yes.  Can I hang with the grandparents?  Yes, but please be very cognizant as to what you are doing together.  I would strongly urge masks for all in such situations.  Come Thanksgiving and meals with them, keep a distance when unmasked and chowing down.  Kinda like a “Kiddie Table,” only different.

And folks, be honest with yourselves.  If you feel sick, don’t go to work or school.  I know we have all done it before, but even if it feels like the common cold, it may not be. If you have had exposure and are called by contact tracers and told to isolate, listen.  If you test positive, cooperate with the contact tracers so they can properly do their job.

Forward Thinking

I believe that we have somewhat better positioning at this time than when all this began in earnest back in March and that may be enough for us to avoid the severity of the restrictions we needed to endure.  We have far more data, more testing capability, improved contact tracing, and formal guidelines for action based on various circumstances.  We have been more respectful of certain situations that can lead to severe outbreaks such as nursing homes.  We have also learned to manage those that fall ill better.   Use of steroids and other interventions has improved the odds of survival if one should have a more severe presentation.

Remember that our current situation is not likely to resolve completely until we have a cure or a prevention (ie: vaccine).  Our lives must continue as the time scale for both those end games is indeterminate.  Could be a few months.  Could be a few years.  We cannot prevent all cases of COVID at this time, nor make it our goal to do so.  We need to be aggressive with those that are high risk and dependent on our care.  Again, creating a safe environment in a nursing home is a prime example.  Your average 70 year old overweight, mentally stable type II diabetic with six stents in his coronary arteries gets to decide what level of risk they wish to endure.  That is what amounts to informed consent.

Other considerations that continue to be a societal issue.  There is a difference between taking risk yourself and imposing risk on others.  Wanna sky dive?  Have fun, just don’t follow Michael Sergio’s lead.  Not that you could nowadays, as there are no stadium events at this time. Wanna drive fast?  Do it on a track.  Don’t place others at risk doing the Cannonball Run.  How does this mentality apply to all of us?  Wear masks in public whether you feel ill or not.  Stay out of public if you are ill.  If you are the caretaker of three kids with fever and runny noses, send someone to the pharmacy to pick up your favorite remedy.  My favorite Remedy (not a clue for today’s trivia question)?  You are entitled to kill yourself (actually technically illegal still in many places, but if you believe in an afterlife, I will wager United States law will not apply there).  You are not entitled to kill others without a government sanctioned declaration of war, and even then there are rules.  Also, you can pick your friends, you can pick your nose, but you can’t pick your friend’s noses.

All kidding aside, we have to keep the case count in check because we have to ensure that we maintain the capacity to assist those that cannot avoid getting ill enough to need medical attention.  And I don’t mean just COVID.  Imagine getting appendicitis and not being able to be seen quick enough to be evaluated.  Or receiving delayed treatment for what could have been a mild heart attack or stroke.  If we start to fail here, I guarantee a long winter of lockdown.

Looking for Clues?

Looking for Clues?  Despite the hyperlink, Robert Palmer is NOT one of the clues. Just a half decent 80’s tune for your entertainment.  Your next two clues are below.  First is a tune named “Harold The Barrel” by Genesis.  Voice sound familiar?  It would be Peter Gabriel and the tie in from your initial clue.   The second clue is a cover of “Land of Confusion” by Disturbed.  Thank my wife, Jamie, for that one.  Two weeks in a row with a Disturbed tune.  Disturbing for me, and will not make a habit of it.

Progress Reports

Now that it appears that we have a new president elect, what are the implications as it pertains to COVID?  Tough to say.  The one that we will all notice, for better or worse depending on your perspective, is that messages will be delivered in a different manner even if the message is the same.  One message though that will certainly be expressed more clearly regards mask wearing.  That message is to wear it.  I find I say that a lot.  Probably because I cannot believe that I continue to see throngs of folks hanging out in Port Jefferson without such when driving through to visit my grandmother.

One aspect that won’t change is the determination to end the pandemic and willingness to spend to do such.  President Trump and President Elect Biden have both either shown by action or stated that cost is not the issue.  Here is hope that Biden oversees the completion of what Trump initiated in this case.  Spend and encourage spending on the development of therapeutics and vaccines to assist us all.   For all the criticism that the current president has faced during the pandemic, to his credit he was not fearful of throwing money at this aspect of the problem.

One aspect of pandemic management to date that I hope is addressed is how to manage personal protective equipment (PPE) purchases.  We are again beginning to see strain on the supply of PPE for health care providers.  This honestly should never be, and that goes just the same for the general public.  Two things that could be done to assist are to purchase on a federal level PPE and then distribute to the states based on need.  Currently health care entities and states are bidding against one another for PPE and this runs up cost and limits often what they can obtain.  The other thing that could be done if supply continues to be a concern is to actually build or commandeer manufacturing facilities to make more.  It is the right of the government to do so during situations such as this.

Vaccine Updates

No major news to report regarding the clinical trials for vaccines or imminent availability of any.  However there are some vaccine related studies worth noting this week.  First, there has been concern that a vaccine may have safety issues with respect to immune-associated disease enhancement.  A review, published in Science Translation Medicine, discusses this concern and based on current data is somewhat reassuring.  Another concern that has been raised is that as other strains emerge, the vaccines currently in development may be useless.  A study in Science Advances, demonstrated that there may well be cross immunity between strains by looking at the ability of antibodies to SARS (original flavor) being able to neutralize COVID (aka SARS-CoV-2).  Essentially, there may be conserved regions between all strains that, if  made the target of a vaccine, may provide immunity for all coronaviruses.  Over the last couple of weeks, Novavax became the seventh company to receive funding from Operation Warp Speed for a vaccine in development, increasing the potential for a success story in that regard.  Side note:  the Senior Director, Nita Patel, for the Vaccine Development Program at Novavax is female, and why again it is important to encourage STEM for our daughters as we discussed in a prior blog.   Lastly, as vaccine research continues, there are novel mechanisms being developed.  One such involves nanoparticles and was the subject of a study published in Cell.  Not currently as advanced in study as other candidates, but interesting nonetheless.

Testing Updates

Remember CRISPR from a couple of weeks back?  Scientists have been developing a rapid test for COVID based on the technology.  Very different than the genetic modification applications we discussed in that prior blog.  This test may eventually be coming to your living room.  Read a bit more about this technology here.

Other studies that may have clinical applications

A couple of quick mentions for basic science studies of interest.

  • A study published in Nature Communications that associated viral load with disease severity and mortality.  The potential application here is to identify those with high viral loads at time of diagnosis for the purpose of risk stratification and determining how aggressive a treatment regimen is required early in the disease process.
  • A study published in Nature Immunology identified distinct antibody responses to COVID in children and adults.  This type of study furthers our understanding of how the response to COVID infection in children and adults is different and how that may apply both to preventative and therapeutic measures for different age populations.
  • A study published in Scientific Reports discussed the use of machine learning tools to identify peptides (protein pieces) that may be useful as therapeutics.
  • A study in Cell Research may have started to explain how “silent hypoxia” develops in patients though interferon mediated mucous production.  Again, this furthers our knowledge as to how the disease develops and provides insight as to how to develop therapeutics to treat aspects of the condition.
  • A paper in Communications Physics discusses the impact of travel and timing in eliminating COVID.  This paper ties in R-values as a measure of spread and how we can mitigate disease spread.

Closing Thoughts

I know, should have picked a better section heading.  Here is to hoping there are no significant local closures similar to those we endured already this year.  I am a numbers junkie, and I am telling you we are not heading in a great direction and there is much risk ahead.   Please be mindful.  Be considerate of others.  Be patient.  You have scientists and doctors working relentlessly to help this reach a definitive conclusion, but these solutions take time to develop.  Our collective goal is to make the most of a really lousy situation.  Do your best to help minimize spread so we can live our lives to the max of what the situation gives us.  And as always be careful with the elderly.  They cannot be left to live in isolation as it is in many ways a fate worse than death.  At the same time, take every reasonable precaution to not introduce COVID to them.

Winner Winner, Chicken Dinner?

Solution to today’s Final Jeopardy answer is “Who is Phil Collins?”

How your clues tied in:

Phil Collins started as the drummer for Genesis when Peter Gabriel was their front man.  When Peter moved onto pursuing his solo career, Phil stepped in and took over for vocals in addition to his role as drummer.  Much as the situation with Van Halen and their vocalists, many Genesis fans identify as with either the Peter Gabriel era or the Phil Collins era.  Mike + the Mechanics was the side gig for Mike Rutherford, the bass guitarist for Genesis. The Genesis tune presented was from the album Nursery Crime.  Lastly, the Disturbed tune presented was a cover of a later Genesis tune that featured Phil on vocals.  Below is perhaps Phil Collins best known solo song entitled “In the Air Tonight.”  It has also been the subject of an urban legend.   

Post authored by Jason Halegoua PhD, MD, MBA, FAAP.  Jason is the founder of Peds First Pediatrics in 2009, and has been a practicing general pediatrician since completing residency at Schneider Children’s Hospital in 2004.  In addition to earning his medical degree from the Medical College of Pennsylvania, Jason earned a PhD in Molecular Pathobiology for his work contributing to the understanding of the genetic regulation of immune responses to murine leukemia viruses from Hahnemann University in Philadelphia and an MBA in Finance from Hofstra University.