During the Pandemic: Medical Advice Is Challenged & Questioned While Patience is Thin

I, like most of the western civilized world, have had my fill of the pandemic. I see patience short both in the general population and in the medical community. The problem is that everyone seems to have lost their perspective and the value of education, experience and caring.

I received a phone call from a relatively new patient. He and his wife are recovering from breakthrough Covid-19. They are well past the point of being required to quarantine whether you use the original 14-day recommendation prior to vaccines, the revised 10-day program or the 5-day program. They still have deep, barking coughs. They do not have a fever, nor are they short of breath and they are not complaining of difficulty breathing. The cough keeps them up at night sometimes and produces clear to yellow phlegm. I advised patience, warm clear fluids, tea and honey, cough syrup and time. The patient asked for a Z-Pack (zithromycin , an antibiotic). I explained this was a viral illness not requiring an antibiotic and that the cough might be present for weeks to come. The message was poorly received.

Today as I was leaving the office the patient called back. He said that the stress of this all had stirred up his angina. He felt like he had an elephant sitting on his chest. I again asked if he was having trouble breathing and he said a bit more. He was not wheezing. He was talking comfortably on the phone. The symptoms associated with the pain did not include nausea, vomiting or massive sweating which sometimes are seen with an ongoing heart attack. The description of crushing chest pain like an elephant on the chest was sufficient to require an evaluation at a cardiac center. I suggested he sit down, take a nitroglycerin if he had one with him and call 911 immediately. He declined. He said it is probably just bronchitis and “If you don’t want to see me because of Covid issues I will just find a clinic to go to.” He told me he had heard on the news that there were no hospital beds and he didn’t want to wait for hours in an emergency room.

This patient has a history of high blood pressure, high cholesterol and had previously had a mini stroke . I explained that his complaints needed a cardiac center with heart rhythm monitoring, a quick lab to monitor cardiac enzymes and defibrillators with advanced cardiac life support trained personnel.

I called him back an hour later to see how he was feeling and what he decided to do. He was on his way to a clinic. “Must be bronchitis and if you won’t see me they will.”

As the pandemic rolls on there are no suggestions, recommendations or advice given that is not challenged and questioned. Sometimes I have to remind myself that we are on the same team, with the same goals of keeping you independent, healthy and feeling well.

I would expect with 20 plus years of schooling and training, and 40 plus years of experience and continuing education, my patients would remember we are on the same team and trust my professional experience rather than their own, or that of others, when it comes to the best interest of their health.

My interests and intent are to keep you healthy and well. However, there are medical conditions that cannot be safely seen in the office. A potential heart attack or ongoing stroke, a loss of consciousness, inability to breathe or unstoppable bleeding are a few of the conditions which require an ER not a walk-in center or physician’s office. When I suggest that a patient be seen in the emergency department I am doing so in the best interests of the patient!

I am not quite certain why when the advice is given, based on the information the patient and family provide, it is received with such skepticism?   I just know that skepticism and pushback are far greater now than they were before Covid appeared. 

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Optimizing Disease Detection and Containment Through a Waste-Before-Case Approach

by Megan Diamond – Manager, Health Initiative, The Rockefeller Foundation & Aparna Keshaviah – Senior Statistician, Mathematica

When a new public health threat emerges – like the highly infectious Omicron variant of the SARS-CoV-2 virus – detecting the first case before there has been widespread community transmission can be like searching for the proverbial needle in a haystack.

Yet wastewater testing is a tool optimized to do just that. People infected with SARS-CoV-2 shed the virus when they go to the bathroom – including asymptomatic people who may not even know they are infected. The sewers then act like large magnets, aggregating the virus particles found in feces into centralized locations where researchers and public health officials can take samples and detect the virus, sometimes before a clinical case emerges. In fact, over the past week, multiple cities in the United States were able to detect Omicron in the wastewater before a clinical case was identified.

As vaccinations plateau and testing declines, public health officials are looking for alternative means to passively collect data that provides real-time insights for decision-making. Wastewater testing does exactly that, at the fraction of the cost of clinical testing.

Wastewater-based epidemiology (WBE) is not a new field. Decades of evidence have shown that WBE is an effective tool for detecting outbreaks of pathogens like poliovirus and typhoid, with the potential for much more. And although it has been used in several countries, including in the United States, to monitor for SARS-CoV-2, ongoing questions remain on how to best interpret and use data derived from wastewater for pandemic response.

For example, wastewater data is inherently messy, and more work is needed to reliably distinguish signal from noise in viral concentrations collected from wastewater to detect a rising threat. It’s also unclear how wastewater data should be synthesized with other local public health data—such as clinical case counts and reports of Covid-like symptoms—to provide officials with a more holistic measure of Covid-19 risk in their community. The potential of sequencing viral RNA in wastewater remains underexplored, too.

The creation of the Wastewater Action Group (WAG) – which includes leading researchers and public health officials in Atlanta (Emory University), Houston, Louisville, Tribal Nations (Arizona State University) and Tulsa  – is one of the ways that The Rockefeller Foundation and PPI are supporting cities across the US to translate wastewater data into action.  Together, this network of partners is refining wastewater sampling, testing, and sequencing protocols; developing metrics and strategies for wastewater-based risk communication; and expanding wastewater testing to underserved populations that are not connected to centralized wastewater treatment plants.

The impact of these efforts are being seen in real time:

• In Houston, Texas, partners at the Houston Health Department and Rice University detected Omicron in the wastewater before a confirmed clinical case and subsequently sequenced positive samples from school children residing in the service areas of the wastewater treatment plan.
• In Louisville, Kentucky, partners at the University of Louisville and Louisville Metro Dept. Public Health & Wellness detected Omicron in the wastewater before a confirmed case in Jefferson County. Through close collaboration with the State of Kentucky, they can now do targeted sequencing within the community.
• In Tulsa, Oklahoma, partners at the Tulsa Health Department and University of Oklahoma saw an increase in influenza A virus concentration was detected in the wastewater, enabling quick communication to the public.

PPI recently met the growing need for rapid peer-to-peer learning by hosting an urgent meeting focused on wastewater sequencing in light of the emergence of Omicron. More than 30 wastewater testing leaders attended and since then, more than half have either reached out to someone they met on the call or adapted their response plans based on information shared during the session.

PPI is also dedicated to hearing from end users of public health data. Through a collaboration with Mathematica, The Rockefeller Foundation is fielding a nationwide survey among public health leaders.

The results of the survey could inform the development of decision-making tools for public health departments and help policymakers determine how they can best support wastewater surveillance across the country.

At present, no single data source provides a full picture of COVID-19. The most widely reported data—clinical case counts—overlook large swaths of the population that lack access to quality health care. As a result, the first signs of an outbreak are often detected weeks, if not months, after the emergence of a new threat. Wastewater testing is a way to fill this critical data gap.

The world can no longer wait for fragmented, delayed, and biased data. By supporting the development and scaling of wastewater-based epidemiologic tools and knowledge, PPI seeks to boost the capacity of public health officials to detect infectious disease outbreaks and prevent the next pandemic.

Concierge Medicine and the Pandemic

Twenty years ago I practiced internal medicine and geriatrics locally in a traditional medical practice. I cared for 2700 patients seen in 15-minute visits with an annual checkup being given a full 30 minutes. The majority of my patients were over 55 years old and many had already been patients for 10-20 years. The practice office revenue was enhanced by having an in house laboratory, chest x-ray machine, pulmonary function lab and flexible sigmoidoscopy colon cancer surveillance program. If patients needed more time, we allotted more time or, more likely, we just fell behind leaving patients stranded in the waiting room wondering when they would be seen. I had a robust hospital practice made easier by the fact that the hospital was a short walk across the street and most of my hospitalized patients came from being required to cover the emergency room periodically for patients requiring admission but not having a physician.

Much changed quickly in the early 1990’s as we approached the millennium. Insurers managed care programs kidnapped our younger patients by approaching employers and guaranteeing cost savings on health insurance by demanding we provide care at a 25% discount. In addition, mandatory ER call became a nightmare because insurers would only compensate contracted physicians to care for their hospital inpatients.

My very profitable chest x-ray machine became an albatross because that $28 x-ray reimbursement was now accompanied by a fee to dispose of the developing fluid by only a certified chemical disposal firm even though the EPA said there was not enough silver in the waste to require that you do anything other than dump it down the sink. The lab closed too. Congress enacted strict testing and over site rules which made the cost of doing business too expensive and not profitable. That flexible sigmoidoscopy went the way of the Model-T Ford when the medical community enlarged to accommodate board certified gastroenterologists certified to look at the entire colon under anesthesia not just the distal colon and sigmoid.

We tried to overcome increased costs and lost revenue by seeing more patients per day. We banded together as physician owned groups owning imaging centers and common labs but the Center for Medicare Services (CMS), which runs Medicare, and private insurers plus Congressional rules on conflict of interest thwarted those ideas. We attended seminars on becoming a member of an HMO and taking full risk for a patient’s health care and cost.

The message was clear, you could make a great deal of money if you put barriers in front of patients limiting access to care and especially in patient hospital care. The ethics of that model did not sit well with many. So, we started earlier, shortened each visit and worked later and harder. As time wore on, and our loyal patients aged, we realized that we needed to spend MORE TIME with them more frequently.  Not less time!

Spending less time with patients was the primary impetus which prompted my exploration of concierge medicine when I realized I was better off emotionally, ethically and morally caring well for fewer patients. Financially, seeing a smaller panel of patients who paid a membership fee generated similar income to maintaining a large panel of patients in a capitated system or fee for service seeing more people with shorter visits.

I discuss this now because I often wonder how I would be able to care for my large panel of patients today in the midst of this COVID-19 Pandemic.

For the most part I have been able to give my patients the time and availability they need to stay safe from Coronavirus and still keep up with the prevention and surveillance testing they need periodically. The 24/7 phone, email and text message access has allowed me to stay in touch with patients – something that would have been near impossible to do in a practice with 2700 adult patients.

I applaud my colleagues who continued in the traditional practice primary care setting despite the fact that most sold their practices to local hospital systems or large investment groups who placed administrators in the care decision-making process dictating time and number of daily visits, referral patterns and products used in the care of the patients.

As an independent physician, I have been able to continue to provide services and referrals that are the best in the area using doctors and equipment I would see as a patient and proudly refer my parents, my wife and children, beloved friends and family members. I am able to guide patients based on evidence and quality of measures not only what is most cost effective. I have no contract with a health system that requires me to see a certain number of patients per day, per week, per month or face a drop in salary or dismissal. I am proud and fulfilled at the end of the day because I can look in the mirror and know that I tried my best for the patients.

I additionally have the ability to say “no” to a potential new patient that I believe would not benefit from being in my practice for numerous reasons. Providing time to meet potential new patients gives both the patient and physician an opportunity to assess whether developing a professional relationship would be a good fit for both.

During the pandemic these meetings have become tele-health virtual meetings which are far more impersonal and less educational for both the potential patient and the doctor. It is still far better than having an administrator schedule a new patient, with no questions asked, on your schedule with the only criteria being can they pay the price?

Sadly, this horrible SARS 2 Coronavirus pandemic has made concierge internal medicine and family medicine more attractive than less. Having your physician available to discuss prevention, vaccines, testing methods and locations and treatments, if infected, is much easier in these membership practices than in a traditional practice where your phone calls are routed through an automated attendant phone system, reviewed by a non-physician provider and handled usually by a nurse practitioner or physician assistant with only the most serious and complicated situations reaching the physician’s desk.

I predict that more and more patients will seek concierge care in the next few years because patients are getting tired of fighting the bureaucracy and struggling to get the attention of their health care providers when they think they need it.  But don’t blame the providers.  It’s the dysfunctional, inefficient and profit driven corporate system that has created this situation.

Aerobic Training Helps Blood Pressure Medications Do Their Job

We are always looking for ways to stay healthy with less medicine.  Miguel Ramirez-Jiminez, PhD of the  University of Castilla-La Mancha, Toledo, Spain presented a paper to the American College of Sports Medicine recently week and addressed this topic.

His group looked at 36 obese and overweight adults who normally did less than 120-minutes of physical activity per week. Ages ranged from 53 – 65 years with 22% postmenopausal women. They had all been taking blood pressure medications for at least eight years and all met the criteria for having the metabolic syndrome which includes hypertension, elevated blood glucose, elevated triglycerides and a large waist.

The group was randomly divided into a placebo group whose medication was stopped or a trial group who continued their antihypertensive medications for the next three days. All participants then underwent 24-hour ambulatory blood pressure monitoring. All the participants were then entered into a four-month cycling program three times a week. 

After completing the four months of cycling training the placebo group again did not receive their medications for three days while the trial group did.  Twenty-four-hour ambulatory blood pressure was then checked in both groups.

The group exercising plus taking their medications saw an average drop in blood pressure of 3-5 mm Hg in addition to the 5mm Hg noted just from the medication’s pre-exercise training. When the exercise program stopped, the extra drop in blood pressure additionally dropped. There is a phenomenon known as “post exercise hypotension” that can reduce your blood pressure for up to 24 hours after training. This is the reason experts advise 3-5 exercise sessions per week.  

The study also revealed that if you exercise aggressively, and hope to permanently stop your blood pressure medications, your pressure usually rises above acceptable levels.  Exercise is not a substitute for prescribed blood pressure medicines. The article can be found at www.medscape.com  

A New Device To Protect the Brains of Athletes From Head Impact

As a parent of athletic girls who played competitive soccer and other sports that involved using your head to control a kicked or thrown ball, I always knew that studies of the brain of European professional soccer players showed much of the same brain injuries seen in professional boxers. We also saw several goalies diving to prevent a ball from entering the goal collide and hitting their heads with the goal’s metal side supports or with an opposing player. Several of the team parents and I tried to design a protective helmet for youth soccer but we never came up with anything that FIFA, the soccer world’s governing body, would allow to be worn during a game.

I played high school football, and a year in college, once suffering a concussion requiring an overnight hospital stay. Later in life as a physician I have followed the discovery of traumatic brain injuries and long-term permanent brain damage in football players, hockey players, soccer players and our military in combat. I wondered when the same creative humans who can send men to the moon and back would design items to protect the brains of competitive athletes.

Q30 Sports Science, LLC apparently has. They received FDA approval for their Q Collar which is designed to prevent deep tissue brain injury from head impacts. The Q Collar is already being marketed and used by athletes in Canada.

The Q Collar is a neck brace worn for up to four hours a day. It was designed after looking at woodpeckers head battering rams and trying to determine why, with all the head trauma they sustain, they do not develop CTE or other permanent traumatic brain injuries. Human brains are suspended in protective fluid inside a bony skull. The force of our head neck and shoulders colliding with a person or object allows our brains to slosh around unrestrained inside the skull and often hitting the extremely hard bony skull bones.

The Q collar increases the blood volume in our internal jugular veins causing a much tighter fit of the brain within the skull and preventing the movement or slosh. By reducing the movement of the brain within the skull it protects the brain from head impact injuries.

The collar was tested on a high school football team who wore state of the art football helmets plus an accelerometer which measured every impact the head sustained during play and practice. There were 284 participants with 139 athletes wearing the Q collar and 145 did not. Each athlete underwent a preseason specialized MRI study of the brain and a post season study. This allowed researchers to look to deep tissue brain injury that occurred over the course of that season. Significant changes were found in the deep tissue of brains on 106 of the 145 (73%) of the participants in the non-Q collar groups. No significant changes were found in 107 of 139 (77%) of the group who wore the Q collar.

The Q collar can be worn for four hours at a time and should be replaced every two years. No pricing data have been released but the intention is to sell the device directly to consumers. The National Institute of Neurological Disorders and Stroke states that in any year there are 1.6 million to 3.8 million traumatic brain injuries related to competitive and recreational sports.

As a parent I would want my child to be wearing this type of device when they engaged in sports that had head impact injuries as a potential side effect. It will remain to be seen just how effective this type of device will be in other recreational activities such as skiing, snowboarding, biking, riding scooters or skating and; will it have an impact in the military on blast injuries? Will insurance companies require such a device for contact sports?

Put on a Mask and Just Stay Home!

I listened to the Governor of my home state, Florida, declare our state the freedom state because all the businesses are open and running full tilt.  He cited his success in keeping deaths from coronavirus low while keeping the economy running and jobs available.

I bring this up because on my way to visit my fully vaccinated adult children last weekend I passed by at least 20 overhead electronic road signs proclaiming, “Miami Beach Curfew 8PM – 6 AM Causeways Closed!”  Yes, here it was springtime with Passover and Easter on the horizon and the famed Miami Beach was closing at night.  We are at a critical point in the fight against the Sars2 COVID-19 coronavirus. We are trying to vaccinate enough people quickly so that the virus does not enter a vulnerable host and mutate to a form that the vaccine is less effective against.   We are so close to controlling this pathogen but human nature and failure to be able to delay gratification, and put off travel and group activities, is leading to a potential fourth surge of COVID-19 related illness and death.

My cell phone rang twice with patient calls on the 60-minute trip southward. The first was from a patient whose adult children came to visit him. His unvaccinated eighteen-year-old grandson was with them. After spending four days together they received a phone call that the grandson’s girlfriend was sick and tested positive for COVID-9. The next two calls were from patients who had been to two different Passover seders. One was outdoors, the other indoors with 20 plus guests. Both had been exposed to a person who called the next day to say they were COVID-19 positive.

I watched the director of the Center for Disease Control and Prevention (CDC), an experienced infectious disease and critical care physician, beg Americans to wear a mask and social distance while she was brought to tears by the thought of another wave of illness, death and prolonged restrictions. I listened to the President of the United States plead with state governments to maintain mask restrictions a bit longer to save lives and control the disease. I listened to the Vatican public relations division discuss not holding an Easter Service in St. Peters Square this coming weekend and wondered what it will take to convince people that we just are not ready to resume full activities.

The Governor of Florida is correct. Deaths are down due to vaccinations and the elderly staying home. I suspect if he tracks the cell phones of the tourists and spring breakers to their home states and countries three weeks from now, he will see an increase in hospitalizations and deaths.  Florida’s economy may boom but we certainly are maintaining it at the cost of illness and death elsewhere.

Do Cipro and Levaquin Cause Abdominal Aortic Aneurysms?

Melina Kibbe, MD, of the University of North Carolina Medical Center at Chapel Hill published an article in JAMA Surgery reviewing any possible relationship between taking fluoroquinolones antibiotics such as Cipro or Levaquin and the subsequent development of an abdominal aortic aneurysm.  An aneurysm is a weakening in the wall of a blood vessel that balloons out like the defect on a damaged tire or basketball and has the potential to rupture causing exsanguination and sudden death. Dr Kibbe is also the editor of JAMA Surgery.

The study looked at health insurance company data on antibiotics and aneurysm diagnosis and repair.  They found that 7.5 aneurysms formed per 10,000 fluoroquinolone prescriptions filled at 90 days. This was significantly higher than the 4.6. per 10,000 aneurysms formed after patients took non-fluroquinolone antibiotics.  Patients filling fluroquinolone prescriptions were more likely to undergo repair of aneurysms than those who took other types.

The study used data from IBM MarketScan health insurance claims from 2005 to 2017 in adults aged 18-64.  The study included data on 27,827,254 individuals. The data did not include smoking or hypertensive history or family history of vascular disease. The authors were hoping the FDA would require a warning or caution to high-risk individuals for developing an aneurysm.

We already see an increase in ruptured tendons in patients taking fluroquinolones – especially women who have taken corticosteroids. They are also associated with C difficile colitis, nerve damage, emotional health issues and low blood sugar events. 

Despite these known draw backs to these medications, patients continually demand to have Cipro or Levaquin on hand in case they develop a urine infection or upper respiratory infection or are travelling and concerned about traveler’s diarrhea. 

More research is needed to determine the exact risk of prescribing these medications. Should we be doing scans on patients with hypertension and or smoking history who frequently use these drugs to screen for an abdominal aortic aneurysm?  This is a question that will be addressed by a study soon.  While the research is in process, we need to make sure that our prescribing of these antibiotics is the safest choice for our patients.

The COVID-19 Vaccine Is Becoming More Available. Exercise Patience.

COVID-19 vaccine preparations are arriving in South Florida with several hospital systems opening appointments for men and women 65 and older to receive their first injection. Some will receive the Pfizer product, others the Moderna product. If you wish to travel to Dade County go to https://jacksonhealth.org/keeping-you-safe/  and sign up for the vaccine. They are taking appointments.  West Boca Medical Center and Boca Regional Hospital have opened appointments for non-employed medical staff members and their office staffs to receive vaccine with the hint that the week of January 11, 2021 they will start vaccinating community members.  

There is a sense of urgency and panic in the community about not having access to the vaccines. That is unnecessary and raising the stress level inappropriately.

After you receive your first vaccine dose you will still need to avoid crowds, social distance, wear masks and practice impeccable hand washing hygiene because you will not be immune. Twenty-one to 28 days later you will receive your booster shot and it will take about two weeks before we can detect antibodies to COVID-19 if you develop immunity.  You will have peace of mind, but won’t know if the vaccine prevents individuals from catching COVID-19 when exposed completely?  Will they get COVID-19  and have a very mild case because of the vaccine prevention?  Will these people be contagious to others? We do not know the answers to these questions yet.

If you get the vaccine, develop immunity and are exposed to someone with COVID-19, will you possibly transmit the virus to others without you yourself becoming ill?  No one knows the answer to that question yet either.  If everything goes perfectly well, and you develop a protective shield of immunity like a comic book superhero shield or cape, how long will that last?  Nobody knows that answer either.

The point is the vaccine is coming.  Once vaccinated we will still have to behave the same as before until the answers to these questions are known!  Please be patient.

COVID-19 Vaccine Availability

Update January 4, 2021

Last week the Florida Department of Health discussed providing the Moderna vaccine to our office for staff members who wished to receive the vaccine. Our office manager, Judi Stanich, requested enough vaccine to cover the entire practice. We were told we would have a confirmation this morning.

This morning we learned the vaccine isn’t available yet. The vaccine comes in vials of 10 shots. The vials are kept frozen and can remain active in that state or in a refrigerator for 30 days. Once a vaccine vial is opened the entire vial must be used in under six hours or it degrades.

Moderna and the Florida Department of Health require patients to complete legal release forms for the vaccine. They must then be registered into the Florida Shots data bank and a national data bank. That is one of the reasons patients are asked to bring their driver’s license with them.

If you have had a severe allergic reaction to any medication the Pfizer and Moderna mRNA vaccines may not be best for you. If you have ever had to use an Epi Pen or have been treated for anaphylaxis these shots are not for you. The Astra Zeneca Oxford vaccine and the Johnson and Johnson vaccine are thought to be more suitable for those individuals

After receiving your shot, you will need to be observed by medical staff for 15 minutes to look for adverse reactions. You will be given an instructional sheet on how to register with V-SAFE which is a CDC vaccine monitoring app. Every day, at about 2:00 p.m., you will receive a text message with questions about how you feel related to the vaccine.

Medical malpractice insurance companies have not yet formally announced whether physician insurance policies will cover administration of this vaccine in their offices because none have been FDA approved. The Pfizer and Moderna vaccines have received FDA Emergency Utilization Authorization (EUA) which is not the same as approval.

Currently the only avenue to obtaining the vaccine in Palm Beach County is to try and get through on the 561.625.5180 phone number or leave your demographics on an email at CHD50Feedback@Flhealth.gov. Baptist Health System is planning on opening reservations for seniors 65 years of age and older the week of January 11 working with Boca Regional Hospital, Bethesda Hospital and the FAU Schools of Medicine, Nursing and their EMT program. They have not announced how to make a reservation or if they will be using the data from the Palm Beach County Department of Health through the phone number and email address provided above.

I suspect that by the middle of February there will be plenty of vaccine available locally including the Astra Zeneca Oxford product and the Johnson and Johnson products. In the meantime, remain patient and continue to avoid crowds and continue to social distance, wear suitable face masks and keep up the hand hygiene. Please remember that after you complete your vaccinations (two shots for the Pfizer and Moderna Products) we will not know how much immunity the shots will provide and for how long.

We additionally do not know if successfully vaccinated individuals are completely immune or partially immune if they are exposed to the virus. Furthermore, we don’t yet know if you are vaccinated whether you can carry the virus and transmit it to someone else even if you don’t have any symptoms.

Getting the vaccine will not be a reason to resume activities at crowded gyms, crowded bars or go on that cruise ship just yet. The hope is that by the summer 2021 we will have the answers to the many unknowns.

Keep Your Guard Up As The New Year Approaches

As we head into the last work week of the horrendous year 2020, my advice to my patient population is keep your guard up. Most of you have social distanced, worn masks, washed your hands until they are raw and avoided close contact in a social setting with friends and relatives to avoid contracting or transmitting the coronavirus to others.

I have been receiving phone calls for the last several weeks now from patients who have younger family traveling to Florida by commercial airlines or driving by car for the holidays and they ask me about how to stay safe. I applaud them for their common sense and decency after months in virtual isolation and advise them to continue their social distancing, hand hygiene and wearing masks.

If your family members do not have 14 days to self-quarantine from you upon their arrival, and prior to their visit, then there is a risk of contracting the disease from an unknowing asymptomatic carrier. Make sure the visit is outside in a well-ventilated area with at least 10 feet between individuals and you are all wearing up to date functioning face masks. If a meal is involved, make sure not to serve buffet style and don’t share food from each other’s plates.

If your visitors are feeling well and have no symptoms of illness and wish to try the short seven-day quarantine with testing for COVID, I suggest the standard nasopharyngeal or saliva PCR tests sent to a lab because they are more accurate in this situation than the quick tests. The test sites at FAU (they take walk-ins but are closed on Mondays) or the Town Center Parking Lot test site are professional.

In a few weeks, the Ellume home test kit should start to appear in pharmacies and its results even in asymptomatic individuals is remarkably accurate and quick. That test is a game changer.

Many of us have stayed out of restaurants and bars, avoided theaters and shows, postponed travel and worn masks now since late February. The vaccines are beginning to appear in the area and there will be an opportunity over the next few weeks to receive it. I will provide more details when they are made available to me.

Happy New Year to you all. May 2021 be sweet – filled with joy and health.  But please, until we have you vaccinated, stay strong and keep your guard up!