There is Still a Pandemic in Florida Folks!

I opened the local newspaper to headlines that the Palm Beach County Commission has opened county facilities but is not requiring visitors to wear masks, facial coverings or observe social distancing rules.  A county commissioner was quoted as believing that it was not within their authority to require facial coverings.  Strange opinion when they have closed businesses , facilities and services due to COVID-19 and then reopened them independent of Public Health, CDC or even White House guiding rules and regulations and published the conditions under which these facilities will open and operate.  I imagine, or hope, the County civil servants have union representation that will address the issue of their employees being called back to work with their health and safety being taken for granted.

Recently, I spoke to a patient who believes COVID-19 is overblown. They are closer to 80 years old than 70, continues to smoke tobacco regularly despite having documented coronary artery disease and is incensed that the free flow of patients has not restarted in our medical practice.

I keep coming back to the same question.  Despite our Governor opening the state up again, what has changed medically or scientifically?

  1. We still do not have an onsite quick accurate test to determine if a patient has COVID-19 and is a contagious asymptomatic carrier. Yes, testing sites have increased but most test results come from a lab with a 48-hour wait delay.  Our local medical center, Boca Raton Regional Hospital Baptist Health system has on the physician website a request to only perform quick in-house COVID-19 testing one time on admitted patients only because they do not have enough supplies on hand.  Patient’s presenting to the Emergency Department still receive a nasal swab which is sent to an outside reference lab and results take 48 hours.
  2. We don’t have enough personal protective equipment for hospital staff to change masks, capes, face shields and gloves according to their own guidelines for treating an infectious patient and preventing transmission of the pathogen to others, including you! In view of the shortage of equipment, the CDC and hospital infectious disease departments have relaxed their own guidelines several times to ensure their guidelines agree with the way equipment is being used.
  3. We still do not have a treatment other than supportive care. Yes, there is some evidence that remdesevir early in the course helps and that a triple drug regimen in more severe cases helps.
  4. We are still months away from having a vaccine.

In Palm Beach County, civic leaders admit they bowed to the pressure of struggling businesses, distressed parents out of work, and home with school age children, and political pressure from Washington and Tallahassee in deciding to open the economy back up.  With Palm Beach County opening May 11th and Dade and Broward County on May 18th, we should begin to see an increased infection rate over the next two weeks based on the incubation period of COVID-19 and its complication rate developing around Day 8 or 9.  

I sincerely hope I am wrong about this, but my infectious disease colleagues, critical care colleagues and Emergency Department colleagues have shared this professional opinion with me.  This disease infects and kills youngsters, young adults, teenagers as well as senior citizens.  Asymptomatic carriers of the COVID-19 bug infect 5.7 individuals before they discover they are sick. 

Despite this, we ask county employees and restaurant servers to spend time up close with no requirement to wear a facial covering.  Tell me, what has changed other than the level of patience of our elected officials and their overwhelming desire to gain public favor and get re-elected regardless of the health care costs and carnage from COVID-19?

I’m Dealing With the Silent Fear of Infection

I saw a patient yesterday with a cough and intermittent fevers. I believe based on her history she is a low risk for COVID-19 disease. One must treat all patients as if they have COVID-19 until proven otherwise so I wore a double mask including a N95 respirator mask, a face shield and gloves.  The face shield limits your peripheral vision and fogs up easily as do your glasses. I could feel and hear my heart pounding and racing as I got close to the patient for an exam and the sweat pouring down my forehead into my eyes stinging and burning did not help.

The visit was uneventful.  I maintained my sanitary protective field, removed my protective gear afterward, as per protocol, and washed up extensively. The weather outside was stormy with torrential rain, thunder, lightening, high winds, flooding and some hail – adding to the apocalyptic climate that now exists in the patient care arena.

Yes, I began to relax some as the visit progressed but there was always this uneasiness wondering if I careful enough?   It reminded me of 1979 before we knew what the HIV virus was and what AIDS was. I was seeing a brand-new patient in the intensive care unit of Boca Raton Community Hospital. He was the editor of an internationally known tabloid published just north of Boca Raton.

Married to a French national, he had left New York to come oversee this paper and had taken ill.   I had seen many cases of this immune system destroying disease during my residency in Miami at Jackson Memorial Hospital. This obese gentleman struggling to breath had none of the risk factors for this new disease. He denied drug use or intravenous drug use. He denied being in relations with other men.  How could he possibly have this horrible new disease with none of the risk factors. His wife was testy when I questioned her alone about private and personal areas of their relationship all necessary to determine her husband’s risk of having this immune destroying disease. She was vigorous in her defense of his very ordinary, very traditional behavior.

In those days we rarely wore gloves to draw blood. It was unheard of. We rarely put on gloves to start an IV line. With this disease things were different.  I was in a paper gown, gloves, face mask, goggles and face shield as was the young pulmonary expert I was working with.  The confinement of the personal protective gear and the warmth and fogginess of your vision led to a rapid pounding heartbeat and the same sweating I was experiencing 40 years later. It calmed down some as we got into the procedure.  I was wearing scrubs then which never left the hospital locker room. I am wearing scrubs now which never leave my office. I come to work in pants, shirt and tie and change into special scrubs plus sneakers that are kept here. At the end of the day the scrubs go into a laundry bin. 

As a physician who cares for patients, I need to take this risk. As a human being over 60 years of age I realize I am high risk for developing complications and death if I catch the COVID-19 virus. I am most afraid of transmitting it to my wife, my children, my grandchildren unknowingly. I hope they have the courage to put up with my risk taking.

Absence of Leadership Is Why COVID-19 Is Destroying The USA

Two articles arrived at my desk discussing the ongoing tragedy of COVID-19. One is written in the New England Journal of Medicine by Dr. Eric Schneider. Dr Schneider sees the ability to test someone quickly and reliably as the only way out of the pandemic and back to some degree of normal life without there being mass casualties and deaths. He is appalled that foreign nations with far less developed scientific communities have developed testing and contact tracing so that they can limit the spread of the disease while safely opening those societies again. 

He cites the failure of the Trump administration to heed warnings, prepare for the arrival of the virus and more importantly to produce, distribute and test the public while collecting and organizing the data as the only reason we are now left with “non pharmacological interventions (NPIs)”   Shutting down society and staying at home is our only successful  NPI option to date.  He goes on to criticize the administration for looking for that magic cure with a medication or a quick vaccine which the scientists working on them insist will take longer than the President claims it will.  While Dr. Schneider believes that NPI’s have been successful, they carry their own price of economic ruin, social isolation and a restless population now demonstrating loudly to resume commerce and normal activities even though the infection rate and death rate will be so much higher. 

An editorial in the revered British Journal The Lancet today discusses the need to revive the CDC. The editorial highlights the history of the Center for Disease Control and its role as a world leader in public health and safety.  It then goes on to illustrate how the Ronald Reagan and George W. Bush administrations, and now the Trump administration, have destroyed its funding and marginalized its role.

The Lancet editorial board first criticizes those administrations for reducing funding when the CDC was leading the fight against HIV disease worldwide. The current administration has eliminated funding and support even further.

The CDC always kept pandemic surveillance personnel in China since Asia has always been a birthplace of new serious viral illnesses such as SARS, Bird Flu and MERS. Funding elimination resulted in the last CDC surveillance officer leaving China in July of 2019.

When the current CDC Director Nancy Meissonier, MD warned the world about the COVID-19 pandemic on February 25, 2020; she was removed from White House briefings and public appearances because of her prophetic statement. “The CDC needs a director who can provide leadership without the threat of being silenced and who has the technical capacity to lead today’s complicated effor. Americans must put a president in the White House come January 2021, who will understand that public health should not be guided by partisan politics.”

Easing the COVID-19 Restrictions

I read an article written by an infectious disease physician in the state of Georgia. She was quite critical of her Governor Kemp opening the society prior to the state of Georgia meeting the very minimal guidelines for reopening the economy set down by the Trump Administration.  She believes it is a mistake and will be followed in 14-21 days by an increased rate of infection and death.  I next read an article on the CNN website about the reopening of Wuhan, China for business.  Wuhan is a big industrial manufacturing and commerce center of 11 million people who were ground zero for this pandemic.  Businesses are staying closed. Restaurants that could open for takeout are closing because consumers are still afraid and staying home. They fear a second wave of infection and death.

I say this as an introduction to my trip south down to Palmetto Bay, Florida south of Miami in Dade County.  It is a residential community of single-family homes in a reasonably well-to-do and well -educated diverse community.

My daughter and son-in-law moved into that community this past summer. We have not seen them face to face in over six weeks of our self-isolation and stay at home sequestering and miss our 2-year-old grandson desperately.  We had a ton of supplies at our home for them that just never made it south due to the disruption of the pandemic.

My daughter is pregnant and isolated because she too is considered “high risk.”   The trip reminded me of the sci-fi apocalypse series Mad Max Road Warrior. Traffic was light on the Florida Turnpike as I creeped along doing 75 miles per hour in the right-hand lane with SUVs roaring past me at 120+ mph. At certain times, I would see an auto in the left lane doing 80+ mph with the middle and right lanes empty and a faster driver would pull up behind them and tailgate them for miles. It was unclear why they just did not change lanes and safely whiz on by.

When I exited the turnpike for the Palmetto Expressway west the amount of traffic was incredible.  We dodged speeders and creepers and made it to the end on US-1.  The streets south were jammed. As we turned off onto 152nd Avenue, we noticed the young homeowners of Palmetto Bay were all out in their driveways and streets with their children, no masks on and weren’t the social distancing guidelines recommended by Public Health Officials.

Three homes north of my daughter’s home a pool party was in progress with multiple vehicles in the driveway and people of all ages attending.   We dropped off the supplies in my daughter’s driveway, talked for 20 minutes through their impact windows and then headed home.

When I turned into my community and passed our children’s playground, still closed per executive order of the County and Governor, a high school graduation party was in progress.  Multiple vehicles from outside our non-gated community were parked at the park entrance and a large crowd of diverse ages was congregating and celebrating at distances far less than the suggested six feet.

While I am not a registered fortune teller, I do not need a crystal ball or Tarot cards to predict that 14-21 days from now there will be an increase in COVID-19 cases and deaths in Dade, Broward and Palm Beach Counties due to the reopening of the society.  No one seems to care about how highly transmittable this pathogen is and its devastating effects on the older population.

We are approaching off season in Florida. Traditionally the snowbirds or seasonal visitors go home, and the economy is supported by year-round residents most of whom are older Americans. Each newly infected Coronavirus victim, with or without symptoms, will transmit the disease to an average of 5.7 individuals before they know they are ill.

With the rush to open the economy in Florida championed by the Governor, following the President’s lead, if the over 60 crowd is sick or dead, who will financially support the economy this coming off season?

Aspirin Reduces the Risk of Several Gastrointestinal Cancers

With everyone focused on surviving the Coronavirus epidemic, it’s easy to miss articles dealing with issues other than COVID-9   The Annals of Oncology published a review study performed by Cristina Bosetti, M.D. and colleagues from Milan, Italy.  They performed a literature search examining studies looking at the relationship between aspirin consumption and gastrointestinal cancer.

They found that taking one or two aspirin per week was associated with a reduced risk of pancreatic cancer, colon and rectal cancer, squamous cell esophageal cancer, stomach cancer and hepatobiliary cancer.  When they looked specifically at colon and rectal cancer, they found the risk of developing the disease dropped with increased aspirin dosages. “An aspirin dosage between 75-100 mg a day was associated with a 10% reduction in a person’s risk of developing cancer compared to people not taking aspirin.  A dose of 325 mg a day was associated with a 35% reduction and a dose of 500 mg a day was associated with a 50% reduction in risk.

To obtain this type of risk reduction, patients had to be taking the prophylactic aspirin for a long time, at least 10 years. The ingestion of aspirin may have lowered the risk of intestinal cancer, but it carried with it the increased risk of bleeding.

Much has been written recently about the lack of protection against cardiovascular disease in patients without diabetes or documented heart disease who take daily aspirin. That may be true but there does appear to be a positive effect in preventing intestinal cancer. This is a complicated topic which should be discussed with your physician before embarking on a course of prevention.

Dogs, Cats and Coronavirus

There has been conflicting information on whether our pets can contract and pass on COVID-19 to other pets and humans. Initially, a report out of Wuhan, China noted that a dog tested positive for COVID-19 infection. Additional evaluation of that animal proved the test result was a false positive and the animal was neither ill nor contagious.

Several articles have appeared in newspapers and on TV news shows encouraging individuals to cuddle with their pets for anxiety and stress reduction. Then came the report out of New York City that one of the big cats at the Central Park Zoo tested positive for Coronavirus and was ill. Shortly thereafter, several more of the big cats tested positive.

This week an article was published in the peer reviewed journal called Science. Zhigao Bu, PhD, of Harbin University Veterinary Research Institute of the Chinese Academy of Agricultural Sciences in Harbin , China looked at whether animals could pass the virus through respiratory transmission. The purpose of the study was not initially to determine whether the virus could travel from pets to humans. The real purpose was to find an animal model that they could test new vaccines against COVID-19 on and test medication regimens.

They first looked at ferrets and found that while the virus could replicate in the upper respiratory tract of the animals for three to eight days, it did not make them sick and they were not contagious. They next turned to young cats. They inoculated their nasal passages with the virus and placed these infected kittens next to healthy kittens. They found that the virus was transmitted to the healthy non-inoculated cat with the animals developing the respiratory disease. Necrotic lesions were found in the respiratory tract of these test animals and they were found to transmit the virus by an airborne route.

They next tried the experiment on young beagles. While the virus was detected in the blood of the dogs inoculated with the virus, none of the healthy dogs exposed to them contracted the virus. The inoculated dogs developed antibodies against the disease but none of the beagles became ill. The dogs were felt to be non-contagious. Similar experiments showed that pigs, chickens and ducks did not contract the virus nor were they contagious to their species or humans when inoculated with the virus.

From their research it is probably true that dogs will not contract the disease and transmit it to other dogs or humans. It appears that felines however are susceptible to COVID-19 and may be a reservoir for the disease or a vector of transmission.

Ranitidine (ZANTAC) Removed from Market By FDA

Ranitidine is an H-2 receptor blocker marketed in the United States as Zantac. It is sold over the counter (OTC) without a prescription at the 20 mg dosage and with a prescription at the 40 mg dosage. It is used for peptic ulcer treatment, gastritis treatment, heartburn, gastroesophageal reflux and other diseases in which gastric acid causes inflammation of the lining of the stomach and discomfort.

It is being recalled because when manufacturing this product, new techniques are apparently inadvertently producing a probable carcinogen known as NDMA (N-Nitrosdimethylamaine). The longer the ranitidine sits around, the more NDMA is found. None of the levels measured are believed to be toxic.

Ranitidine is a relatively inexpensive blocker of histamine-2 receptor sites resulting in less digestive acid secretion in the stomach. The NDMA in the production product is the same chemical that resulted in the blood pressure medicine losartan and similar products being recalled. There are several alternative H-2 receptor blocker drugs on the market to replace ranitidine or Zantac. NDMA has not been found in Pepcid (famotidine), Tagamet (cimetidine), omeprazole (Nexium), lansoprazole (Prevacid) or omeprazole (Prilosec).

Globalization started during the Clinton administration, and encouraged by subsequent Republican and Democratic administrations, has resulted in pharmaceutical manufacturers moving their plants to Asia and other overseas areas where labor is cheaper, and regulations are less rigid. Ronald Reagan eliminated the Food and Drug Administration’s testing lab which set the gold standard for protecting Americans against tainted drugs. Prior to this action, no pharmaceutical product ever reached the American market and had to be recalled.

Subsequent administrations reduced the funding for the FDA, especially in the inspection department. With production now overseas, and virtually unregulated, we are dependent on the goodwill of foreign governments, and the liability attorneys for big pharma, to protect us from tainted products. Almost all antibiotics, both oral and intravenous, and all IV solutions are produced overseas in addition to most of the oral generics we are forced to take by our insurer every day.

We are currently living in a civilization altering pandemic with Coronavirus COVID-19. When this plague is under control, the country will need to reset our economy. My hope is that the big pharmaceutical firms will be legally forced to bring the pharmaceutical manufacturing back to U.S. soil. At the same time, the FDA inspection division needs to be funded fully to ensure that the products we need and ingest are safe and pure!