The Re-Opening

What day is it? It’s definitely Friday, but Day Fifty Something for Lees on Lockdown. At this point most of us are well past the biblical 40 days of temptation and testing, but I think we’re collectively doing all right. From my screens, I see people reaching out to help those struggling mentally, financially, and spiritually. Our Steps to Success fundraiser could only be held via email blasts and status updating, but somehow raised more money for low-income students than we thought possible. Those who know how are sewing masks; those that don’t are buying them and delivering. Free meals, sidewalk chalk encouragements, Teddy Bear hunts, crooning from city balconies, family dinners, and Lisa on YouTube. This is the good stuff.

I’ve let loose only two primal screams of rage that were mostly directed at teenage boys WHO HAVE ONLY ONE JOB SO GET OUT OF BED ALREADY OMG WHY ARE YOU ASLEEP, but otherwise we’re safe and home and healthy, if also drinking far too much. One night after salivating over episodes of Salt Fat Acid Heat, I looked at our sleepy puppy and suggested to Bernie that we call it a night. It was 9:30. NINE-THIRTY. We hadn’t even finished the Pinot Gris.

Like all of you, I feel like I should be accomplishing stuff with all of this time. In addition to actual work that needs doing (65 manuscripts in the queue), maybe I should be learning to knit? Shredding old tax returns? Teaching Hero useless tricks? Shaping my eyebrows? Something. Instead, this cartoon pretty much sums up every day:

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H/T to Tom Fraatz for posting this from @instachaaz

Zealot Sister lives in Georgia, so we’ve traded thoughts about the safety of doing the things their governor is letting them do. She has no plans for urgently overdue tattooing (wtf), but is going to brave the world and odds to attend to her grays and nails. Is that bonkers?

Probably not. Her county isn’t a hotbed of positive cases. But then again, they haven’t tested everyone, so who can say? With strict hygiene and mask compliance, could it be safe? Safe enough? Honestly, I don’t know. But we’re Americans and not typically great at rule-following when doing so feels like an affront to our personal liberty—or even just makes our glasses fog up. Really, we’re gonna be the worst at this re-opening thing.

Here’s what I do know: as the country starts allowing us to eat together and permanently ink each other–either in a stepwise sort of scientific way or as a recklessly impatient public experiment– my phone is going to blow up the same way it did when the WHO finally said “pandemic.” I’m happy to be your go-to non-practicing physician and immunologist, but at the beginning, I had more answers. Now, nothing seems certain. And as a scientist, when nothing seems certain, it is because we don’t have data.

The smartest people are offering models and recommendations that seem to change daily, but they are still guessing at how many of us have been exposed. The R naught, or coefficient of infectivity—essentially how contagious a virus is—was originally estimated between 2 and 3 for COVID-19. Newer data suggests it could be twice that. And if asymptomatic virus-shedders getting their gel tips and lowlights can infect 5-6 people, a second spike bigger than the first might be inevitable. An R naught over 5 also means we need to wait until over 85% of us have “beaten” coronavirus before we can spring the kids from Zoom School and back to square pizza Fridays in a brick and mortar way in the name of “herd immunity.”

Are we willing to risk the morbidity and mortality of thousands more to achieve this? Or should we suffer this no-end-in-sight life without dine-in restaurants, grandma hugs, or Sox games until a vaccine or miracle treatment is widely available? More importantly than when this ends is how.

Most of us are itching for sero-positive proof as a Get out of Jail Free Card to get back to a pre-COVID-19 existence, and a quick and widely available antibody test will give us a clearer picture of where we stand immunologically. But it won’t be the panacea we crave. Most if not all tests that have been authorized for use are only allowable through the Emergency Use Authorization (EUA) pathway. Doesn’t mean they are bad tests. They’re just tests that haven’t been… tested. And as a result there could be a significant number of false positives because coronaviruses are as common as, well, The Common Cold. There can also be a significant number of false negatives because your plasma cells pooped from combating COVID-19 have stopped making IgG because your memory B cells can always pump out antibody later, if needed.

Do you wanna know how these tests work? You can Google ELISA or trust me when I tell you that they slather a shmear of COVID-19 surface protein onto the bottom of a teeny plastic well and test if your blood is carrying antibodies that stick to it. Some identify IgM antibodies—the first ones your body uses to fight disease—suggesting a more recent response to an exposure. Others detect IgG antibodies—made by B cells that “learned” a bit more about the invader, and indicate a later or resolved infection. Some tests can detect both. But the antibody to the shmear doesn’t prove that they actually neutralize the COVID-19 you transferred from the grocery cart to your nose. The test doesn’t mean your antibodies are effective warriors, it just means they stick to the COVID-19 protein shmear.

What will an antibody test tell us and how can it shape our path forward? It will give scientists more data, but only as much as a stack of Polaroids from the table centerpieces will tell you about how great the wedding was. The IgG assay is only a snapshot. To wit, if we tested everybody right now, we’d likely find that far fewer than 85% of us have mounted an IgG immune response to COVID-19. Herd immunity is likely many months (and deaths) away. What is the power of your personal IgG positive test? Scientifically, not much other than proof that you were exposed. Also, your laminated IgG+ CoronaCardTM might not protect you from a newer, mutated version of the virus… and we have no idea if or when a COVID-20 will emerge.

SO WHAT CAN WE DO? I think the only way forward is to learn from countries that take personal hygiene (mask-wearing, hand-washing, forbidden handshaking and double kissing) seriously. We can dramatically reduce transmission if we maintain the 2-meter rule as much as possible, wear masks, and act like reasonable people in the midst of a pandemic. It won’t be forever… just until we have more data, a treatment, a vaccine, or herd immunity. As the country opens up, we’ll move about in different ways that protect others and ourselves, and I hope we’ll be patient and kind as everyone gets on board. Seven weeks ago I could meet you bare-faced at Starbucks, kiss you hello, catch a late movie, or watch the Celtics with thousands of fans. We’ll get there again. Just not tomorrow or because your governor said you can. Slowly, surely, with caution, common sense… and a mask.

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Buying these from Remy supports #Masks4Meals, providing food for caregivers at Mass General… and they’re wicked cute.

Coronavirus 101

Jason started feeling sick. Not “COVID-19 sick” he wrote, but definitely sick. Though his presenting symptoms were not the classic myalgia/sore throat/cough, I told him what I’m telling everybody:

Assume it’s COVID-19.

Don’t Panic, is the first and hardest instruction to follow. But yesterday Jason earned an A+ in Coronavirus 101: What To Do When You Get Sick During a Pandemic. Jason realized he did not need medical attention, and stayed home. Jason knew COVID-19 testing was not necessary because even if he tested positive, there are no medicines to treat coronavirus (though new ones are being tested in a controlled, scientific way)… so he stayed home. Also, Jason’s COVID-19 status wouldn’t alter his behavior because he was already self-isolating, by staying home.

Social media is bursting with criticism: “I went to/called the doctor with xyz symptoms and risky exposures, AND THEY REFUSED TO TEST ME.” Angry, scared, and looking for people to blame, test-seekers are also unwittingly lowering the confidence we need to have AND SHOULD HAVE in our front line medical staff. And while they are out in the world attempting to tap limited resources unnecessarily, they’re potentially spreading COVID-19 or other pathogens. I’m going to repeat this a million times:

COVID-19 TESTING IS NOT MEDICAL CARE.

And this:

If you aren’t sick enough to consult a doctor or need the ER, you need to stay home.

This is Day 8 for Lees on Lockdown. We’re not protecting ourselves so much as shielding other people. Bernie was in and out of the hospital until Monday, so we’re assuming all four of us have been exposed and could be shedding virus with no symptoms. Does this mean after 2 weeks of isolation we can start sneaking in short visits with people who promise they have been at home, where no one is symptomatic, and everyone promises to wash their hands?

No. Nope. Not yet. No.

The most common text message in my phone right now is asking how long will this go on. And friends, there are no answers for this. We only have mathematical models, daunting statistics, and sobering graphs from experts who predict a more immediate crisis before any possibility of returning to a world where there is lots of toilet paper. But China reported no new local cases yesterday, and I’m clinging to that. Can you envision a cascade of mini celebrations as each city in the US begins reporting 14 straight days with zero positive tests? We’ll get there.

If you stay home.

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This t-shirt exists, and I want it.

A message for young people: quit it, and stay home

Dear Young People,

If you don’t kill us with your refusal to adhere to social distancing, we’ll all be hen-pecked to death by your annoying insistence on meeting up with friends. So quit it, and stay home.

The messaging that COVID-19 is less lethal to your age group–which is true, thank God– is being translated by some in your age group as “we won’t get it,” which is really really really untrue. Instead, because you have already been everywhere (school and sports and Starbucks) and with everybody (ditto) you’re carrying a risk of having contracted COVID-19 that is not zero. People your age are also more likely to walk around shedding virus while having no symptoms at all.

Some of you have become armchair epidemiologists and are manufacturing relative risk estimates based on positive COVID-19 reports in your area. Whatever you are guessing, you’re wrong. We aren’t testing enough people to know what the community penetrance is. Even if you arrived at the hospital right now and with the classic presentation (body aches, fever, cough, and fatigue), they wouldn’t test you for COVID-19 unless you were sick enough to be admitted. And though very few of you will get that sick, some of you will. Instead, you’re more likely to infect 2-4 people (that’s the R naught) every time you insist on going over to Emma’s.

Also, I don’t care what Emma’s family is allowing. Social distancing means you stay home. And if you have to go out–and let’s be honest, you don’t– you stay 6 feet away from other people. We’re also not buying your “I’ll go to the grocery for you” or “just gonna run up to Panera for a sandwich.” Children, please.

On Wednesday, I gave a COVID-19 overview to high school seniors who told me they hadn’t gotten much more information than, “wash your hands.” On Wednesday, which was just 72 hours ago, they didn’t entirely believe me when I told them schools would be canceled by the next day. I showed them graphs that prove how contagious COVID-19 is, and said out loud what no one is telling you: some of your grandparents will die if we do not slow its spread. You know what those kids aren’t doing now? They aren’t asking to go over to Emma’s.

Things might get grim, but right now you have an opportunity to help save lives by doing something you already love to do: stay home and play with your phone. Make some TikToks. Learn how to skateboard or practice your three-pointer. And armed with science (R naught! Homeschooling done for the day!), you can be an ambassador for public health just by telling your friends you’re not meeting up with them at Shake Shack.

Tell them to quit it, and stay home.

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Remember summertime when you didn’t know who these guys were? They are the definition of VIRAL. Related: the Hype House needs to be shut down. #socialdistancing

So you think you have coronavirus…

In a day or two, nearly all of us will have a version of this story, and this is just one example of many that I’ve gotten within the last 12 hours:

So, my wife went to Starbucks with Beka yesterday… and Beka called this morning to say she has a fever and there is a woman in Beka’s lab who is self-quarantined because her husband was in Spain for a conference in February and he’s sick. Should I be worried?

By St. Patrick’s Day, this story will be met with, “She went to STARBUCKS?” incredulity. But right now, and in the next couple of days, all of us will have a similar risk to assess as the friend of a friend of a friend that was exposed gets closer. Here is my take home message if you read no further: you are most likely going to be absolutely ok.

I write about COVID-19 yet again because my phone is on fire, because the high schoolers I spoke to yesterday were absolutely starving for information, and because you guys are reading and sharing. Many of you are leaders of organizations in your own spheres and I APPLAUD YOU for taking action early to cancel events that put us within 6 feet of each other. Your caution is helping to #flattenthecurve and will ultimately conserve resources if not save lives. By now you’ve seen that awesome graphic showing how even if we don’t prevent a single infection, by merely stretching out the rate at which that happens, fewer people die.

Here around Boston, schools are beginning to close. Unfortunately, not all of them yet, but let’s try to be kind while everyone gets on the same page. There is so much conflicting information circulating, new and alarming data hourly, and our own very human fear and skepticism to overcome. By now, I hope most of us are being mindful of how risky that Starbucks stop could be, but even the most vigilant of us will have a “Beka story” soon.

So you think you could have coronavirus… what do you do? Here is what the large medical centers are recommending right now:

Don’t panic. 80% of infected patients experience a mild or moderate course that requires NO medical treatment.

If you have no symptoms, there is nothing to do but self-isolate. Most people show symptoms within 5 days, but during that “incubation period,” if you have been infected, you are contagious even though you feel fine. THIS IS WHY WE’RE CANCELING EVERYTHING RIGHT NOW. If you think your exposure is especially risky (e.g., your college student home from abroad is feverish and coughing) you have an even bigger responsibility to self-isolate. Some patients have not reported symptoms for up to 2 weeks, which is why these “mandatory quarantines” are for 14 days.

IF YOU GET SYMPTOMS, COVID-19 looks like this: tickly throat progressing to sore throat, low grade fever, body aches, and all of those things that make you say, “ugh, I’m definitely coming down with something.” Abdominal pain, diarrhea, nausea, and vomiting are also being reported. Sneezing, runny nose, and postnasal drip is NOT how COVID-19 presents.

IF YOU HAVE COVID-19, symptoms could escalate to a persistent, dry cough and high fever. Testing kits are still not universally available and providers are hamstrung by strict criteria that indicate their use. But you don’t need it. You can call any number of hotlines if you have questions, but remember that 80% of the time, COVID-19 will run its course and you will get better within two weeks. The recommendation is that you STAY HOME and treat with Tylenol, lots of fluid and rest, hot showers to help with cough, and limiting contact with housemates. That last bit will, obviously, be difficult.

YOU NEED TO GO TO THE DOCTOR IF… you have shortness of breath and feel like you are worsening to point of needing care, and/or you are over 60, and/or you have co-morbidities like diabetes, heart disease, or are immunosuppressed. Those with risk factors should set a low bar for seeking medical attention if symptoms are consistent with COVID-19 infection. Our Taiwanese friends have offered this simple test: if you are sick and cannot take a deep breath and hold it for 10 seconds, you need to seek medical attention immediately. (NOTE: if this “breath test” is easy for you, it does NOT mean you are negative for coronavirus.)

If you have decided you need to go to the doctor, CALL AHEAD. The instructions for how each center is handling presumed COVID-19 infections are changing daily. In public, you should wear a mask (or get one as soon as you get there).

And now I leave you with a hopeful message from J.P. Hong, our dear friend from the Asan Medical Center in Korea… and the future:

“First comes denial and then confusion and then you will see so much rapid change and development in the next few days…. it will be incredible how we adapt…. and hopefully see the better side of humanity as doctors volunteer and various innovations occur to fight the virus.”

Those who have bravely canceled events and schools and gatherings are past denial, but most of us are still muddling through the confusion. I hope these guidelines help as all of us inevitably acquire our own Beka Stories.

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