Covid Vaccines – a few more links

As more coronavirus vaccine manufacturers have press releases touting their vaccine trial news, we all need good sources to understand what is going on. Therefore, here are a few more links to help you understand all of the information being thrown at you:

  1. My first blog post about the covid vaccines
  2. Deplatform Disease: a great website by biochemist Edward Nirenberg, primarily discussing vaccines and Covid-19.
  3. Skeptical Raptor’s blog debunking common vaccine myths, but also putting in a nice amount of skepticism
  4. Some recent news articles that may be of interest

November 2020: Covid Vaccine News

Guest post by vaccine advocate Denise Kesler Olson. She currently works for an Immunization Coalition in Arizona, helping others feel as passionate about vaccines as she does. You can read how she got involved in the immunization movement here.  This information originally appeared on her Facebook wall, and she has graciously allowed me to post this edited version on my blog. – Dr. Shaham

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Part I: “But How Do We Know If It’s Safe!?”

The most common criticism I get is that I keep telling you how every vaccine is safe, and therefore I must unconditionally love all vaccines and accept them all blindly. No. I – and really, we’re talking about the scientific establishment I support and not me personally –accept only vaccines that have been through the rigorous testing process and are found to be safe and effective. The vaccines on our standard schedule have cleared that hurdle. Covid vaccines aren’t in that category yet. We do not know if they work nor if they are safe. I wouldn’t recommend everyone get them yet, and no responsible organization should either.

A little background information will go a long way to help us here. Vaccines are a special type of medical product because they are given to healthy people instead of sick people. This might seem like a small thing, but it’s actually a HUGE difference. Pharmaceuticals are only ethically given when the possible benefit outweighs the possible risk. If you are already sick, it may be worth risking side effects, especially when they rarely happen or if they are less serious than the problems you already have. A vaccine given to healthy people must never make them into really sick people, or the whole point of preventing illness is defeated! Any effects need to be better than the alternative of not getting the vaccine at all. 

Vaccines need to pass through four specific development phases to be proven safe and effective (preventing the disease). If any serious side effects are found throughout this process, the vaccine will not be approved for mass use – about 60% of vaccines fail to be approved in the end (compare this to 84% of other pharmaceuticals which fail). First, various vaccines that have worked in the laboratory setting, and look good on paper and computer modeling, are tested on animals to prove that the formulation isn’t harmful to live beings and see which candidates are the most promising. The vaccines that work safely and as expected in animals can then move forward to be tested in humans in phase I, II, and III clinical trials. Pediatric vaccines (the ones we use in kids) usually undergo phase IV clinical trials as well, which are formal studies that occur after the FDA approves a vaccine. Check out this infographic from the CDC about how a vaccine gets to market (click on the sentence to open the link in a new window) or click here for a short YouTube video about the process

There are currently Covid vaccines undergoing phase I, II, and III trials in adults all over the world. The phase III studies on people are double-blind. That means the participants are divided into groups, and half of the people are randomized to receive the real vaccine that is being tested, and half receive something else (a placebo), such as a saltwater injection or a different vaccine. Neither the patient nor the medical staff administering the vaccine knows if the real vaccine was given. Only the data analysts have this information, and it is kept separately from any information identifying people in the trials, such as their name, birthday, street address, or characteristics. This is important because not everything that happens to people after getting a shot will be because of the injection. People in both groups will get sick or injured by random chance -especially when following up with them for a long time. Scientists look for patterns. If one thing shows up repeatedly in the group of people who got vaccinated, then that may be a sign that the vaccine caused it.

This knowledge will help you understand scary headlines in the news. Recently, there were wide reports that someone in Brazil had died while participating in a vaccine trial. When the researchers paused the trial, they used emergency protocols to unblind his records.  It turned out that he was not given the real vaccine during the trial, so the vaccine they were testing could not be the cause of his death.

Obviously, you test vaccines not just to prove that they are safe but also to prove that they prevent people from getting sick. There are two ways that people can go about this. One way is to continue watching phase III trials (around 30,000 people or as many as they can get for vaccine trials) for a very long time until enough people are naturally exposed to the virus. Over time, you hope to see a pattern of people who were given the real vaccine not getting sick, hardly ever getting sick, or only getting mildly sick. If the vaccine does not work, then the people who got the real vaccine and the people who got the placebo will get sick roughly in the same amount and severity overall. Remember this when you hear numbers like “this vaccine is only 50% effective,” because it means people in the vaccinated group were half as likely to get ill with COVID-19 compared to the placebo group. While that would not be the best, it would be a huge reduction of disease overall.

The other way to see if vaccines work is controversial, but it did get approval for use in the UK recently in healthy and willing volunteers. This is the old-fashioned challenge trial. In a challenge trial, you give the vaccine and then deliberately try to infect those people with the disease you are trying to prevent. The advantage is knowing right away if people get sick in the same numbers and skipping months of waiting around for people to become exposed. Still, infecting people on purpose with a disease, when you do not know if you have a safe or effective vaccine, has many disadvantages and is considered unethical by many people. 

Part II: Operation Warp Speed

There are a couple of hurdles that keep vaccines from coming to the market quickly, even if the idea is good and it works. 1: There may not be enough money to continue research and development. In that case, work must be paused as researchers try to obtain new grants/investors/sources of funding. 2: It’s hard to scale up the production of an effective vaccine so that there are enough doses to immunize everyone in a large population. It costs quite a bit of money to build or retrofit a factory and obtain all of the necessary materials to make millions of doses of a new vaccine.

Operation Warp Speed was passed as part of the CARES act in March 2020 to speed up a successful Covid vaccine’s availability. Ten billion dollars went into funding a public-private partnership that gives R&D money to companies with candidate vaccines, as well as supplying funding to scale up factories to manufacture those vaccine candidates, even when we are not sure they will ever be approved. They did this with the knowledge that some of them would probably not be proven to be effective in the trials and would ultimately have to be tossed out, but that if one worked, then there would be millions of doses sitting ready to be shipped out as soon as final approval was given. The reasoning behind this effort was set out by top economists who supposed that a delay of even one year could cause much more economic damage and turmoil than simply funding the vaccines upfront and getting things back to normal.

Like everything that comes out of Congress, the law is very complicated and full of fine print. It leaves a lot of questions, such as:

  • What loopholes could pharma companies exploit to inflate their stock prices?
  • Should the American people have to pay for a vaccine funded by taxpayer dollars?
  • Should we be awarding money to foreign companies under this program?
  • Were contracts awarded fairly and subject to enough scrutiny?

And on and on and on. We will probably be talking about what went right and what went wrong with Operation Warp Speed for decades to come. However, that is an argument for somewhere else. I brought it up because I want to help everyone understand that Operation Warp Speed does not fundamentally change the clinical trial process I talked about before, where we check the safety and efficacy of vaccines. It has a dramatic name, but it should really be called “Operation Fund COVID Vaccines.” There are legitimate reasons to critique the operation, but they have nothing to do with the safety and effectiveness of the eventual vaccines produced. Questions about pharmaceutical companies, including how much money they should be allowed to make if they receive public funds, are economic and political questions at heart. The companies participating still have to prove that their vaccines are safe and work; otherwise, their whole tax-payer funded factory will just sit there gathering dust.

Addendum from Dr. Shaham: Operation Warp Speed is allowing manufacturers to reduce the typical 2-year long phase II clinical trials and 2-year long phase III clinical trials into an overlapping 6 month trial period before assessing the vaccine safety and efficacy, due to the urgency of getting a vaccine out to halt the pandemic, and a large number of people in the trials. However, this does shorten the time we have to determine the long term side effects of the vaccine. For Covid-19 we also do not know the long term effects of the virus itself, since it is new to humans (but has been in animals for years); therefore, there will be ongoing data collection and research long after initial approval of a covid vaccine, and we will be learning about both what the virus itself does, and the vaccine does, for years to come. 

Part III: Big News in Big Pharma: Pfizer says their vaccine is 90% effective. 

Two large but competing pharmaceutical companies, Pfizer (of Germany) and Moderna (of the U.S.A.), are attempting to make their covid vaccine candidates a new way. Not only are these two vaccine candidates designed to fight a new infection, Sars-CoV-2, but they are designed using mRNA (messenger RNA).

A typical vaccine takes a virus (or bacterial) toxin, or parts of the microbe that were grown in a lab, harvests it, kills it, chops it up, and purifies it until only 1 part is left, which we call the antigen. The antigen is mixed with things that help your body recognize it and defend itself against it, and that vaccine is injected either under your skin or into a muscle. Your body then mounts an immune response under the belief that these inert germs pose a real threat. Later, when the body actually encounters the real germ, it is easy for your immune system to retrieve the antibodies created in response to the vaccine, copy them, and use them to prevent or blunt the real thing’s effects.

The mRNA vaccines work by skipping the part where the lab makes an antigen. They are counting on the fact that our own body is as good as any lab at manufacturing parts of a virus. After all, that is the reason that viruses want to infect you in the first place. They can’t duplicate themselves the way bacteria can, so they trick your cells into making more viruses by hijacking their ability to make proteins. First experimented with for cancer treatment, the idea of the mRNA vaccine is to trick a few of your cells into manufacturing parts of the virus – NOT the whole virus, so it can’t give you Covid. It tells some of your cells to make the Sars-CoV-2 spike protein, for example, which is enough to make your body mount an immune response against the real virus.

Does this actually work? We don’t know yet, but in a press release on November 9, 2020, Pfizer claimed that it is working well in their data so far. Remember, in trials, half of the people receive the real vaccine they are testing, and half of them receive something else. Then everyone has to wait around and monitor the participants until people get exposed to Sars-CoV-2. They have regular visits with researchers, have blood and nasopharyngeal swabs examined, keep symptom journals, and report everything. Pfizer claims that out of the more than 44,000 people in their trial, only 94 people so far have been sick with Covid-19. When the researchers analyzed the data, they found that only nine of the people with Covid got the real vaccine candidate. The other 85 people were in the control group. That certainly looks like a pattern starting to develop. A group of different researchers ran a statistical analysis and found that if this rate continues, the vaccine would be >90% effective. This is well above the 50% floor the FDA set for approval of any COVID vaccine, moving it from being as efficacious as the influenza vaccine to put it more in line with the far more effective polio vaccine. For more information on the statistical side, check out the tweet threads linked here

So what are the catches? The most important is this trial is not finished, and this data came from a press release, not a journal. Only once is published can independent researchers run more analyses to validate the claims. There also haven’t been enough Covid-19 cases in the participants to know if this pattern will hold, and the FDA has said that they would not even consider an emergency application for use until there had been at least 161 confirmed cases of Covid-19 in the trial. We don’t yet know if the vaccine prevents severe disease because it was reported that no one so far has gotten seriously ill. Since this was a press release, they did not address the biases in their research, such as volunteers for the vaccine trial being more likely to wear masks and socially distance, nor confounding factors, like the participants’ socioeconomic status. Another consideration for this new vaccine type is that it must be kept very cold at -80 degrees C, and once the vaccine is thawed, it must be used very quickly. It won’t be easy to distribute it outside of a large hospital setting since it has unique storage requirements.

Another potential effect for people to be aware of and that is vaccines of this type by their very nature stimulates both the nonspecific and specific set of immune responses our body has. Your body may try to fight this “infection” with a fever and make you feel achy and tired for a few days before it gets down to building specific antibodies. That wouldn’t be dangerous, but it would be something to be aware of, or you may be afraid you’d gotten ill from the vaccine. The side effects are likely to be a bit worse than those from the annual flu shots.

In the end, it is hard to know if this is the vaccine that turns out to be the most widely used. Assuming the trend holds; however, I think it could be a useful measure to vaccinate healthcare workers who are most at risk.

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A final thought added by Dr. Shaham:

The data is promising, but we have to have patience and wait for more data and independent analysis before making any decisions about using this (or any other) vaccine in the population at large. The mRNA vaccines will need even more long term data before their safety can be established since they are a totally new type of vaccine. My best prediction at this time is that more data will be available in early 2021 so that people at very high risk (like high-risk healthcare workers) will start to get one of the covid vaccines by Spring 2021. Still, it will be a long time before something is tested enough and available to children.

Covid-19 Part 3: What We Know & What We Should Do Fall 2020 Edition

We are learning new information about the pandemic and Covid-19 everyday, so this information is what I know as of October 1, 2020. Please check out all of the linked articles – they are underlined in this blog post, and should open in a new window when you click on them.

As a reminder, here is a good website for general information about coronavirus and the pandemic: Johns Hopkins Medicine.

COVID-19isolateExposure

Covid-19 is still much rarer in children than it is in adults, but cases have risen sharply since schools have opened, and overall cases have gone up. As this AP article pointed out, younger children were less likely to be affected, but teenagers were more likely than young kids to get sick, and cases are really going up in young adults (age 18-22).  Children are also less likely to be hospitalized, but if your child is one of the rarer cases to get sick enough to require hospitalization, to get MIS-C from exposure to covid-19, to get heart damage from covid-19, or even die, then exposure was not worth it. This is why I am currently NOT recommending in-person school or daycare for anyone. Another thing to consider with daycare or in-person school, is that for every regular cold/fever your child gets, they will likely need to stay at home and isolate for 14 days (this varies, please see the chart below and speak to your doctor for individual advice), since covid tests still have a pretty high false negative rate, and it is difficult to rule out covid without a 2 week wait. This generally means paying for daycare/school, but still needing to find alternatives for your child at home for weeks at a time. For a good blog post going over most scenarios of illness in a state with open schools, please see Dr. Stuppy’s recommendations. Here are 2 images copied from her blog about common scenarios for her school district:

I know virtual school is not fun – I’m having a very hard time with it myself! However, the risks of my child getting covid-19 are not worth the benefits of learning or socialization at this time. I enjoyed this comic from Vox about the stress of remote learning on parents. school_meme_18_1

Another reason you do not want your child (or anyone) having covid is that it can damage the heart. Even if someone just has a fever and sleeps it off at home with covid, and does NOT need to be hospitalized, the American College of Cardiology recommends a gradual return to play protocol. This is similar to what we do after someone has a concussion, so please see your pediatrician, and have them do a cardiac exam (listening to heart with a stethoscope, checking pulses with their hands, looking over the child in person), before resuming any strenuous physical activity.

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The safest thing everybody can do at this time, is continue to stay home and limit contact with other people. The biggest risk is spending time together with other people – the virus is spread by breathing in germs that are breathed out by other people, especially “superspreaders”, – so wearing masks and staying away from others is the only way to prevent the spread right now. Cleaning surfaces is nice, and may help prevent other infections, like staph, e coli, and RSV, but it is not a good defense against covid. Some even refer to this obsessive surface cleaning as “hygiene theatre“. UCSF has a nice summary of how masks protect us, and Johns Hopkins Medicine has a good blog with graphics on how to properly wear masks.

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Finally, now (as always), is a good time to talk to your kids about living a healthy lifestyle. Virtual school can lend itself to too many hours of screen time, too little time being active, and overeating. Combat this by setting up limits on your devices, using apps like Family Link on Android devices / Chromebooks (I like the features on this, espeically the ability to make time limits on individual apps), parental controls on Apple devices, Family Safety on Microsoft/ Windows devices (I find these controls to be very limited, and work best from the website, but not the app), and the Bark App for overall monitoring (I like the ability to designate certain apps during school hours, certain apps for free time, and the monitoring of text messages and websites by the app for dangerous content).

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Encourage kids to be physically active for at least an hour a day. Take walks, jump around, do free yoga classes on zoom, or whatever you can manage. Remind your tweens and teens of the dangers about smoking or vaping, and that it can be especially harmful if they get covid (see the article linked here).  Encourage them to drink a glass of water instead of reaching for a snack. When they do want a snack, make fresh fruit and vegetables readily available. Encourage them to eat the rainbow! Don’t forget to keep everyone in your family up to date on all of their vaccinations! The last thing you want is to have a fever or cough or rash for any reason during a pandemic – even if you don’t have covid, you will miss school / work, and increase your chance of catching covid by needing to go out to the pharmacy and other places for help.

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Covid-19 Part 2: More Coronavirus

April 24th, 2020

Most of what I put in my first blog post on the 2019-2020 Coronavirus (officially SARS-CoV-2, causing COVID-19) at the beginning of March still stands, but now that we have all been sheltering in place for over a month, much has changed as well. Therefore, I decided to start a new post, rather than edit the last one.

The first thing most people ask are the symptoms, and how to distinguish them from a cold, influenza or allergy.

Covid vs Cold vs Flu Vs Allergies

The second thing I am usually asked is about the how many people are affected. Currently, the best source for information on COVID-19 cases in the USA is Johns Hopkins University. The best source for local information on what to do is your local health department (this link takes you to the Los Angeles Department of Public Health coronavirus information page, for example) and your primary care physician.

StayHome

As I wrote this, California is “social distancing” and will remain so for a while. I think social distancing should actually be called physical distancing, because the point is to stay as far away from as many people as possible. When you do need to go out you can reduce your risk of catching anything, or passing on the virus, by wearing a mask (only for kids age 2 and above!), washing your hands frequently, leaving your shoes at the door, instead of tracking in whatever is on them inside your house, and bathing and changing clothes when you get home. 

20200420_144532Why you should wear a mask (click on the sentence).

How to make a mask.

How to wear a mask correctly

How to use gloves correctly.

Food safety.

Cleaning your home.

Babies and toddlers under age 2 should NOT wear a mask and should NOT have anything covering their mouth and nose, due to the risk of suffocation.

If you or your child accidentally gets cleaning fluid, or anything else that could be dangerous, in their mouth, nose, or eyes, and they are stable, in the U.S. please call poison control – a free, 24-7 service that lets you speak to a physician specializing in toxicology. The number is 1-800-222-1222, and should be in everyone’s phones. It’s also good when your child breaks a glow stick and gets the glow-juice in their eyes or mouth, for example.

A good source of information for parents is Healthy Children from the American Academy of Pediatrics. This link is to their post on parenting in a pandemic, and this one is information for families with kids with special needs.

Another common question from parents is “How did my kid get sick now, after they’ve been home for a month?!”. My colleague Dr. Iannelli addressed this in a comprehensive post here.

Finally, please be wary of where your information comes from, and what bias it might have. The pandemic has lead to a large increase in false information being passed around. NPR has a great comic (with cats!) to help us all spot faux information

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Stay home, stay safe, and be well!

The first thing most people ask are the symptoms, and how to distinguish them from a cold, influenza or allergy.

Covid vs Cold vs Flu Vs Allergies

The second thing I am usually asked is about the how many people are affected. Currently, the best source for information on COVID-19 cases in the USA is Johns Hopkins University. The best source for local information on what to do is your local health department (this link takes you to the Los Angeles Department of Public Health coronavirus information page, for example) and your primary care physician.

StayHome

As I wrote this, California is “social distancing” and will remain so for a while. I think social distancing should actually be called physical distancing, because the point is to stay as far away from as many people as possible. When you do need to go out you can reduce your risk of catching anything, or passing on the virus, by wearing a mask (only for kids age 2 and above!), washing your hands frequently, leaving your shoes at the door, instead of tracking in whatever is on them inside your house, and bathing and changing clothes when you get home. 

20200420_144532Why you should wear a mask (click on the sentence).

How to make a mask.

How to wear a mask correctly

How to use gloves correctly.

Food safety.

Cleaning your home.

Babies and toddlers under age 2 should NOT wear a mask and should NOT have anything covering their mouth and nose, due to the risk of suffocation.

If you or your child accidentally gets cleaning fluid, or anything else that could be dangerous, in their mouth, nose, or eyes, and they are stable, in the U.S. please call poison control – a free, 24-7 service that lets you speak to a physician specializing in toxicology. The number is 1-800-222-1222, and should be in everyone’s phones. It’s also good when your child breaks a glow stick and gets the glow-juice in their eyes or mouth, for example.

A good source of information for parents is Healthy Children from the American Academy of Pediatrics. This link is to their post on parenting in a pandemic, and this one is information for families with kids with special needs.

Another common question from parents is “How did my kid get sick now, after they’ve been home for a month?!”. My colleague Dr. Iannelli addressed this in a comprehensive post here.

Finally, please be wary of where your information comes from, and what bias it might have. The pandemic has lead to a large increase in false information being passed around. NPR has a great comic (with cats!) to help us all spot faux information

FB_IMG_1587356743760

Stay home, stay safe, and be well!

Coronavirus COVID-19 Information

COVID-19 information for families

This post is to summarize all of the current information and links I have been sharing regarding the 2019-2020 pandemic #coronavirus illness, as of March 11, 2020.

To clarify, COVID-19 is the name of the illness, and the type of coronavirus that causes this illness is the SARS-CoV-2 strain. Coronaviruses in general are quite common, and usually only cause mild colds, but this new strain attaches to receptors in our lungs, instead of just our noses/ upper airways. It is more closely related to other outbreak strains that caused MERS and SARS, the main difference being that COVID-19 is far less deadly than those, while being more easy to spread. This means that more people will get sick with the mild form of the virus, and spread it. Unfortunately, the latest numbers show it is still at least 5 times as deadly as the regular seasonal flu (influenza case fatality rate, or CFR, 0.1% in the U.S.A., best epidemiology guess on total CFR for COVID-19 is 0.5% from several sources, including the American Hospital Association, but it could be as high as 10% if spread is not controlled and there are not enough hospital beds and ventilators, so anywhere from 5 times to 100 times more deadly than influenza). For more on the CFR and risks, please look at the end of this blog.

For a great video that you can watch WITH YOUR KIDS, please see Brain Pop (the links will open in a new window). You can also click here to see a comic about this new virus, made for kids, but nice for the whole family.

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Check out the World Health Organization COVID-19 Outbreak page for the latest statistics, videos, and science.

WHO Symptom Comparison

Symptoms of COVID-19 are similar to influenza, but there is still a lot of influenza going around right now, so don’t forget to get your flu shot to reduce your chances of being hospitalized or worse with the flu! Symptoms of COVID-19 to watch out for include are fever with shortness of breath.

Case Fatality Rates for COVID19 by age

The good news for parents is that young children are much, much less likely to become sick enough to need the hospital or die of COVID-19, worldwide. Children usually have mild cold symptoms, or may be silent carriers (have the virus passed to them, but get no symptoms, but be able to pass it on to others). This does not mean to ignore serious symptoms in your kids, but at least there is some hope. The elderly, especially those with lung and heart problems, are the most at risk for getting very ill and dying from COVID-19, but everyone has some risk, and everyone can spread it to the others. Therefore, we ALL need to do our part to flatten the curve! Currently, you can help by staying home, physically distancing, wearing a mask (only age 2 years and above) if you go out, and washing your hands a lot.

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To prevent yourself from getting sick, or even passing on germs, the most important thing you can do is WASH YOUR HANDS!!!

Coronaviruses have a fatty outer layer which makes them very easy to kill with soap. Use warm water, any regular soap (it does not have to be labeled anti-bacterial), and SCRUB for more than 20 seconds. Get all of the nooks and crannies, and create friction while washing. Then rinse and dry. This method is much better than using hand sanitizer gels. Use those if there is no access to soap and water, but use soap and water when possible.

Coronaviruses can live on some surfaces for days, if not cleaned, so wipe down surfaces and clean your home and work areas with sanitizing wipes or diluted bleach (click on the underlined words for links on how to make it at home).

Try and keep your hands off your face, and remind your kids to do the same. Face masks can prevent you from exhaling your germs onto other people (regardless of which germs you have), so if everyone wears them, even silent carriers will reduce spreading the illness. However, please do NOT hoard face masks!!! Currently, there is a worldwide shortage so bad that hospitals and clinics are unable to buy them for the people that are actually at risk.

20200420_144532

If you think you might have this virus, please CALL your doctor first, do not go straight into the office.

Most clinics in the USA still do not have tests for COVID-19, as of March 10, 2020. Some clinics, especially on the West Coast, in states whose governments have agreed to pay for testing, like California and Washington, are now able to send the test to commercial labs, like LabCorp. However, that doesn’t mean your insurance or the state will pay for your specific test with your criteria, and they could be quite expensive, so please triple check.  The department of public health is running free tests for people at high risk (such as known contact of someone with COVID-19, or hospitalized in the ICU with risk factors, or very ill and recent travel history), so your physician can help direct you to where you need to go, if you qualify for testing. If you are being tested or think you might have the virus, you also need to keep yourself totally isolated until you get a negative test result, or continue to be isolated if positive. That means no school, no supermarket, no playdates, no park, etc.

If you are very ill (such as short of breath, chest pain, dehydration), call 911 or go to the emergency room. If you have fever, cough, sore throat, or other symptoms that are getting worse, or not going away with usual care, make an appointment to see your doctor – we are still seeing plenty of influenza and strep throat. However, you must let the scheduler know if you have been traveling in the last 14 days or have had direct contact with someone who is positive for the virus.

Treatment of COVID-19 is mostly supportive – alleviating the symptoms, while waiting for the body to heal itself.

Around 80% of cases just have mild symptoms, similar to the common cold, so treat it that way: nasal saline mist in the nose, a clean humidifier with distilled water, etc. For specific tips, see this post. For a small subset of people, mainly the elderly with comorbidities, especially smokers, COVID-19 can progress to pneumonia and/or ARDS, which may be deadly. Early treatment plans included steroids and antibiotics, but we now know that steroids are not recommended for outpatient treatment in most cases because they prolong the illness, and do not prevent its progression, and antibiotics are not indicated because the pneumonias that the virus cases are viral pneumonias, and there is very little secondary bacterial pneumonia. (Antibiotics only kill bacteria. Compare this to influenza, where secondary bacterial pneumonias are much more common, and antibiotics are indicated if that happens).

Here are more links with easy to read information about COVID-19:

Summary information from Dr. LaSalle.

5 Things To Do If You’re Worried About Coronavirus In The U.S. 

Mixed Messaging – What You Need To Know

A letter from a PhD in Public Health about COVID-19. 

In conclusion, prepare yourselves and your families, but there is no need to panic. This is not the zombie apocalypse, but it will be a lot worse than a bad flu season. Do your part by physically distancing, washing your hands, staying home, and encouraging social distancing. One thing that makes things out of control is people’s over reactions, so please stay calm and help your neighbors. When in doubt, ask your doctor.

P.S. A bit about CFR / Mortality Rates – as of 3/8/2020

As we get some great news on very low death rates from places like South Korea, and predictions from some US organizations, the World Health Organization conversely has higher CFR (case fatality rates) rates published. Why the discrepancy?
To get the CFR, you take the number of people who have died from the illness and you compare that to the number of people who have been infected with the virus. The humongous difference in reported rates is because of this bottom number – the number of people infected. To get this number we use the number of positive tests. But that does not account for silent carriers and people with mild diseases, except in places where they actually test everybody. 
In South Korea, they have drive-by testing for SARS-Cov-2 (the virus that causes COVID-19 illness, aka the novel Coronavirus) for everyone- if you feel sick or you just want to, you drive up, someone comes and swabs your nose, and you get results later. They currently run 15,000 tests EVERY DAY. This way they know actual background rates of how many people are infected. They publish these numbers online at their center for disease control daily. Their mortality rate is currently only around 0.6% (that’s less than 1%, which is great, but still 6 times higher than seasonal influenza’s CFR).
The WHO is also being transparent in their math, but they use numbers from many countries where they only test the people who are sick enough to be hospitalized. This is similar to what the USA does, but here we are currently only testing a small subset of those cases, so we do not have accurate numbers of how many people are actually infected in the USA. Therefore, the WHO gets a 3-4% case fatality rate based on people who are already very sick with COVID-19, not all of the people infected or exposed.
The BMJ is publishing a report that gets a CFR somewhere in between these two reports, at 1.6% for China alone, based on statistical modeling that takes into account that people with very mild disease may not be tested at all, but still uses the numbers officially given by China, which some people say is much lower than their reality.
The CFR age stratification risk chart is based on the WHO criteria, so the risks is actually likely lower than this chart. Still, it doesn’t comfort the families of the 2 men in their 20s who are currently hospitalized with ARDS in the USA as of this posting.
Case Fatality Rates for COVID19 by age

The take away from that is that we should be testing more people, and starting to quarantine ourselves more in the USA. The more we do this, the lower our own CFR will be. So please, cancel those big parties and conferences, and play some board games or do some art with your kids. It will be healthier for the whole country. 

For more on why social distancing and canceling plans is very important, click here.

Understanding American Health Insurance

Health insurance in the U.S.A. frequently changes and is never to simple. Two different people may both have “Aetna PPO”, for example, but with different plans within that insurance company, because they work for different companies, or signed up for different levels. Therefore the same plan name may cover different physicians, procedures, and medications, and have different deductibles or fee schedules, so that two people who think they have the same insurance actually have very different medical bills.

For PPOs: Before seeing your physician for anything, check with their office as to the officially billed name or doctor’s name (often only the main doctor that owns the practice) that is billed to your insurance, then check with your insurance that this physician is covered. Ask ahead about any regular procedures for your child’s next check-up (like vision screening at 6 months old, and lead screening at 9-12 months old), then you can check with your insurance company ahead of time to make sure those individual procedures are covered benefits, and if not, how much they will cost.

For HMOs, your primary care physician name is on your insurance card, and you can only go to that person’s office for your primary care. You must also see this doctor in order to get an official referral before seeing a specialist or having any imaging or lab tests done.

Here are some handy blog links to help you learn more about insurance. Good luck!

Health Insurance Overview: Here and here.

Health Insurance Basics from the U.S. Government

U.S.A. Insurance Today

Prior Authorization Calls

 

A Spoon-full of Sugar Helps the Medicine Go Down

Lots of parents have trouble getting their children to take medicine, so here are some tips to help:

Some techniques to help medicine go down easier:

Marry Poppins was right- a spoon-full of sugar helps the medicine go down! More accurately, a spoon-full of chocolate syrup will cover up the taste of most yucky medications. Apple sauce and yogurt are other common foods used to mask bad tastes. Many medications can be made to taste like your child’s favorite flavor by the pharmacist before you even pick it up, so ask about this when you submit your prescription. Some medications come in “orally dissolving tablets” which kids (age 3 and older) can put in their mouth and they will dissolve without having to chew or swallow.

Liquid meds are often easiest to give to babies with a syringe (a tube that looks like shot, but does NOT have a needle on it), which you can get at any pharmacy, baby store, or from your physician. Squirt small amounts of medication into your baby’s cheek and they’ll usually swallow it. Don’t squirt it directly onto their tongue or into the back of their throat, as this can lead to gagging. Follow-up with breast milk or formula (whatever they normally drink), before giving the next part of the dose. Alternatively, you can put the liquid medication in a bottle nipple along with a little breast milk/formula, and have them suck directly from the nipple, without the bottle attached. I do not recommend mixing the medication in a whole bottle, unless you know the baby will take the whole thing regardless of taste.

Most baby stores also sell special devices to help kids swallow medications,such as something that looks like a bottle, but keeps the medication separate, so you know exactly how much the child takes. I do not recommend giving children medications with droppers, because it’s difficult to measure the amount you’re giving, difficult to get all of the medication out of the dropper, and difficult to clean and dry the dropper fully between each use.

Learning how to swallow pills:

Once your child is ready to swallow pills (often by age 5!), it’s a great help to teach them how, since many medications are easier to take in pill form, the older they get, the bigger the dose, and some medications are not available in liquid/ chewable form. Starting young can also be beneficial in preventing anxiety associated with swallowing pills. Adolescents and adults often have trouble swallowing pills because they fear that the pill will get stuck in their throats. Relaxation techniques and deep breathing can help. Looking in a mirror, sticking your tongue out, and saying “aaah” out loud (this lifts the palate so you can see your throat), can help people see that their throat is much bigger then the pill, and ease some of the anxiety.

The first step in learning how to swallow a pill is to practice with something that is NOT medication. I recommend starting with small, smooth, round candies (such as mini m&m’s), and progressing to slightly larger candies (such as regular m&m’s). People with anxiety may want to start with tiny candies, such as sprinkles. Other people prefer to start with tiny bread balls (made from mashing a tiny piece of bread between your fingers), and go progressively bigger, since the bread dissolves easily in the throat. You will also need a big glass of water, juice, or carbonated beverage (such as plain soda water, which the pill can float on).

Younger kids can be told to just try swallowing the candy without chewing, because they are often successful without thinking about it. Older children, or those without a natural tendency to swallowing whole pieces, can start by visualizing the item floating down their throat on water, like a little boat. They should start by making sure the mouth is moist, by salivating or taking a sip of their drink. Nest place the candy as far back on the tongue as possible, using the teeth to scrape the candy to the back of the tongue (a mirror helps some people see how far back it is). Then take a big gulp of the liquid, which should float the candy and allow it to be swallowed, just as you would usually swallow any regular drink. Some children will swallow the candy (and later pills) more easily by drinking the liquid through a straw.

When it comes to taking real medicine, some people hide their pills in mini-marshmallows, which are slippery when wet, and therefore easier to swallow. I recommend trying this without medication first, since these are bigger then most pills. You can also try covering the pills in chocolate syrup, applesauce, yogurt, or jam (but see the warnings below before trying that).

I suggest experimenting with these techniques in a relaxed environment until you find something that works for you.

Warnings:

These techniques are for generally healthy children, with normal anatomy and mentation! They should not be used for children with any anatomical abnormalities, dysphagia (trouble swallowing regular foods or drinks), or any medical conditions that effect swallowing, the head/face, the GI system, or the neurological system.

All children should be supervised when practicing swallowing candies, and when taking ANY medication. NEVER tell your child that the medication is candy, as this can cause them to sneak some more when you’re not looking (many medications these days actually do taste like candy). Always keep medications (over the counter and prescription) and vitamins/ supplements out of reach AND in a LOCKED container. Kids are good at climbing and getting into high cabinets, purses, closets, and other hiding places.

Please speak to your pharmacist (who is usually in the back of the store, who has spent at least 5 years in post-graduate university studies, getting a doctorate degree in pharmacy), about what you can take your medication with, and whether you can cut, crush, chew, or open the medication. Many medications should NOT be taken with grapefruit juice. Some medications should NOT be taken with anything dairy. Some pills can be crushed and mixed with foods, where as others can not. Your pharmacist and/ or physician are the best people to speak to before taking your medication with anything but water.

Stomach bugs: what to do if your child is throwing up or having diarrhea

Vomiting and diarrhea viruses are not fun for anyone. Doctors refer to the most common cause of these symptoms as “viral gastroenteritis”. Some kids just vomit, some kids just have diarrhea, and the most unlucky have both. 

Most of these illnesses do not need to be treated with medications (antibiotics can make it worse, since they also kill the good bacteria in your tummy), and anti-diarrheal medicines (like Imodium) can be harmful to children. The most important thing is to keep your child HYDRATED (more on that below). If you suspect your child has vomiting or diarrhea from food poisoning or any other type of foreign ingestion, please call poison control 1-800-222-1222, who are free and staffed with physicians 24-7!

How can you tell if your child is starting to get dehydrated?

– their mouth/lips are very dry

– they are peeing less than usual

– they are thirsty

Now what?

You need to keep your child hydrated!

– A baby can continue to breast feed or take infant formula, if they are just a little dehydrated. If they vomit after every feeding, or are refusing the breast/bottle, then try to hydrate them with an Oral Rehydration Solution, like Pedialyte. Warning: the plain ones taste like salt water, so I suggest getting a few flavored ones and trying them out, to see which ones they will take. If they refuse the bottle completely, you can try feeding them via a syringe or spoon, giving small amounts every 15 minutes.

– A child who is getting electrolytes from food (such as chicken soup, or crackers, even if it’s just a little bit) can hydrate with water. If they are not taking in any food, or if they are throwing up the food, please hydrate them with an ELECTROLYTE solution (aka Oral Rehydration Solution, aka ORS). You can buy them at most USA markets (under brand name Pedialyte, or generic versions), you can make your own by mixing 1 liter (5 cups) clean water with 6 level teaspoons (=2 tablespoons) sugar and 1/2 teaspoon salt. You can add a little bit of orange juice or a banana for potassium. Common substitutions are rice water, congee, green coconut water, or mixing gatorade with water (although I do not recommend doing this, since it is hard to get the right balance of electrolytes this way). If your child does not want to drink, try giving them sips every 15-30 minutes, or giving them the ORS/Pedialyte in frozen popsicle form.

– For every age, and everybody in the house, WASH YOUR HANDS A LOT to prevent spread/transmission of the stuff that gets you sick. Teach everyone to wash their hands in warm water, scrubbing for at least 20 seconds (2 rounds of the Happy Birthday song). Try and use real soap and water, instead of no-rinse hand sanitizers, since they do a better job at killing the tummy microbes.

But what if they keep vomiting?

– Let their tummy rest.

– Call your pediatrician, or go to the hospital, if they have signs of dehydration tat are not resolved by giving fluids by mouth (see more below).

– Ask your pediatrician if your child is old enough and healthy enough for a medication against nausea/vomiting.

– Start with no food, but still give an electrolyte fluid (like pedialyte or ORS above), for the first 12 hours.

– When they are ready/want to eat, give bland foods (e.g. the popular rice, toast, soup broth, apple sauce) and avoid foods that are fried, acidic, oily, or contain milk.

But what if they have icky diarrhea?

– Change the diaper or bring them to the toilet frequently. Use a LOT of diaper cream to keep the area from getting chapped/sore. Put on a zinc cream (like the purple desitin) as if you are icing a cake – this acts as a barrier layer, to prevent acidic poop from sitting on the skin.

– Feed them binding foods, like rice.

– Sometimes the microbes that cause diarrhea, also cause a temporary lactose (the sugar in cow’s milk) intolerance, so avoid lactose-containing stuff, like cow’s milk and cheese. You usually have to do this for 2-4 weeks after the onset of the illness, until their GI system is back to normal.

– Try a children’s probiotic with lactobacillus once per day, such as children’s culturelle.

When my patients get sick this way, I often refer them to the great patient resources at UpToDate, such as this one on nausea and vomiting in children:

http://www.uptodate.com/contents/nausea-and-vomiting-in-infants-and-children-beyond-the-basics?detectedLanguage=en&source=search_result&search=patient+information&selectedTitle=7~150&provider=noProvider

or this one on diarrhea in children:

http://www.uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics?source=see_link

How can you tell if your child is dehydrated enough to warrant intervention (like an urgent care or ER), or at least a call to your pediatrician?

– they are not urinating (peeing)  often enough (every 4-6 hours for a baby, every 6-8 hours for a toddler/child, every 8-12 hours for an older child/teenager)

– they are crying, but can not make tears

– they are an infant whose fontanel (soft spot on top of the head) is more sunken than usual

– eyes look very sunken

What are some other signs that I should call my pediatrician about, or head over to the local urgent care/ER?

– persistent high fever (above 102.5 F)

– any fever in an baby younger than 3 months old

– severe abdominal (tummy) pain

– abdominal pain that moves to the lower right side

– lethargy or decreased responsiveness

– bloody (red or black) or bright green (like pea soup) vomit or diarrhea

– diarrhea not improving after 1 week

 

The good news is that most of these illnesses pass quickly without any medications, so hang in there, and keep washing your hands with soap and warm water!

Coughs, Colds and Croup

Even though it’s a beautiful Spring here in Southern California, we are still seeing some coughs, colds and croup, so here are my tips to help keep your family comfortable as they clear their viruses:

Helping a child with nose congestion:

–          Use a nasal saline mist (the kind that comes in a metal can, not drops) to spray moisture into each nostril and help clear her out. I like the mists more than the drops because you can hold the canister right below her nose and spray it in, without touching the canister to the actual nose, and without sticking anything directly up the nose. These are also sterile, so you don’t have to worry about the water source. The mist is gentle and cleans out the nose better than the drops.

–          Use a humidifier. Only put distilled or sterile water into it (not tap water). Clean it at least every 3 days. Do NOT use the menthol or eucalyptus discs/drops that come with some humidifiers.

–          If your child suffers from allergies and is over age 4, you can use an over the counter antihistamine to help dry her up (e.g. children’s Benadryl). Under age 4: ask your pediatrician about these. Do NOT use the over the counter medications known as “decongestants” or “medicated cough syrups”, as these have been shown to have more risks than benefits in children under age 6 years old.

–          If your child is very congested you can steam up your bathroom and sit in the bathroom with your child. Make sure the air is okay and the child does not have any access to the hot water. Never leave a child alone in the steam!

–    If you want to, you can use a vapor rub on the feet or chest of a child. It has not been proven to help or hurt. However, do not let the rub get near her nose or mouth! Vapor rub placed under the nose has been reported to cause wheezing in some children, and it is dangerous to ingest. Call poison control if your child eats any of this, or gets it in their eye 1-800-222-1222 (an important number to keep in your cell phone for emergencies).

–          Children under age 2 years usually can not blow their noses, so help decongest them (e.g. get the boogies out) by using a snot sucker device such as the Nose Frida (http://www.fridababy.com/) -you put in the nostril and use to literally suck the snot out. Sounds gross, but there is a filter (which needs to be changed every day) which prevents you from getting any snot in your mouth. You can do this before feeds and before sleep, or just as needed to clear out the mucus in your baby’s nose. I like this better than traditional nasal aspirators because it’s much easier to clean, is difficult to put it too far into the baby’s nose, and it gets a lot more of the snot out. The key to good suction is to hold the other nostril closed, when you suck out boogers from the first nostril (should take less than 1 second).

Helping a child with a “wet” or “phlegmy” cough:

Do all of the above for nasal congestion plus the following:

–          Have your child sleep propped up at 30 degrees so the mucus drains easily.

–          Give children over age 1 year a big spoonful of honey twice a day. The honey has been shown to help relieve cough symptoms in kids & help them sleep, in published randomized control trials (scientific studies). The honey they used was NOT “raw”, which can have dangerous bacteria in it. nor was it Menuka. Just plain pasteurized honey from the store works.

–     Warm liquids, such as chamomile (caffeine-free) tea and lemon, or chicken soup, can help people feel better.

–          Zinc may help shorten colds and soothe sore throats, but this has not been proven conclusively. You can get this in some non-medicated cough syrups, such as Zarbees (for over age 1 since it also contains honey), or in zinc lollipops (over age 2, observing child while they eat them). If your child is over age 6 years you can give him the zinc cough drops that are available at all pharmacies, but please supervise to prevent choking.

Helping a child with a dry, barking, or croupy cough:

Do all of the above for nasal congestion & wet coughs plus the following:

–          Use a cool-mist humidifier. Use distilled/sterile water in it. Clean it at least every 3 days by rinsing out the water tank with distilled vinegar and then washing that out. Do not put oils in the water.

–          If the child is having a coughing fit, or breathing like Darth Vader, take him/her for a walk outside in the cool air, or hold him/her in front of an open freezer for a few minutes, to reduce the swelling in the throat. If that is not helping, call your pediatrician for immediate medical advice, take the child to the office or ann ER. Please call 911 if (s)he is actually having trouble breathing.

Check out other mom pediatrician blogs on the topic, such as this one from Dr. Stuppy:

http://pediatricpartners.blogspot.com/2013/12/but-snot-is-green-or-how-can-we-treat.html

Other Important Stuff:

–          If your child is wheezing, noisy breathing, breathing hard, breathing quickly, breathing with flared nostrils, or other signs/symptoms not mentioned, please call your pediatrician or 911, or take them to the ER immediately. This information is not intended to act as a substitution for speaking to your physician or using common sense!

–          If your child is breathing so hard that they have trouble walking or talking, or if their lips or fingernails turn blue, please call 911 for immediate medical assistance.

Wheezing: Tips for Kids Using Inhalers

There are different kinds of metered dose inhalers (“MDI”):

1)      A “rescue inhaler” contains Albuterol or Levalbuterol, which opens up the lungs and reduces inflammation for quick relief. Brand names include Ventolin, ProAir, Proventil, or Xopenex. 6 puffs of these are equivalent to putting 1 vial of Albuterol or Xopenex in a nebulizer and sitting with the mask on your child for 15 minutes. These are usually used on an as-needed basis, up to every 4 hours. If your child needs to use this every 4 hours for more than 24 hours, needs it more often than every 4 hours, or needs this more than twice every week, please call your pediatrician.

2)      Some inhalers are used to prevent asthma, wheezing, and breathing trouble. These are only effective when used every day on a continuous basis. They are not used for fast-acting relief of an acute breathing difficulty, but may help when used during cold or allergy season, or if started right at the beginning of an asthma exacerbation or when a child is exposed to known triggers. Brand names of some of these medicines include Flovent, Qvar, Symbicort, Dullera or Advair. Flovent and Qvar are like using the Pulmicort/Budesonide in the nebulizer. Symbicort, Dulera and Advair also have other medicines in them for stronger asthma prevention. Please discuss if and when you should use these with your physician.

3)      There are also inhalers that contain powder or are not used with a spacer. Some brand names are: Maxair autohaler, Proair RespiClick, Asmanex Twisthaler, or Pulmicort Flexhaler. None of these need a spacer to work effectively, but these are only for older children who can control breathing in the medication and not breathing out into the device.

Please see the “Asthma Education For Kids” playlist from BoosterShotComics on YouTube, especially episode #1: “Iggy & The Inhalers” to better understand the roles of different medications used for wheezing or asthma. Episode 4 explains how to use a spacer with mouthpiece.

There are 4 main brands of spacers. They may be cheaper online than from a pharmacy, but always require a prescription.

1)      Aerochamber with flow-vu. This brand is a clear tube with colored ends and teddy bears on the side. It has a two-way valve (to get the medicine in and air out) and is anti-static (so the kid can inhale all of the medicine and it won’t stick to the sides). The flow-vu allows you to see when a child gets a breath with a good seal. There is a small orange one for infants, yellow medium one for age 1-5 years old, blue one with mask for older children that still need a mask, and blue one with mouth-piece for older kids that can seal their lips around it instead of having to use a mask (more comfortable, kids can usually start doing this around age 6).

2)      Vortex Non-Electrostatic Valved Holding Chamber. This device also has a two-way valve and is anti-static. It is metal, so it is more durable and machine-washable. It comes in 1 size with different sized masks that fit on the end. This has the advantage of only needing one device as the child grows older (you just switch the mask on the end, not the whole device).

3)      Optichamber. The original device is a plastic tube with 1-way valve that most pharmacies try to give our patients. Some versions are NOT anti-static, therefore much of the medicine sticks to the plastic, instead of being inhaled by the child. The single valve can make some children feel suffocated when breathing into the mask. I do NOT recommend this device. However, there is now an Optichamber Diamond version, which is anti-static, has a 2-way valve, and can be used comfortably. It comes with different size masks or a mouth piece, all clear, and very soft.

4)      InspiraChamber. This is a clear, anti-static, valved chamber, with purple ends. It offers very soft masks with a special place in the small mask to fit a pacifier, to calm the child while they inhale. It also has a flap that moves, so you can see if the child is taking a breath with a good seal and getting the medicine.

How to Use Your Inhaler:

Before using a new inhaler for the first time, shake it up, then put it into the spacer and press it 10-15 times to prime the device (e.g. makes sure the medicine is coming out in an even dose, and not just the propellent). The next time you use it, shake it first, but you do not need to prime it.

My son playing with his inhaler and spacer to get used to it

To use a spacer with a mask:

  • Shake the inhaler before each use.
  • Put the inhaler mouthpiece into the spacer.
  • Hold the mask over your child’s nose and mouth and create a good seal. Holding your fingers like the letter C can help. If you’re using a device with flow view, you should see the flap move with each breath the child takes. Otherwise look at the child’s chest to count breaths.
  • Press the inhaler.
  • Have your child breath in and out six times (about 30 seconds).
  • Remove the mask and let your child breath normally for a minute.
  • Repeat if more than one puff was prescribed (most inhalers need 2 puffs per dose, but some use more or less).

While your younger child may not like the spacer and mask being held over his mouth and nose, it will go much quicker than using a nebulizer. Let the child play with it and practice putting it on stuffed animals or family members to make them comfortable. Some children will allow you to use it if they get to be the ones to hold it or press the inhaler (just make sure the seal is tight over their face so they get all of the medicine).

To use a spacer with mouthpiece (older children and adults):

  • Shake the inhaler before each use.
  • Put the inhaler into the spacer.
  • Have your child seal their lips around the mouthpiece and exhale.
  • Press the inhaler.
  • Have your child breath the medicine in and hold their breath for about 30 seconds. If they can’t hold their breath, they can take another breath or 2 in to get more medicine from that puff (any extra medicine should be sitting in the chamber).
  • Take the spacer out of their mouth and have the child breath normally for a minute.
  • Repeat if more than one puff was prescribed.

Keep in mind that while many experts believe that an MDI with a spacer is as good as, or better than, a nebulized treatment, some parents prefer a nebulizer, and that is okay.

If you are not sure if your child is actually wheezing, or what they have, this blog from Dr. Stuppy can help, with descriptions of different kinds of coughs and breathing, along with youtube video links.

If your child does NOT have asthma, reactive airway disease, wheezing, bronchospasm, or difficulty breathing, my post on Coughs, Colds and Croup may be more helpful.

Please note that this guide is NOT intended to diagnose or treat any illness or condition. Always speak to your own physician for advice.