The Flu Shot Lowers Stroke Risk. It’s Time to Schedule Yours.

Fall is just around the corner and its time to start scheduling your flu shot. This season we have the high dose quadrivalent vaccine for people 65 years of age or older and the Quadrivalent for those younger than 65 years of age. The vaccine takes about two weeks to provide full immunity and will reduce your chance of catching the illness.  Most importantly, it will prevent serious illness requiring hospitalization and or death. Last year influenza caused almost 45,000 deaths in the USA.

The vaccine is being given in our office. My patients should call 561.368.0191 to schedule the flu shot. You can take this vaccine at the same time as the new Omicron specific booster and near that vaccine which is being given at local pharmacies including CVS and Walgreens.

The journal Neurology published a peer reviewed article that examined whether getting a flu shot provided any additional protection beyond preventing the flu  The study, led by Francisco Jose de Abajo, MD, MPH, PhD of the University of Alcala in Madrid Spain, showed that the flu vaccine reduced the risk of stroke by 12% in those who had risk factors for cerebrovascular or cardiovascular disease. The study noted the protection began within two weeks of receiving the vaccine for both patients with cerebrovascular risk factors regardless of age.

Another study published several weeks ago noted that the risk of dementia was diminished in those patients receiving the flu shot as well.

Flu season is here. Please call the office and schedule your vaccine.

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Before You Travel Please Learn the Covid Rules for Your Planned Stops

I received a phone call last week from a long-time senior citizen patient who was in London, UK with his wife and two traveling friends on a long delayed pleasure trip. His wife and friends both had just tested positive for COVID-19 and were denied access to commercial airlines scheduled to fly them home the next day. My patient had tested negative.

They phoned their hotel and extended their stay for several days. My patient asked me for medical advice about treating COVID-19 for his wife and two friends – both not patients. All were vaccinated and had taken a booster shot already. None were terribly ill.

I told them that in Florida we would prescribe the Pfizer pill Paxlovid, the Merck pill Lagevrio or send them to the local hospital as an outpatient to receive an injection or infusion of the latest monoclonal antibody that was effective against the Omicron and Ba2 variant strains. I had no idea what services were available in London but suggested that the hotel concierge must have a private physician who attended to sick hotel guests. If that was unfruitful, I suggested calling the United States Embassy and see where our State Department personnel go for emergent health care.

The hotel concierge sent a private physician who came over, took a history, examined them and pronounced them fit but infected. He suggested treatment with rest, cough medication if a cough developed, Tylenol if a fever or aches and pains developed, warm clear fluids and call again if they developed breathing difficulty. He suggested they retest in five days and if negative get on with their lives.

After the hotel physician visit, my patient called again from London. He asked us to prescribe Paxlovid or Lagervio for him in Boca Raton, pick it up for him and ship it to London via overnight FedEx. I explained to him that he was not infected, and the drug was in short supply plus, there was only one pharmacy in West Palm Beach and one in south Fort Lauderdale distributing it (we have since learned there is one in Boca Raton as well).

The pharmacy said the drugs should be started within five days of testing positive and having symptoms to be effective and they made it very clear shipping it across state lines or internationally was illegal. Shipping it violated United States and United Kingdom laws.

The patient and I spoke daily and thankfully no one in his travel group became very ill. On Day four, my patient tested positive for COVID-19 putting his wife and travel group in the position of having to decide whether they all stay behind and wait for his negative test or whether they travel home separately?

Another patient spoke of his upcoming scuba diving trip to the Maldives. His itinerary took him through the United Arab Emirates and he was very upset that the Middle Eastern airline he was flying insisted on a negative COVID test a day in advance of his flight home. He could not find a testing site in the Maldives that fulfilled the requirements of his air carrier or the UAE.

We are in the middle of a worldwide pandemic. Just because you want it to be over doesn’t mean it is over. I suggest you review your itinerary for overseas travel carefully. Know all the rules for the countries you are flying to even if it is for a layover.

I additionally suggest you research what type of restrictions and care are available at that locale. Just because we have medications to give to COVID infected patients to prevent progression to more serious disease in the USA doesn’t mean those medications or equivalents are available or approved in other nations.

 If you must go you might consider joining an air ambulance service which guarantees to transport you home safely if you become ill while traveling. Make sure your contract specifies you will be transported to the care center of your choice not the closest facility that can provide the service.

We are all sick and tired of COVID-19 related rules regulations and restrictions. We all want to regain the freedom to travel as we please but it’s just not that simple. If you travel, please learn the rules and restrictions for your destinations in advance and make sure the care you need is available if you become infected.

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.

Omicron is the Grinch That Stole Christmas

The Center for Disease Control (CDC) is reporting that up to 90% of the infections with COVID-19 Sars 2 Coronavirus are the new Omicron strain. It replicates itself 70 times faster than the Delta strain and contact with an infected person within 12 feet for one or more seconds can result in infection. For those who have been vaccinated against COVID-19 with the Moderna or Pfizer Vaccine, and received a third shot or booster, the expectation is that if they become infected with Omicron, they will either have no symptoms or a mild case. By definition “mild COVID” means your respiratory system is not compromised enough to require hospitalization. Despite this, most of the current deaths in countries which are having a COVID surge are in people older than 65 years of age.

In the past, when patients in this area became infected with COVID-19, we arranged for them to go to the local hospitals to receive an infusion of a monoclonal antibody solution made either by Regeneron or by Eli Lilly. The infusion prevented the infection from becoming severe enough to progress to a severe state requiring inpatient hospital respiratory care. These monoclonal antibodies do not work against Omicron. For this reason, the FDA and CDC have removed the Emergency Use Authorization and ended the administration of these drugs nationwide.

There is a third monoclonal antibody made by Glaxo and Var called Sotrovimab which effectively throttles Omicron, but it is in limited supply. As of today, the State of Florida has received 1050 dosages. Production has been accelerated and hopefully the drug will be available in mid to late January for infusion. There are two new antiviral pills which should work as well. The Pfizer product received FDA approval today and, with production acceleration, some should be available by mid-January. Until these drugs are locally available the medical community has no medications to offer patients who contract the COVID-19 Delta or Omicron variant to limit the severity of the disease.

My advice to my patients and loved ones is to reintroduce distancing and masking. Wear a good N95 mask when you will be around others – especially indoors. If you must be indoors with others, make sure the windows and doors are open and the ventilation is excellent. If there is an air filtration system with HEPA Merv 13 level filters and ultraviolet light that adds protection. Distancing with the aggressive Omicron variant will require 12 feet not six feet.

This is a heartbreaking restrictive change in scheduling and behavior we are asking for at a time of the year when families and friends travel to gather to celebrate. Younger and leaner healthier individuals who are vaccinated will survive this. The real questions are who they will transmit this infection to unknowingly, who is too young to be vaccinated or too old to have a robust immune system?

Our office staff will be reassessing the risk to patients and staff daily. With the local testing positivity rate >10% in Palm Beach County, our contacts will be by phone and telehealth. When the Pfizer anti-viral pill Paxlovid is available, and or Sotrovimab for infusion, we will return to regular in-office patient visits.

I apologize for the inconvenience. Stay safe and call if you have questions.