17 minute read
A VIEW FROM THE INSIDE
An infectious disease physician’s COVID-19 journey in Sonoma County
BY GARY GREEN, M.D., FIDSA
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In October 2019, China began to experience the outbreak of a novel viral respiratory illness, a new disease strain that had not been previously identified in humans. he hinese government suppressed the information for political reasons. In December 2019, however, hinese health authorities and the World Health Organization (WHO) announced discovery of a new and severe acute respiratory syndrome coronavirus 2 (S RS- o -2). he illness it caused was named O ID-19 (COronaVIrus Disease 2019). Once the world was alerted to the threat, clinical and international events happened quickly. ust days after the WHO bulletin, O ID-19 cases were reported outside of hina, and it became clear the virus was spreading internationally. In mid- anuary 2020, the first cases were identified in the nited States. On anuary 11, 2020, hina shared the virus’ sequence with the international scientific and medical communities, and work began around the globe to address the rapidly spreading health crisis. ebruary 22 report, issued in the Journal of the American Medical Association ( M ) and co-written by a representative from the hinese enter for Disease ontrol and Prevention in eijing, provided vital information on severity of the disease. ccording to the article, 1 percent of early cases could be mild, only 1 percent were asymptomatic the overall case fatality rate was 2. percent, but those over 60 years of age had nearly a 1 percent case fatality rate. his became a clinical compass for healthcare providers. ach day brought an onslaught of new information some true, some not and medical professionals were tasked with sorting through the deluge to find the facts, while at the same time fielding frantic calls and questions from patients and the public. he chaotic, rapid-fire progression felt like standing unprotected in front of an open fire hydrant.
FIRST SONOMA COUNTY CASES
In late ebruary 2020, only six weeks after S RS- o -2 was sequenced, Sutter Santa Rosa Regional Medical Hospital admitted the first two O ID cases in Sonoma ounty. he patients had recently returned from a cruise to Mexico, but that epidemiological link made no sense at the time.
On March 1, a 2 a.m. phone call to my personal residence from the .S. enters for Disease ontrol ( D ), asking, Where is this cruise ship now? aligned Sutter Santa Rosa closely with the alifornia Department of Public Health ( DPH), which turned the cruise ship around on its voyage to Hawaii and delayed early spread of S RS- o -2 to that location. Once O ID arrived in the nited States, it spread quickly.
On March 1 , 2020 less than two weeks after Sonoma ounty identified its first O ID case the White House declared a state of national emergency in response to the now-classified pandemic. irst, we struggled with the loss of our elders grandparents, great aunts and uncles, beloved neighbors and friends who, ill and isolated, could only communicate by phone or tablet and never got to say goodbye in person. s variants emerged, our peers younger people, middle-aged husbands, wives, brothers and sisters were hospitalized with severe illness, struggling to breathe and to survive. Some did not. Sonoma ounty has also experienced critical cases of O IDrelated multisystem in ammatory syndrome in children.
In my 2 -year career studying and treating infectious diseases, I haven’t seen so much desperation and death since the IDS epidemic. My fellow physicians, nurses, pharmacists and other clinical staff have experienced ongoing physical, mental and emotional exhaustion for nearly two years.
It’s not entirely accurate to say no one saw it coming. Most of my infectious disease colleagues were anticipating a novel in uenza pandemic sometime this century. However, fewer expected a novel coronavirus pandemic, since 200 S RS and 2012 M RS coronaviruses did not spread worldwide. ( or more on these comparative diseases, see iruses at a Glance, page 6 .) COLLABORATION WAS KEY
he early international sharing of the S RS- o -2 sequence from hina was an absolute critical step for development of diagnostic tests, treatment considerations and vaccine planning. he ebruary JAMA publication, which delineated the first case series, became our first clinical guidepost S RS- o -2 was 10 times more dangerous than seasonal in uenza, but not as lethal as S RS, M RS or the 191 in uenza (H1N1). he intervention surrounding the cruise ship fostered collaboration with the CDC, PDH, Sonoma ounty Public Health and the Mayo linic, which paved the way for Sutter Santa Rosa Regional Hospital to
participate in international treatment trials of intravenous (I ) remdesivir and convalescent plasma (two therapies investigated as possible treatment).
Sutter Santa Rosa was able to stay one step ahead of the epidemic by gathering real-time information in a grass roots D weekly meeting, which later evolved into a weekly briefi ng between the D , IDS (Infectious Disease Society of merica) and treating providers.
We quickly learned I remdesivir has a modest benefi t, and convalescent plasma treatment only worked if it was administered within 2 hours of infection and if the plasma had high titres (levels) of protective antibodies. Plasma treatment was soon eclipsed by monoclonal antibody cocktails such as Regeneron’s. s the pandemic hit the ast oast of the .S., our colleagues in New York ity realized and shared the survival benefi t of anticoagulation treatment to prevent or treat the unique thrombosis events (blood clots that block veins or arteries) that occur with this viral infection. he nited ingdom-based R O RY trial, launched in March 2020, is the world’s largest clinical trial into treatments (www. recoverytrial.net). Many of the world’s successful interventions have stemmed from this study, and it continues to deliver meaningful data. R O RY confi rmed a survival benefi t to dexamethasone (the most potent steroid available). Later studies supported the survival benefi t of tocilizumab and barcinitib (both potent immune suppressive treatments). Not all immune suppressive treatments are eff ective, however, as we recently learned with the lack of benefi t from Inferferon-1 . We further learned that diabetes control (before and during hospitalization) was as potent as other measures for survival. MOVING QUICKLY
Within a month of seeing our fi rst O ID cases, we had an evidence-based, fi ve-pronged treatment strategy for patients hospitalized due to O ID-19 pneumonia Supply oxygen support Stop virus replication Slow down the immune system Prevent blood clots and ontrol blood sugars.
VIRUSES AT A GLANCE
Severe acute respiratory syndrome (SARS) is a viral respiratory disease fi rst identifi ed at the end of February 2003 during an outbreak that emerged in China and spread to four other countries. World Health Organization coordinated the international investigation with the assistance of the Global Outbreak Alert and Response Network (GOARN) and worked closely with health authorities in a ected countries to provide epidemiological, clinical and logistical support to bring the outbreak under control. Source: www.who.int Middle East Respiratory Syndrome (MERS) is a viral respiratory illness that is new to humans. It was fi rst reported in Saudi Arabia in 2012 and has since spread to several other countries, including the United States. Most people infected with MERS-CoV develop severe respiratory illness, including fever, cough and shortness of breath. Source: www.cdc.gov H1N1 infl uenza A: The 1918 infl uenza pandemic was caused by an H1N1 virus with genes of avian origin. Although there is no universal consensus regarding where the virus originated, it spread worldwide during 1918-1919. It is estimated that about 500 million people — one-third of the world’s population — became infected with this virus. The number of deaths was estimated to be at least 50 million worldwide with about 675,000 occurring in the United States. Source: www.cdc.gov Cytomegalovirus (CMV) is a common virus for people of all ages; however, a healthy person’s immune system usually keeps the virus from causing illness. In the United States, nearly one in three children are already infected with CMV by age fi ve. Over half of adults have been infected with CMV by age 40. Once CMV is in a person’s body, it stays there for life and can reactivate. A person can also be re-infected with a di erent strain (variety) of the virus. Most people with CMV infection have no symptoms and aren’t aware that they have been infected. Source: www.cdc.gov Multisystem infl ammatory syndrome in children (MIS-C) is a condition where di erent body parts can become infl amed, including the heart, lungs, kidneys, brain, skin, eyes or gastrointestinal organs. Its cause is not yet known. However, we know that many children with MIS-C had the virus that causes COVID-19 or had been around someone with COVID . MIS-C can be serious, even deadly, but most children who were diagnosed with this condition have recovered with medical care. Source: www.cdc.gov
Some of these treatment modalities can be aggressive and risky, but also lifesaving. We heavily weighed the risk and potential benefits for each and every patient, and carefully planned the timing of each treatment strategy. onscientiously, we followed the Hippocratic oath to Do no harm and avoided adopting unproven and unsubstantiated treatment modalities that could also prove inadvertently harmful. rom the start, our mantra has been to trust in the science. If a report or study wasn’t biologically plausible or didn’t make sense, we waited for more data and rigorous investigation. ach treatment modality and policy decision was determined by evidencebased rigorous science not by rumor, anecdote, weak science or social media speculation.
We quickly learned that hydroxychloroquine, azithromycin, colchicine, ivermectin, vitamin mega doses and uvoxamine don’t work and can be toxic. We felt validated when such treatments were also discouraged by the National Institutes of Health (NIH), considered by physicians as one of our country’s most credible institutions.
Recently, more hope is emerging as the first oral antiviral medication, molnupiravir, received .S. ood and Drug dministration ( D ) approval, and a new S RS- o -2 antiviral protease inhibitor is just around the corner. lthough promising, we are waiting to see if these medications offer a quantified survival benefit. s with seasonal in uenza, antiviral medication can shorten the illness duration, but a vaccine offers the most significant chance of survival. THE VACCINE ARRIVES
In spring of 2020, the NIH started vaccine trials less than one month after hina shared the full sequence of the virus.
Was that too fast ? No. It was 1 years in the making.
In 200 and 200 , the NIH developed a new mRN vaccine platform (that is, a new application of science led to its development) for the original S RS coronavirus. It took 20 months to develop this new vaccine, which demonstrated safety and e cacy in healthy volunteers. ut by the time it was ready, S RS had evaporated, and we couldn’t test this promising vaccine against that illness. his new vaccine platform had also been studied as a revolutionary vaccine for the M RS coronavirus, rabies virus and cytomegalovirus ( M ). ast forward to 2020, and the NIH took the earlier mRN S RS vaccine research, which had been studied and improved over the years, and started vaccine trials using the S RS- o -2 sequence hina had provided in anuary. We were standing on the shoulders of molecular biologists, biochemists, virologists and vaccine scientists dating back to 19 on mRN nanoparticle, liposomal and vaccine research. he White
House called the O ID-19 vaccine efforts Operation Warp Speed, which, understandably, frightened many, who questioned whether protocols had been set aside in favor of a fast introduction. ut it was really a culmination of decades of hard and laborious science.
Late in 2020, data from large vaccine trials across the globe were released. he medical community hoped for at least a 0 percent vaccine e cacy for D approval (for more on the D approval process, see Risk Reward, page ) Our hopes were bolstered with percent protection with the ohnson ohnson adenovirus platform O ID vaccine and, even better, with 9 to 96 percent protection of the mRN Pfizer and Moderna vaccines. his was a home run, and serious side effects were very rare. here was no in uenza vaccine in 191 and more than 0 million people died of the disease globally. o date, we have lost .2 million to this pandemic too many, to be sure, but imagine the devastation if vaccines weren’t available. accines have made O ID a preventable disease, similar to polio, measles, mumps and rubella, among others. hey’ve already saved millions of lives.
What’s more, the nited States has the three best and safest vaccines in the world. Our science has been rigorous and cautious, unlike Russia, which released its Sputnik vaccine before trials were finished, meaning safety and e cacy data was unknown.
VARIANTS EMERGE ollowing viral science, we expected this virus to make random mistakes when it replicated these errors create new forms of the virus that we call variants. he first one, originally designated as D61 G, evolved only one month after we sequenced the original virus from hina. Soon, a more contagious and virulent variant emerged from the , and we designated this as .11 or the alpha variant. Other variants emerged in South frica, razil, olombia and even the nited States.
In October 2020, further random mutations in the virus created an even more contagious and harmful variant designated .1.61 or the Delta variant, which emerged from India and quickly circulated worldwide. o date, virologists have documented more than 12,000 significant mutations to this novel virus, which have created 2 new variants being tracked and monitored by the WHO and a consortium of international virology labs. learly, the virus’ transmissibility, virulence and pathology are changing. he only way to break the epidemic cycle is by lowering the asic Reproductive number (called Ro) the only way to do this is for more people worldwide to get vaccinated. he more this virus circulates and replicates, the more mutations and variants will arise. urthermore, none of the available treatments not even monoclonal antibody cocktails are as life-saving as vaccination. ven surviving O ID doesn’t offer as much immune protection (called natural immunity ) as vaccine immunity, and surviving patients are encouraged by the D and our medical society to get vaccinated. Re-infection is real and dangerous, especially for the elderly and those with significant medical problems.
When countries, whether poor or wealthy, aren’t successful with high-rate vaccine programs, more virus will circulate and mutate, and more variants will emerge.
his is a certainty, and the Omicron variant, which is estimated at four times more contagious than the Delta variant, is a testament to that certainty. arly evidence from South frica, which fi rst reported discovering the Omicron variant, suggests that natural immunity from previous O ID infection may not off er much protection at all against this new strain. We may have to lean even harder on vaccination.
With more contagious variants, we need more people vaccinated to break the epidemic cycle, by lowering the Ro. Nearly 99 percent of patients now hospitalized are unvaccinated, and much younger people are becoming critically ill. Some do not seem to respond as much to our treatment strategies, and either perish or are transferred to other medical facilities on chronic long-term oxygen support. his is a very dangerous time to be unvaccinated.
DRIVE SAFELY hink of O ID prevention and treatment as similar to the daily risk of driving.
ollowing the rules of the road is similar to your decision to wash your hands, not touch your face, wear a mask and social distance in public it keeps you and those around you safe. On the other hand, how fast and recklessly you drive and how you maintain your vehicle are equivalent to aunting recommended social distancing and mask protocols and underlying health risks.
Some of the treatments we’ve discovered are similar to air bags in an automobile, which ensure many more people will survive a collision but not everyone. he incredibly safe and eff ective vaccines we have in the nited States (Pfi zer, Moderna, ohnson ohnson) are more fundamental and eff ective, like seat belts.
It would be very rare for a seat belt or airbag to fail, and most of us don’t lose sleep over this infi nitesimally low risk. his is analogous to the rare risk of a serious adverse reaction to the safe O ID vaccines available in the states. We know these devices reduce the chance of death in automobile accidents by 0 to percent.
o help each of us, our families, our friends, our co-workers and our neighbors survive this pandemic, it’s wisest to get vaccinated, continue sensible public health measures and, if needed, turn to evidence-based eff ective treatments such as monoclonal antibodies. accination wasn’t available during the 191 in uenza pandemic, and the disease persisted globally, in deadly fashion, for four more years. ventually, this virus will become endemic hopefully more quickly than the 191 in uenza strain. In the meantime, we need to prepare for the long haul sensibly. accination is the most vital factor toward this outcome.
About the author: Gary Green, M.D., FIDSA, is an infectious disease specialist who serves as Medical Director of Quality, Infection Prevention and Stewardship for Sutter Medical Group of the Redwoods and Sutter Santa Rosa Regional Hospital. He has published on COVID-19 in the Morbidity and Mortality Weekly Report published by the CDC, and on IV remdesivir use in COVID-19 in the New England Journal of Medicine.
SCMA RESPONDS TO THE PANDEMIC
BY SUSAN GUMUCIO AND WENDY YOUNG
The Sonoma County Medical Association (SCMA, now known as Sonoma Mendocino Lake Medical Association, or SMLMA) supports the business and practice of medicine in Sonoma, Mendocino and Lake counties. SCMA provides a multitude of advocacy, wellness and practice assistance programs to member physicians, as well as offering opportunities for community involvement and service.
Never has this commitment been so needed as when COVID-19 arrived in the North ay early in 2020. Once the O ID vaccines became available, S M helped lead efforts to vaccinate county residents to protect as many as possible from this devastating disease.
In partnership with the County of Sonoma, SCMA opened a O ID vaccine clinic in anuary 2021 at Grace Pavilion in the Sonoma County Fairgrounds in Santa Rosa. It later teamed with Santa Rosa Community Health, expanding services to underserved populations and providing pop-up sites throughout the area. etween anuary and ugust 2021, almost 6,000 vaccine doses were administered by SCMA volunteer physicians and medical staff.
Supporting medical professionals and the community during the COVID crisis has been SCMA’s most important accomplishment of the last year. In addition to the vaccine clinic, SCMA initiated the statewide Care4Caregivers program, which provided housing and services to physicians and all medical staff exposed to the virus in the course of their essential work at hospitals and medical practices.
S M also supported local efforts to create and distribute handsewn face masks to physicians, first responders, essential workers, schools and shelters in the early days when N95 masks were being recommended, but were di cult to obtain. hey also delivered desperately needed personal protective equipment (PPE) supplies to medical practices in Sonoma County.
SCMA supports county public health initiatives addressing vaccine advocacy, smoking cessation, youth vaping, heart health and more. Its long-standing Health Careers Scholarship program guides local students planning a career in medicine. t community events, you may see our first-aid tent, staffed by volunteer physicians. SCMA is actively engaged during times of crisis including wildfires, oods and, now, the O ID pandemic.
SCMA also provides referrals for those seeking a primary care or specialty physician in our service area. You can check our Physician inder at www.scma.org or call 0 - 2 - for assistance.
About the authors: Susan Gumucio is the Communications Director and Wendy Young is the Executive Director of the Sonoma-Mendocino-Lake Medical Association (SMLMA).
