Covid Update for Travelers

I have always been a kind of bottom-line kind of guy.  So here it is, despite any and all precautions anyone takes, every human being on the face of the earth will catch Covid-19.  It is just a matter of time.  That is the bad news.  The good news is that for 99.9% of those who are fully vaccinated with boosters, at least one, and preferably two, you will have a mild illness not requiring any medical care and you will not die from the disease.  Clark and I just returned from 2 weeks in Canada and despite wearing a mask, taking Vitamin D, wearing a negative ion generator, etc., etc. we still caught the damn thing.  But, no fever, no breathing problem, just a very mild cold with a mild cough, running nose, and sore throat for about 3 days.  A nonevent.  To date Covid is one of the most contagious and transmittable viruses ever known to man.  Remember this during the 1918 Spanish Flu pandemic people living in the Mariannis island in the South Pacific all caught Spanish Flu and 1/2 of the population died.  This occured even though they never had any visitors.  Not one ship or airplane landed and despite no contact with the outside world they all got it anyway.  The reason's the mandates for masks for example have not worked is they only have a chance of working if 100% of the population wears a mask 100% of the time and does NOT remove it to eat or drink which is basically impossible.  In addition have you ever tried to get 100% of human beings to do anything??  Just look at China who with their draconian totalitarian system have again completely locked down Shanghai and yet the virus is still spreading there.  I doubt anyone knows why you cannot stop the spread of Covid.  I suspect the wind, birds, whatever help it spead.  The bottom line is I truly believe most humans will eventually catch it.  BUT!  If you have your shots and booster the evidence is clear, your symptoms should be mild and you should not die.  Elderly folks with mutiple high risk factors will still have some risk of hospitalization and death.  Colin Powell is a good example here.  He had all his shots and boosters, but still he caught Covid and died from it.  But he was under active treatement for not one but two cancers so the deck was stacked against him no matter what.  Don't forget every year in America 50,000 die in car accidents and 35 people die yearly falling out of bed and breaking their neck.  Life is a risk factor.  All we can do is mitigate and reduce the risk which we can do with Covid by getting all shots and boosters.

It also needs to be noted that the current requirement of the US Government to reenter the USA from abroad requires a negative COVID test exactly 24 hours prior to the exact departure time of your flight, or if the test is positive a letter from a licensed physician that you had an active COVID infection and have recovered and are safe to travel.  It is somewhat difficult to accomplish this.  All COVID testing sites are not always obvious.  The ones we found all required appointments and prepayment with no provision for walk in's.  Their appointment times where usually 9 to 5 and not conveinent to match your flight times, and resulted in having delays getting an appointment that in our case at least caused us to miss our flights.  One example that can impact you is your flight is delayed a couple of hours and your COVID test is now over 24 hours from the new flight time and you have to go through the entire process again with no guarantee you can get an appointment and result in time.  For us it was a nightmare.  Be sure and consider all of this and have a back up plan in place just in case.  We also had trouble finding a hotel room last minute for even a day or two until we could get everthing fixed.

Protection from Covid, Cancer, and other Infections using Vitamin D, Zinc, and Magnesium

When I started practice in 1981 within a short time frame I started recommending to my patients take a daily supplement that had Calcium(Ca), Magnesium(Mg), and Zinc(Zn) along with me and my family. That combination was readily available at drug stores and I remember researching it because I found it strange that they were selling that particular combination? I wondered why? Why not take a pill with Chromium, Manganese, and Chloride for example. Who came up with the idea for that combination? What I discovered was there were hundreds of well-done research articles in the medical literature going back decades that clearly demonstrated that those 2 of those minerals boosted your immune system and for most of us that is a good thing. It was felt the Ca was needed for bone health. A few years later I discovered the benefits of Vitamin D again in regards to bone health as well as being demonstrated to cut the number of falls in a nursing home by ½. Back then there was not a lot of information or consensus as to what the correct or best dose might be as well as the concern it might be different for men and women. The Government had their recommended daily allowance(RDA) so that is what we went with for the time. I should mention that other than pregnant or menopausal women and children and adolescents I generally do not recommend Calcium supplementation as our diet provides what we need and I rarely see a low calcium level on blood work, in fact, more often than not the calcium levels are high. In addition where I live in South Georgia and Northeast Florida, we are known as the Kidney Stone capital of the world in that our water supply and groundwater is high in calcium leading to an increased incidence of kidney stones here.

Covid has focused a lot of research over the past 2 years and as they told us in medical school the exam questions never change but the answers do. We now know that we have been taking too little of those supplements and we now have a better idea as to what the correct therapeutic window is. What is a therapeutic window you ask? Each drug and/or supplement has a therapeutic window which is the minimum dose/concentration in your bloodstream where the substance actually effectively does what it is supposed to and the maximum dose/concentration in your bloodstream where the substance is toxic or poisonous to you. Good examples here are Tylenol and Aspirin. In general two(2) pills twice a day works fine and does the job. A bottle full(actually in Tylenol’s case over 6 extra-strength tablets a day) can cause organ damage and even death. This is important as in the case of zinc the therapeutic window is narrow. The articles cited, the most recent from Israel this past week, clearly document that zinc supplementation daily provides a significant boost to your immunity and can present Covid, cancer, and other infections. But the dose is 25 mg a day and no more. When you buy it at the drug store they sell it at 50 mg a pill and that is too high and can cause harm. So you must break the pill in half to take it and I don’t think they tell you that on the bottle as they obviously want you to buy more. But you can’t. Stick with the 25 mg once a day and you will do fine. Have your doctor check your serum blood level of zinc a couple times a year. You want the result to be around 1 mcg/ml. My recent level was 0.92 mcg/ml which is close enough. Labs report normal at 0.66 to 1.10 mcg/ml.

We now know Vitamin D is more critical than we previously knew to support the immune system and the highest death rates from Covid were in patients with Vitamin D levels under 25 ng/dl but labs today still report normal as 20 ng/dl to 40 ng/dl. Trust me you want your Vitamin D level above 40 ng/dl and my family is now consistently above 60 ng/dl which I believe we all should be. To get that level you need to take 4000 IU a day, not the recommended dose of 1000 to 2000 which is ½ what you should take. Another way to do it is take a 50,000 pill 3 or 4 times a month and again follow with measuring your serum levels. In general Vitamin D has a large or substantial therapeutic window so it is hard to overdose on Vitamin D and super high doses at least over short periods of time don’t hurt you. The best example here is a study done in Norway where they gave people 2 million IU of Vitamin D at one time once a year and followed them. There was no harm but it didn’t work and it didn’t boost the immune system. This means it is important to take Vitamin D on a regular basis to get the benefit. Trust me taking one pill a year is very appealing as opposed to having to take one a day. No one likes taking pills every day but if it doesn’t work it is what it is.

In the list of articles to check out we now know Magnesium is important for immune health. There are multiple formulations of Magnesium in Chloride, Citrate, Oxide, and other forms. In general, Chloride and Citrate have fewer side effects. Currently, the proper dose seems to be 400 mg a day and you want your level to be 1.7 mg/dl to 2.2 mg/dl with above 2.4 mg/dl considered too high, so again what we would consider a narrow therapeutic window. Also taking too much will cause diarrhea. That is why Milk of Magnesia treats constipation.

The bottom line is we know unequivocally that Vitamin D 4000 IU a day, Zinc 25 mg a day, and Magnesium 400 mg a day for most people significantly boosts their immunity and reduces the chance and incidence of many infections, especially Covid, and in the long run prevent many cancers. My family currently takes all three as described. If you are into the research minutia I have links below to some current articles that support the above information.

https://www.saintlukeskc.org/about/news/new-research-suggests-magnesium-and-vitamin-d-can-help-reduce-covid-19-infections

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7861592/

https://www.naturalproductsinsider.com/ingredients/covid-study-finds-zinc-effective

https://www.frontiersin.org/articles/10.3389/fmed.2021.756707/full

https://www.timesofisrael.com/israeli-study-offers-strongest-proof-yet-of-vitamin-ds-power-to-fight-covid/

https://www.dailymail.co.uk/news/article-10477041/Does-Vitamin-D-work-Covid-Israeli-study-finds-nutrient-big-indicator-severity.html

https://www.businessinsider.com/study-identifies-link-between-vitamin-d-levels-and-covid-19-severity-2022-2

Wine Travel with Covid, Or Not!

So we are all bummed out right now as we felt compelled to cancel our upcoming trip to France to attend the Tastevin St. Vincents festival in Puligny Montrachet.  Despite having boosters after speaking and emailing plenty of friends and associates in France this is what we learned.  In order to enter France, you have to have some kind of negative Covid test no later than 24 hours before entry at the airport.  The problem is that gives you no wiggle room for delays or other issues that might delay your flight, not to mention dependent on your time schedule and flight schedule it might be near too impossible to meet that requirement.  After Customs and Immigration let you enter you then have to obtain a French Health Pass which requires another negative Covid test within 24 hours, your passport, and original vaccination cards.  The problem there is you can only obtain it at certain pharmacies and we were told as of today, just like the USA, it is impossible to get tests done and there are lines down the block at most pharmacies to get the tests done.  So it could be days or weeks before we could obtain the said pass.  We were told today that weeks ago museums, restaurants, etc. would accept your vaccination card but no more.  The French Government is now enforcing the law to the letter and levying heavy fines for anyone who they catch breaking the rules.  In addition, anything public including metro's, train's, supermarkets, you have to have the pass.  Murphy's law always applies to us so no question we got over there and would end up spending the next two weeks in a hotel despite being fully vaccinated and with that in mind we felt compelled to cancel.  So far everyone has refunded any advanced funds except the airlines which only offer a credit good for one year.  Bummer.  And to add insult to injury, Ireland announced today that they were lifting testing restrictions, and with only your vaccination cards you can come on over and go where you wish!  A complete 180-degree change from the Continent.  The problem with that is there are no Irish wines we want to buy right now.  So Covid continues to be a problem.  I wonder how much business France will lose because of this at the same time I understand the need to protect the public.  It is too simple and would take years to put in place but why not have a testing area on arrival at the airport that could do your test check your passport and vaccination cards and issue the health pass before you left the airport?  Too easy probably.  And if you think all of this is a problem be aware that before the end of the year the EU is instituting a new requirement to have a visa prior to entering that you will have to obtain online that from what I can tell is a security pass and similar to the USA Global Entry card that of course will require payment of a fee and good news is at least good for 3 years.  It won't change the length of time you can stay, which is 3 months, but you won't be able to enter without it.

Update on Covid-19 Immunization and Booster Protection

A picture is worth a thousand words. In this case, the number of nursing home residents out of 1000 infected and test positive with Covid based on vaccination status. Of interest, I have seen some recent data suggesting that the 2 shot immunization schedule is so good some infectious disease experts are questioning whether or not an additional booster is really needed. I believe this graph published in the paper today says it all. I assume we can all agree that nursing home residents are the older and sicker of us and living in a nursing home under close quarters would be assumed to spread infection faster than the general population. As the graph shows vaccinated residents have a significantly lower risk of active infection and residents with an additional booster shot have an almost nonexistent risk of infection. One can also assume the extensive reduction in risk of active infection will translate into lower hospitalization and death rates. The reduction is impressive. And to boot, this is over the past 2 months so the data is very recent. For myself and my family, we all have had or will get a booster.

I provide this information to my blog readers as an objective nonpartisan educational piece of the puzzle regarding the Covid-19 pandemic.  I believe the information and graph speak for themselves and answer an important question.  Of interest, I published this graph initially on our local community email group for the same reason.  Within 24 hours a nice gentleman of 84 years of age responded saying that he had had 3 Moderna shots but still tested positive for Covid.  I attempted to respond to him explaining that regrettably, he was THE 1 person out of 1000 the graph was referring to.  The problem with statistics is when there is one chance in 1000 and it happens to you it is 100% for you.  We buy lotto tickets with every expectation that the 1 chance in 14 million of winning will obviously be us and I am certain many who buy those tickets are equally outraged that 1 chance did not happen for them.  Of interest when I attempted to respond to this gentleman the site moderator had already locked any response to my post.  Of course, I cannot judge why and any judgment will be an assumption which I am loath to do anymore.  But it did get me to think in this regard.  Putting aside any discussion regarding the partisan nature of how we as a country are dealing with the pandemic in terms of masking and vaccinations one point to me becomes clearer.  I practiced medicine for over 40 years and was trained that preventative medicine was as or more important than waiting to treat after someone got sick.  For over 40 years I fought the battle advocating to my patients, the insurance companies, and the public at large that an ounce of prevention was worth a pound of cure at a much lower cost.  For all of those decades, I fought a losing battle.  No one wanted to hear it.  No one wanted to invest or pay for the future.  Everything was here and now.  Have a sore throat?  Give me a pill now so I can get on with my life.  Stop smoking, eat a healthier diet, exercise, etc.  I don't have time.  I'm too busy with other things.  Besides later sooner or later medicine will find a better and quick cure.  In Florida, the mantra of waiting until you get sick and then going to a monoclonal antibody center provided by the Governor if you feel sick is the same attitude we have had for decades.  Why waste time and money for prevention when all you need to do is wait until you get sick, assuming you get sick at all, and then there will be a "miracle" cure awaiting you so you can get on with your life.  Believe me, I wish that was how it is.  But the statistics clearly show that is not what is going to happen.  Yes, some treatments save lives, but the data clearly show prevention saves even more lives but we just don't see it because those people never get sick, and let's face it not getting sick is not sexy and doesn't generate any sympathy or newspaper headlines.  Trust me, the above graph is not a fluke, an ounce of prevention is worth a pound of cure but that prevention never once said it will prevent 100% of anything.  Prevention says it lowers the risk of you getting seriously ill and dying, but again not 100%.  Statins prevent and reduce heart attacks but not all of them.  Anticoagulants prevent and reduce stroke in patients with Atrial Fibrillation, but not all of them.  Seat belts save lives, but if your car flies off the Dames Point Bridge the seat belt will not save your life, in fact, it might cause you to die.  So with that in mind do you refuse to wear a seat belt or refuse to drive over any bridges?

Traveling with Covid-19

Having just returned from a trip to Montana it seems like a good time to address traveling risks associated with Covid-19.  Daily there is information put out by the media, some accurate, some not so much.  Who can you trust and what do you do to protect yourself and your family.  Clark and I traveled on American Airlines across the country, changing planes in Dallas going to the Triple Creek Ranch in Darby Montana outside Missoula, Montana airport.  In general, we felt safe and saw no overriding concerns.  There is no question it takes time to overcome ones phobia's and fears, and I am no different than anyone else.  Until I was 28 years old I had a phobia and fear of flying on an airplane.  My father was an aircrewman on a B-24 Liberator flying 30 combat missions over Nazi Germany and as a civilian had a private pilot's license.  When I was 6 years old he took to me to the St. Petersburg airport to fly on a demonstration flight.  I remember it like it was yesterday.  For some reason, I did not want to go and was afraid of the airplane and kicked and screamed until he took me home.  It haunted me for 22 years.  But as a scientist, I recognized that science and data and not perception should guide my decisions in life.  I went to Honolulu, Hawaii to do my internship in medicine for many reasons but one reason was to face down my fear of flying as the only way to get there was by plane.  To lessen my fears I flew first class and got fairly intoxicated on the way figuring if I was going to die might as well go happy and in style.  I enjoyed the trip immensely and now if a trip takes more than 4 hours in a car, I fly.  Today, even with its inconveniences I love to fly.  To me, it is a miracle to break the bonds of earth and soar in the heavens.  Even with the worst years and with the years that included terrorist attacks and 9/11 flying in a commercial airliner is one of the safest things you can do.  Driving in a car is one of the riskiest things you can do.  The majority of people killed in a car accident are 5 miles from home and going 45 MPH.  The chance of dying in a plane crash is in the millions.  Today with Covid, flying is in my opinion still safer.  Looking at the data since Covid the reported cases that were spread on an airplane occurred early in the pandemic before the airlines and the public started taking proper precautions.  Even then the number of cases transmitted was in the low hundreds compared to millions who flew on airplanes so the absolute risk was low even then.  Today as we speak the airlines have taken extreme precautions to prevent any transmission.  Everyone wears masks, filters on airplanes have been upgraded and changed frequently, boarding procedures are safer than before, so in general safety, protocols are working and in just the last month as an example, I have heard of no transmission of the virus on an airplane.  We have multiple friends who have traveled by airplane multiple times in the past month with no problems and no infections.  Clark and I for years now have disinfected our seats and area on a plane immediately when we get on.  We carry Clorox wipes and have been wiping everything down for years and to our knowledge never gotten sick from an airplane trip.  Even with the planes being spotless we still wiped everything down this trip to Montana.  Every passenger had a mask on and everyone seemed to watch out for everyone else.  I at least felt very safe, and again safer than if I was driving in a car.  At the airports, social distancing and masks were done as much as I could tell.  At our destination, the Triple Creek Ranch followed all protocols and we felt safe there.  So we have been home for a few days now, feel fine, felt safe on the trip, and will self-quarantine for at least a week at home.  The reality is that Covid is everywhere, at your home, and wherever you might choose to go.  It is spread with human to human contact through the air with coughing sneezing and talking.  Social distancing at least 6 feet and wearing a mask works.  Washing your hands' works.  If you and everyone around you are doing these things then your risk is less and mitigated.  It will not be 100% risk-free for a long time but nothing is 100% risk-free.  My opinion and comments for many years is if you don't like risk and don't want to take risks please don't get into a car and walk.  The reality is driving a car is one of the highest risk activities we do.  In my opinion, wearing a mask on an airplane is a lower risk than that so I am willing to travel under the current protocols and just did and so far so good.  I should also mention that the day before we left to drive back to the airport there was a huge blizzard that dumped one foot of snow covering the roads.  No one really saw it coming.  As a result, we had to drive down the twisty mountain and drive 80 miles back to the airport.  I assumed out west and in the past, the roads are quickly cleared.  Because this storm was not predicted we ended up driving 80 miles on top of approximately 2 inches of solid ice as the temperature dropped to 5 below zero and no they didn't clear the roads.  I know for sure driving 80 miles on top of fresh ice is the risky thing you could ever do.  Obviously, we did OK but it was an adventure.  We only spun out once.  

Updated Covid-19 Recommendations from CDC

 I have included update recommendations from the CDC issued today. We all need to fully comprehend that as each day passes we learn more and more about this virus. I am witnessing lots of people totally misunderstanding this virus and as a result, it is close to spreading out of control. I can assure you the following is accurate: 

1. COVID-19 is HIGHLY contagious and is being spread exponentially primarily by large crowds of people partying not social distancing and not wearing masks. Physicians are just as bad as the general population. This week close to 1/2 of the Anesthesia physicians in a hospital tested positive after an evening party in one of their homes. Talk about not leading by example. You continue to hear about the "R" value which is an indication of the AVERAGE number of people ONE person can infect. My estimation is that it eventually will be calculated at over 10. Seasonal flu is 1 or less. So COVID-19 to me is at least 10X more contagious than seasonal flu. The virus is contagious the first 14 days you have it, after 14 days for the most part people no longer spread it. That is normal and consistent with most viruses that are spread with the initial exposure and COVID-19 is no different from most viruses in that you are spreading them before you know you have them. Once you are sick, you generally no longer are infectious but even that is not 100% dependent on the virus. Ebola for example spreads from dead bodies days after death. 

2. The death rate for seasonal flu hovers around at about 0.2% of the population. As of yesterday the death rate for the USA as a whole was 7% and for Florida was 1.4%. So COVID-19's death rate even with the best-case scenario in Florida is 7X the seasonal flu. 

3. MASKS AND SOCIAL DISTANCING WORK PERIOD. There should be no discussion regarding this. I previously reported studies that said if only 60% of the population wore a mask in public and followed social distancing the virus would go away in weeks. In my opinion, if 100% of the public wore masks and conformed to social distancing the virus would be gone in two weeks. Italy for one has clearly proven it works. Yesterday there were only 5 deaths in Italy. Medical N95 masks are the best but truthfully any mask helps and is better than nothing. Masks, including N95, are now available online at reasonable costs. Seems like everyone is making them now. 

Updated CDC recommendations based on new data are here: 

Patients with confirmed SARS-CoV-2 infection DO NOT need to have two negative tests at least 24 hours apart to return to work, school, or receive medical care. CDC has reported that COVID-19 cases can continue to test positive for up to 12 weeks after their initial positive test, but that they are only potentially infectious to others for about 10 days. 

As such, for most individuals with COVID-19 illness, isolation can be discontinued 10 days after symptom onset and resolution of fever for at least 24 hours, without the use of fever-reducing medications, and with the improvement of symptoms (changed from "improvement in respiratory symptoms" to address expanding list of symptoms associated with COVID-19). 

The decision to discontinue isolation for patients with confirmed SARS-CoV-2 infection should be made using a symptom-based strategy, not additional testing: 

· Individuals who had a mild or moderate illness and are not severely immunocompromised can return to work after: 

o At least 10 days have passed since symptoms first appeared and 

o At least 24 hours have passed since last fever without the use of fever-reducing medications and 

o Symptoms (e.g., cough, shortness of breath) have improved 

· Individuals who had severe to critical illness or who are severely immunocompromised can return to work after: 

o At least 20 days have passed since symptoms first appeared 

o At least 24 hours have passed since last fever without the use of fever-reducing medications and 

o Symptoms (e.g., cough, shortness of breath) have improved 

Asymptomatic persons with confirmed COVID-19: 

· Who are not severely immunocompromised can return to work after 

o At least 10 days have passed since the positive laboratory test and the person remains asymptomatic 

· Who are severely immunocompromised can return to work after 

o At least 20 days have passed since the positive laboratory test and the person remains asymptomatic 

o Asymptomatic persons who test positive and later develop symptoms should follow the guidance for symptomatic persons above. 

Definitions of mild to moderate and severe illness, and of severe immunocompromise, as well as more information about the science behind the symptom-based return to work can be found at: https://www.cdc.gov/coronavirus/2019-ncov/community/strategy-discontinue-isolation.html

Please note, the recommendation of 10 days is specifically for those who test positive for the coronavirus and have self-isolated. It does not apply to people who need to quarantine to keep from potentially spreading the virus. The incubation period for the virus is 14 days, so anyone who has been exposed to the virus still needs to quarantine and monitor for symptoms.

An Update on my Covid-19 Viral Load Article

I am providing in full an article just published that emphasizes why my previous article on viral load is so important. Bottom line the more virus you are exposed to and have in your bloodstream the greater the risk of death. As we speak the recommended behaviors of wearing a mask, social distancing, staying away from crowds, staying our of confined crowded spaces are all designed expressly for the purpose of reducing your exposure and hence your viral load. Why people will not follow these guidelines is beyond me.


Jul 8, 2020

SARS-CoV-2 Viral Load in Hospitalised Patients Correlates With Risk of Intubation, Mortality
By Denise Baez

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load among hospitalized patients is independently associated with the risk of intubation and in-hospital mortality, according to a study published in Clinical Infectious Diseases.

Reed Magleby, MD, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, and colleagues evaluated 678 hospitalized patients with coronavirus disease 2019 (COVID-19) and found that 35% of patients with a high SARS-CoV-2 viral load on admission died, compared with 17.6% of patients with medium viral loads and 6.2% of patients with low viral loads.

The findings suggest that using cycle threshold (Ct) values, which are available when results from reverse transcription-polymerase chain reaction (RT-PCR) assays are reported to clinicians, could identify patients at the highest risk of intubation and death and guide treatment accordingly.

“We found that admission SARS-CoV-2 viral loads, as determined by Ct values that are generated with standard-of-care diagnostic assays, are independently associated with intubation and death among hospitalized patients with COVID-19,” the authors wrote. “These findings highlight the critical role of viral load in SARS-CoV-2 pathogenesis and suggest that Ct values should be reported to assist clinicians in identifying patients at high risk for adverse COVID-19-related outcomes.”

Dr. Magleby and colleagues analyzed data from 678 patients who were hospitalized with COVID-19 between March 30, 2020, and April 30, 2020, at 2 hospitals in New York City. SARS-CoV-2 viral load was assessed using a cycle threshold (Ct) values from a reverse transcription-polymerase chain reaction assay applied to nasopharyngeal swab samples.

In-hospital mortality was 35% among the 220 patients with a high viral load (Ct <25), 17.6% among the 216 with a medium viral load (Ct 25-30), and 6.2% among the 242 patients with a low viral load (Ct>30). The risk of intubation was also higher in patients with a high viral load (29.1%), compared with those with a medium (20.8%) or low viral load (14.9%).

In a multivariate model that adjusted for age, race, coronary artery disease, congestive heart failure, cerebrovascular disease, hypertension, chronic obstructive pulmonary disease, days of symptoms prior to admission, symptoms upon presentation, initial chest x-ray findings, and level of oxygen support within three hours of arrival to the emergency department, having a high viral load was independently associated with increased risk of in-hospital mortality (adjusted odds ratio [aOR] = 6.05; 95% confidence interval [CI], 2.92-12.52; P< .001) compared with having a low viral load.

The risk of in-hospital mortality was also higher in patients with a medium viral load compared with a low viral load, but this association was not statistically significant (aOR = 2.06; 95% CI, 0.98-4.34; P = .058).

Compared with those with a low viral load, having a high viral load was also independently associated with increased risk of intubation (aOR = 2.73; 95% CI, 1.68-4.44; P < .001). The risk of intubation associated with a medium viral load did not reach statistical significance (aOR = 1.59; 95% CI, 0.96-2.63; P = .07).

Higher viral load was associated with increased age, comorbidities, smoking status, and recent chemotherapy. Patients with higher viral loads were also more likely to develop myocardial infarction, congestive heart failure, and acute kidney injury requiring hemodialysis.

“While prior studies indicated that viral load correlates with severity of COVID-19 presentation, our study of a larger cohort of hospitalized patients adds to this knowledge base by identifying that admission viral load has important prognostic implications,” the authors wrote. “Reporting
SARS-CoV-2 viral load based on Ct values from admission NP swab samples could, therefore, help identify patients who are at the highest risk of adverse outcomes and who therefore may benefit from more intensive monitoring. Identifying high viral load patients could also be helpful for allocating scarce therapeutic interventions such as antiviral agents.”

The authors noted that additional studies that evaluate viral loads and clinical outcomes among all patients who present to the emergency department are warranted prior to pursuing this strategy clinically.

Reference: https://academic.oup.com/cid/article-pdf/doi/10.1093/cid/ciaa851/33448916/ciaa851.pdf

SOURCE: Clinical Infectious Diseases

Medical Update on CoVid-19 offered as a public service

As a physician with 40 years experience here is where we now stand and what we now know in regards to CoVid-19 understanding that with day 1 and patient zero we had essentially no knowledge of what this virus was capable of.

#1 This one of the most virulent infectious virus in the history of mankind and the worst infectious disease I have seen in 40 years. It is HIGHLY transmittable from person to person. It is bad as Ebola and Plague in the number of people it can infect. Many people feel that the Government and media are over blowing this infection in an effort to scare people for some prejudiced agenda. I can assure you this is NOT true and if anything the Government and Media is underplaying this pandemic in this regard. You hear a lot about the "R" value which is the number of people one person can infect if they have the virus. All public health officials report we want the "R" value to be 1 or less which means one person infects 1 other person or less. I can assure you the "R" value of THIS virus will eventually be proven to be much, much, higher. Dozens, hundreds of people have already been proven to have contracted the virus from 1 person resulting in a massive spread of the infection.

#2 The good news is that for the vast majority of people somewhere around 80% will not get sick from this virus and if they do it will be like the common cold. And as it continues to be reported the vast majority of infected people have no symptoms at all. Again the problem is that unknowingly they spread the infection far and wide and eventually susceptible people contract the virus and end up seriously ill.

#3 The bad news is somewhere around 5-20% of the population is at risk from dying from this virus and those people have either some genetic variant that makes them more susceptible or they are immune deficient for some reason. When they catch the virus they end up in the hospital stressing the health care system. There is no question as the number of infected people rises so will the number in the hospital.

#4 Other good news physicians and scientists are getting much better in reducing the death rate with proper and improved treatment. A major cause of death is cytokine storm which simply is even in patients with a deficient immune system the body's immune response goes overboard and causes generalized organ failure resulting in death. Recent research has shown proper use and timing of steroids and anti-immune drugs, more specifically dexamethasone and Acumed are showing great results. The problem is one of timing. If given too soon or too late neither drug helps as much. It is clear today that Hydrochloroquine does not really work and there are other and better treatments. In addition convalescent plasma transfusion from someone who has recovered from CoVid-19 is showing good results as well. So as treatments improve the death rate comes down but not the hospitalization rate which to me is the qualifying data experts should pay more attention to.

#5 Some scientists and physicians have predicted that every human being in the world is at risk and will eventually be infected with CoVid-19. Until the virus goes through the entire population of the world or we have an effective and safe vaccine there is little we can do to prevent ourselves, our friends, and our family from catching this virus but there are things we can do.

#6 Initially the CDC underplayed the use of masks. They did so out of fear hospitals would run out and be unable to protect doctors and nurses. Everyone is aware if all the doctors and nurses caught the disease and 20% died it would be a major issue. It was a mistake and they have admitted so. But that is water under the bridge. There is no question today that any mask made from any material will significantly reduce the spread and infection rate of CoVid-19. In general current research has clearly shown if a full 60% or higher of the population wears a mask it will reduce the infection by over 60%. If two people are across from each other and talking if both individuals wear a mask the risk of one spreading the infection to the other is less than 5%. No, masks do not 100% solve all the problems but along with washing our hands and not touching our faces it is the absolute best thing we can do to protect ourselves and others today. As an additional barrier that poses no risk, I recommend using a coffee filter within any mask you choose. It can't hurt.

#7 A word about testing. Testing is important but only so far as we can identify the people who have been in contact with the infected person and then isolating or quarantining those individuals for 14 days until the danger passes. Unfortunately there is no State in the Union that has the public health infrastructure and the bodies to do all this contact tracing and follow up. The only Country in the world that did was South Korea and only because they were scared to death by SARS 1(CoVid-19 is SARS 2)and subsequently put a robust public health system in place specifically to do contact tracing and quarantine. Testing won't help that much until we have enough people to contact trace exposed individuals and exposed individuals or infected individuals cooperating with public health mandates.

#7 Eventually the one thing that will stop this pandemic will be a vaccine. I support and wish well those labs and companies rushing to bring one to market and want them to succeed. If they can get it done by the end of the year it will be a miracle. I have to say however that I am concerned it can be done that quickly as issues of safety, effectiveness, and ability for mass production are questions that must be answered prior to using it on the public in mass quantities. In my medical career I have seen over a dozen miracle medicines pulled off the market after a few months or year because once used across the country those miracle medicines were killing and harming people and we did not discover that in the initial trials. Don't forget no treatment, no vaccine, no mask is 100% perfect. But what we have today is the best we can hope for.

Viral Load and Covid-19

Covid-19 has thrown a monkey wrench in all of our lives. Clark and I have been quarantined at home now for two months and frankly have not done much. You would think we would have the best organized and cleanest house on the planet but sadly not. I also have terribly neglected this blog and do apologize to my loyal readers. We had two trips canceled due to the virus so really had nothing to report on. As I have sat at home for two months now and watched the Covid-19 pandemic evolve and the citizens of the world reaction to it I have decided to post a short blog on the virus to hopefully offer some factual information to you with sound scientific reasoning. Unable to travel and not having any extensive wine parties to offer I offer this article to help you navigate the reopening of the society. 

The main concept I want you to gain from this is the concept of "Viral or Bacterial Load". Simply put Viral load is how many viral particles(or Bacteria organisms) you are exposed to. Our bodies are bombarded daily with viruses and bacteria. At any given point in time it could be one or two organisms or it could be millions. There are a variety of factors that determine what the viral load might be and a variety of factors that either increase or decrease the viral load. Many we cannot control. A few we can. So when facing a pandemic we need in-depth knowledge of what the risks are and how to reduce those risks and to fully understand and institute those measures that reduce the viral load to a level that presents a low risk to us and our families. The #1 issue regarding viral load that we can control is the concentration of viruses or bacterial particles in a measured space. One million particles in a one-gallon space area is a high concentration. One or two particles in that same one-gallon space or volume is a very low concentration. Obviously breathing air with the concentration of the higher one is going to lead to a high concentration of viral load. So to reduce risk we need to do things that reduce the concentration in a given area. The best way to lower concentration is dispersion. If I take a gallon of one million particles and put it my bathtub and get into the bathtub I get exposed a lot. But if I dump the gallon into my hot tub and get in it may be the same number of organisms but the concentration is significantly reduced. If I am standing next to you talking and you sneeze I get the full concentration of whatever is there.  If I am 6 feet from you or better yet 12 feet the amount, number, and concentration of whatever has 6 to 12 feet to disperse and lower the concentration.  The main way to reduce concentration is through hand washing. You are diluting the number of organisms as well as killing them and the concentration theoretically should go to zero. Inside a building the virus is confined and just hangs in the air. Outside the wind and weather and temperature disperse the virus in a matter of minutes if not seconds. Study after study has shown a rapid reduction in a concentration outside. The #2 thing to consider is the time of exposure. If you breathe air with a concentration of one million virus particles for one minute as opposed to one hour you obviously get more exposure with more time. But if the concentration is one or two virus particles being exposed a very long time could potentially expose you to the same number of particles. So the less time you are exposed, the fewer particles you are exposed to reducing viral load. The #3 way to reduce viral load is filtering. Most of us have filters somewhere whose sole purpose is to prevent whatever we are filtering from getting into something we don't want it to get into. We just made Lobster Bisque. We filtered the soup to remove the crab shells and other unwanted solids from the soup. With Viruses the best way to filter them out is with a mask. Over the past two months these are the three things other than quarantine that have clearly demonstrated close to a 95% reduction in the spread of infection and that is hand washing(lowers concentration) and face masks(filters out virus). At the same time the less time spent out when you must go out also helps. I am going to restaurants but I am no longer sticking around and gossiping for 2 or 3 hours. I go out to enjoy my meal and leave and go home reducing the time knowing I am reducing exposure. I also wear my mask when not eating and wash my hands coming and going to the restaurant and going and coming home. To me it is a small inconvenience but together makes a significant reduction in the viral load I am exposed to. 

Viral load is important as whether or not any given individual will actually become ill from the infection. Average humans with average immune systems most will not become sick if exposed to a very low viral load. Our immune systems are designed to daily protect us and make sure we don't get infected with small exposures. Otherwise there would be no human race. There have actually been experiments where volunteers were injected with one or two HIV viral particles and none of them got infected with HIV. HIV concentration varies in infected individuals from very high number of particles to very low number of particles in their blood and other humans exposed through for example a needle prick may or may not get infected dependent of whether or not the concentration of the HIV virus was high or low when they were exposed. Covid-19 is no different so average humans with good immune systems most likely will not get infected if exposed to low viral loads. The people who get infected get infected because they are exposed to a high viral load or they are more susceptible due to a weakened immune system. I suspect the majority of people who have died from Covid-19 were people with low immune systems and exposed to a high viral load. Other than knowing diabetics and heart disease and high blood pressure and older people have weakened immune systems we don't have a test that tells us for sure who is more susceptible. 

So you ask why is Covid-19 different from the regular yearly flu. We have not needed to wear masks in the past years when the flu came around. The answer has to do with the infectivity of the virus or how efficient it is in infecting you. Bottom line a lower viral load is needed to infect any given person with Covid-19 so it is even more important to lower the viral load with COVID 19. What you are trying to do is lower the viral load of Covid-19 that is too low to infect you. 

So the foreseeable future me and my family wash out hands many times a day and when out and about wear masks. We also add a layer of protection by putting a coffee filter inside our masks. There is no risk and it is one more mechanical barrier that might catch a few additional virus particles. It can't hurt and is not noticeable. We also try hard to not linger as long when out. Along with you we are looking forward to the day when this terrible pestilence is over. But until then please follow the above recommendations to help protect yourself and others.

How to predict the future, "those who ignore history are bound to repeat it"

The following is a good summary and example of why we all need to NOT travel right now which I and my family are doing. It is sort of travel-related and hopefully good information for you.

The Spanish Flu in many ways was very similar to the CoVid-19 pandemic. It was highly infectious, people got very sick very quickly. Young people died and Cytokine storm deaths were recognized. 50 million people all over the world and 675,000 Americans died. This was a time remember of much lower populations and fewer high rises. To predict a worst-case scenario one only needs to look at Philadelphia and St. Louis. Philadelphia held a war bond parade on September 28, 1918, despite 647 cases of Spanish Flu in the town of a population of 1.5 million. St. Louis canceled their parade. The result? Within 3 days all 31 Philadelphia hospitals were full and closed for any additional patients. First responders went around town trying to help where they could and do contact tracing and found entire families dead in their homes. Within one week 45,000 citizens were known infected. By the second week in November 12,000 were dead and bodies were piled on sidewalks as morgues were full. Within 5 months 500,000 Philadelphians were infected and 16,000 were dead. St. Louis had 1/8 the cases. The only difference was one(1) parade. For Philadelphia that translates into 1/3 of the population was infected and 1.06% of the total population died. Extrapolate that to just New York State and Florida both of whom rounded off have approximately 20 million residents would mean in each state 6 million people would get infected and 212,000 people would die in each STATE. So how does the initial projection of 200,000 dead Americans in 50 States sound to everyone now? Was it scare tactics. Was it a worst-case scenario. Was it overblown? Don't think quarantine works. Researchers have now found that cities that quarantined the sick and shut schools, churches, theaters in 1918 saw a 50% lower death rate than those who did not. Milwaukee had the lowest death rate of 0.6% where schools, bars, public places were all closed after the first cases were reported and people were told to shelter in place and stay home. FYI another study just released confirmed the importance of Vitamin D that many are deficient in. The study found that nations with the lowest Vitamin D levels, Italy, Spain, and France have the highest death rate. Brown skin people are particularly deficient and also don't absorb it orally well. I currently recommend everyone take 4000 international units a day or 50,000 international units monthly. Brown people should probably take a little more than that, maybe 5000 international units a day or 50,000 international units twice a month.