Coronavirus 2020

As of:  December 21, 2020

In this emergency situation, my staff and I are working hard to keep you, and us, safe and cared for.  I won’t repeat everything you’re reading in the news.  But here’s my take, and our response.

 

How much has Coronavirus spread?

In Delaware, case numbers have started to increase again recently, in step with the rest of our region.  Almost 10% of new tests in Delaware are positive.  The rate of new cases in Sussex County is now lower than in New Castle and Kent counties, according to State data.  Less than 5% of Delawareans have tested positive since March.  So even if many cases have gone undetected, this still means that almost all of us are still susceptible.

https://myhealthycommunity.dhss.delaware.gov/locations/state/days_to_show/90/primary_trend_type/bar#trends_dashboard

During this entire epidemic, several dozen children in our practice have tested positive for COVID-19. In almost all cases, the family has known exactly who they caught it from, and the nature of the direct exposure.  Generally, the exposure is indoors, and prolonged.  We have not yet seen kids become infected from casual exposure, in parks, stores, or even day care.  Other pediatricians in our area report similar experiences.

This means that, in our community, we seem to be doing a good job so far of using masks, hand washing, and social distancing.  These protective measures clearly help us protect ourselves, and protect each other.

But epidemiologists believe that over 80% of our American population is still susceptible.  The CDC reported in September that less than 10% of Americans have positive antibodies on a blood test.  Even now, 8 months in, we have a long way to go before we see protection from “herd immunity.”

Eventually, I expect over the next couple of years that most of the population will contract the virus and develop immunity (or eventually get a vaccine), just as most of us have had “mono” and other childhood illnesses. But kids will not be vaccinated for quite a while, because the vaccines under development are being tested only in adults so far.

However, we’re seeing kids with ordinary illnesses every day!  Even though everyone is trying to isolate, kids are still getting ordinary respiratory and intestinal viruses (though less frequently than usual).  Most of our patients with fever still have an illness other than Coronavirus.  (So please get your flu shots!)

 

How is it transmitted?

Most epidemiologic evidence is still that most people contract COVID-19 from a direct, indoor, person-to-person exposure with a sick contact.  There probably is also some spread from asymptomatic (or “pre-symptomatic”) people, but even then, the exposure is generally an in-person, close personal contact from relatively heavy “respiratory droplets” that rarely travel more than 6 feet.  This is why mandating masks and social distancing, even among friends and family, has been so effective in controlling the spread of disease.

There has been much scientific debate about “aerosol” transmission of COVID-19 by smaller, lighter particles.  The CDC is now acknowledging that it is possible, generally in closed spaces with poor ventilation.  The evidence for this continues to be mostly theoretical, tracking RNA “signatures” rather than documented illness; there are very few reported cases of transmission of actual illness from small droplets, hanging in the air long after a contagious person has left the room.  Wearing masks greatly reduces infection rates.

It is also theoretically possible to pick up the virus RNA from “fomites:” objects in public places such as door handles, that contagious people might have left their handprints on.  Again, there are very few if any cases of documented transmission of COVID-19 this way.  It’s easy and reasonable to use hand sanitizer when you leave a store or gas station (and don’t touch your face while you’re there!).  And you should wash your hands frequently when you return home.  But I really hope people will soon stop disinfecting their groceries and quarantining their mail.

 

How do I know if my child has Coronavirus?

We can arrange for any patient to be tested for COVID-19, regardless of symptoms, if the family is concerned.  I am generally not encouraging patients without a known exposure to get tested unless they have significant symptoms:

  • Fever for a couple of days,

    Looking unusually ill (more than expected from a usual viral fever),

  • Cough and sore throat, or

  • Direct, personal exposure to a person who is test-positive for COVID-19.

Profuse runny nose is not typical of COVID-19 symptoms.  Most of my patients with fever and cough have had flu, strep, ear infections, or another upper respiratory illness. In our practice, we have still not seen any patients with the Kawasaki-like “multi-system inflammatory syndrome” that’s been reported in children, although there have been a few reported at DuPont Hospital.  But many have been young children and infants with exposure but no symptoms at all, and they are probably just as contagious as older, sicker patients.

 

What testing is available?

PCR testing is available, if symptoms warrant and with an order from us.  Christiana Hospital can perform testing at their facility.  The patient must make an appointment, and bring our signed order for the test.  Also, without a doctor’s order, anyone can get a free test through the State of Delaware; see our website DMPKids.com for details.  Medical Aid Units are doing testing with various technologies; they may charge for the service.

Rapid antigen tests, which give results in less than an hour, are now available on a limited basis in my office.  They are less sensitive than PCR tests, and the CDC recommends that a negative rapid-antigen test should be followed with a PCR test if there is a reasonable suspicion of exposure or illness.  But our experience has been that they are reasonably accurate.

False-negative tests do occur, with all testing types.

Antibody tests on a blood sample can be drawn at a commercial lab such as Quest or Labcorp.  A positive test implies a prior infection, at least 2 weeks ago.  The antibody test may turn negative 2-3 months after a documented infection, unlike tests for most viral infections such as Chicken Pox.   I have not generally been ordering COVID-19 antibody tests for patients.

 

When must we quarantine or isolate?

The distinction is a bit soft, but generally “quarantine” means that if you are exposed, you must stay home (or outdoors well away from others).  “Isolate” means that if you are sick, you must also try to stay away from uninfected household members as well.

If you are exposed to a known case of COVID-19, generally you must still “quarantine” for 14 days from the exposure.  However, new advice from the CDC says that if you quarantine for 7 days (from the LAST exposure to a known case), remain asymptomatic, and THEN get a test, you may stop quarantine early if your test is negative.  (Unfortunately, if a household member has COVID-19, you must start counting your quarantine from the LAST day of the family member’s isolation period.)

If you have COVID-19 yourself, you must “isolate” from uninfected people for at least 10 days, counting from the day of your positive test (or the first day of symptoms, whichever is earlier).  After 10 days, if you are still feeling ill, you should continue to quarantine until you are feeling better, unless cleared by a doctor.

Repeat testing afterwards is generally not recommended.  The CDC specifically recommends against repeat testing as a condition of returning to work or school, unless recommended by a physician.  PCR tests can remain positive long after you are no longer contagious; so your return to work or school would be delayed unnecessarily.

 

Isn’t this all just “media hype”?

You bet – and a darned good thing, too!  In this pandemic, we must count on responsible newspapers and other traditional news outlets to alert the public, to keep each other safe.  Journalists are reporting verified facts, as accurately as possible.

And the facts are concerning.  Infection rates in the USA are far higher than other developed countries; and our numbers are rising, while other developed countries are better at controlling the virus.  COVID-19 is now a leading cause of death in the United States, perhaps the leading cause of death, as reported in JAMA in December.

However, many hoaxes are being spread on the internet, designed to intentionally confuse our trust in scientific reports about the spread and danger of COVID-19. 

  • It is not true that hospitals are paid to over-diagnose COVID-19.

  • It is not true that falsely positive reports are being generated on people who never were tested.

  • Wearing a proper mask is not dangerous for any person, regardless of their youth, age or health, and does not make you sicker.Even babies can wear them safely.

  • The virus’s existence, or its reported spread or lethality, is not a hoax being spread for political purposes.

  • The virus did not stem from a military operation in the U.S., China, or any other country’s labs, accidentally or intentionally.

  • Coronavirus is not going away, or becoming less serious or less lethal.Case numbers are rising, not falling.We are, unfortunately, very far from “rounding the corner.”

  • “Natural herd immunity,” encouraging everyone to mingle without wearing masks or restricting activity, is neither safe nor effective for our public safety.(Sweden tried it, but recognized their mistake quickly when cases rose dramatically.)

  • Hydroxychloroquine, Azithromycin, and Ivermectin have no scientific support for treatment of COVID-19.

Please stay informed by getting your news from reputable newspapers and TV.  Try to distinguish between fact and opinion.  Be wary of home remedies and conspiracy theories.  Do NOT rely on FaceBook!  If what you read sounds crazy, it’s probably wrong.

 

What about masks?

Who?  Everybody should wear a mask if they can, no matter the age.  Even babies and young children can safely wear a mask, if they will cooperate.  Wearing a mask is not dangerous, does not cause breathing problems, and does not make Coronavirus somehow worse.  (Though nobody enjoys them!)

What kind?  Anything that fits tightly, and keeps air from escaping out the sides.  The mask must cover the nose, as well as the mouth.  Don’t use masks with valves that allow easy air escape; they won’t protect people around you.  Beards make masks less effective (sorry, fellows) because the mask can’t fit tightly.  “Gaiters” seem to work fine, if they prevent air escape and have at least two layers.

What material?  Cloth masks are fine for general public use, if the material is a tight weave; double or even triple layers work much better.

Masks with gaskets or pop-off valves are NOT suitable and should not be used in public.  They protect the wearer, but because exhaled air is not filtered through the valve, they do not protect the people around you.  Please wear masks without a gasket, unless it has a separate filter.

In our office, we want to protect you, and protect ourselves.  So our staff uses only N-95 masks (or similar) and eye protection while seeing patients.

Remember that masks are not just to protect you from contagion, but also to protect others from catching something from you!  Wearing a mask is a public courtesy, even if you don’t feel sick yourself.

 

When is the COVID-19 vaccine coming?  When will “this” be over?

We all hope that widespread use of an effective vaccine will cause “herd immunity” to protect us all.  But the release of the first vaccine is only “the beginning, not the end.”  I expect that we will all be wearing masks for quite a while, well after next summer.

The Pfizer and Moderna vaccines have both been given “Emergency Use Authorization (EUA).”  (This is different from “FDA approval”, which is a higher bar and will probably take months.  But an EUA allows manufacture and use now.)

Neither vaccine has been approved for children under 16.  (The Moderna vaccine, which we are more likely to stock, is approved only for adults 18 and older.)  Drug companies have started testing their vaccines on kids 12 and older, but results have not been announced.  Testing in kids under 12 has only just begun.  It might happen that schools may still not be able to open normally in Fall 2021!

At the moment, though, COVID-19 vaccination for children is a moot point.  Vaccine doses are in short enough supply that only a fraction of "front-line" workers will be able to receive the two-dose series anytime soon.  So children would, understandably, be at the "back of the line" for vaccines anyway, for now.

Both vaccines have been extensively tested, and appear generally quite safe and effective.  Some people are concerned that vaccine development was rushed, or politicized.  But all the pharmaceutical companies appear to have been very careful and scientific, and deliberate in developing their vaccines.  Missteps have been few, not major, and quickly and cautiously addressed.  Usually, vaccines are not a big source of profit for drug companies, so R&D is budgeted over many years.    But for the COVID-19 vaccines, the rapid development has generally been propelled by massive funding (and the sense of urgency), not because of politics. These are new medications, of course, and we will certainly learn more as they are given to millions of people (instead of 45,000 people in the initial studies).  Personally, I will be eager to get a COVID-19 vaccine whenever it is offered to me.

Keep in mind that the vaccines have been tested and shown to prevent illness, but we don’t (yet) know that they prevent contagiousness.  Vaccination might reduce the length and severity of becoming sick, but we don’t yet know that a vaccinated person who picks up the virus might still be contagious to others, even if their symptoms are minimal.  So, vaccinated people still must wear masks, social-distance, and wash hands just as before.

Vaccination does not seem to cause false-positive tests afterwards.  We can still rely on testing.

 

What should I tell my child?

Kids may pick up on everybody’s anxiety.  Emphasize that your family has control over your risk, and that hygiene (including universal masks) and social distancing is effective.

It can be helpful to review as a family the positive actions you’re taking, to give everybody a sense of control.  Be a role model:  “Here are the actions we’re all taking to stay safe!”

Reassure kids that children are unlikely to suffer major complications.  But also point out that kids have a responsibility to protect the people they love around them, just as the adults do, by avoiding unnecessary contact and practicing good hygiene.  Kids under 12 seem less likely to catch COVID-19, but they can get it, and they can become quite sick; they have a responsibility to take precautions.  Teens are just as likely as adults to catch and be contagious for COVID-19; it’s dismaying to see teens in public not wearing masks or social-distancing.

Teach the kids good handwashing and sanitizer use.  Practice with them, and teach by example.  Have them search for lots of good kids’ videos that demonstrate hand washing or sanitizing.  (And let me know if they find good ones – I’ll publish them!)

 

What to do with schoolkids at home?

  • Encourage the kids to play outside, even if the weather is bad.Make sure everybody gets regular exercise!

  • Make sure everybody goes to bed on time.Try setting a bedtime alarm, especially for teens.Sleep deprivation will cause behavior problems, and it may also hinder their immune system.

  • Make plans to fight social isolation every day and every week.The whole family can talk to friends or older relatives using FaceTime, Zoom or Skype, or just a phone call (good for both of them!)

  • Schedule a time every day to do an activity with your kids (not watching TV).The kids will look forward to it, if they know what time they’ll have your undivided attention.Try making “family game time” part of your daily schedule.

  • It’s more important than ever to limit recreational screen time.Passive screen time such as watching shows, video games and social media should still be limited to 1 or 2 hours per day.But note that schoolwork on the computer is “free.”So is social time, talking with family and friends by video chat, or even by text; kids can talk with their friends and family as much as they want.

  • I do not recommend that kids with common medical conditions, such as controlled asthma or recurrent allergies, be specially restricted from an in-school environment.

 

What is Delaware Modern Pediatrics doing?

  • We are continuing to provide all routine sick and well care.We have not restricted our hours, since the beginning of the Pandemic.

  • Our office has dedicated Sick and Well waiting rooms; please make use of them!Chairs are placed a “socially distanced” 6 feet apart. All visitors, including accompanying parents and family, must have their temperature measured on arrival.All patients are taken back to an isolated exam room as soon as they are checked in.

  • We have sequestered all our toys (so bring your own). We are diligently disinfecting exam rooms and surfaces between patients.

  • Our staff is wearing protective equipment for all patient encounters.We’re checking our own temperatures every day, and sick staff members are sent home immediately (with sick pay).

  • If there is a reasonable (even if low) suspicion that your child might have a mild case of COVID-19, we may arrange to bring you in at the end of the day.

  • In certain circumstances, we may make use of Telemedicine encounters.

 

How can parents help us?

  • If your child is sick, please call our office first – NOT Urgent Care or the Emergency Room.Usually we can schedule an appointment the same day, if you call us in the morning. Go to the ER only if you think your child is so sick that they may require hospitalization, or if you know that your sick child has a known COVID-19 exposure.

  • If you have an appointment with us but you can’t make it, PLEASE call to reschedule as soon as you know!No-shows make it harder for us to care for everybody.

  • If you’re coming for a routine checkup, but the child has any fever or upper respiratory symptoms, please come to the Sick waiting room, not the Well side – and call us first to let us know.

  • Please do NOT avoid coming to our office for regular care!  We are taking all precautions to keep your family (and ourselves) safe.  You are much safer in our office than, say, in the grocery store!   But deferring infant vaccines simply puts them at risk for epidemics of measles, meningitis and pneumonia.

 

What if I have more questions?

Call us!  We’re working hard, and we’re ready to help you.  Thanks for your confidence in us.

     --  Dr. Epstein