Pandemic

N95s and a Tale of Two Diseases

Posted on by writenp

In the arsenal used to fight COVID, there’s no doubt that vaccines are the non-human heroes of the pandemic.  A close second, though, is the once lowly, often stuffed-in-a-provider’s-desk-drawer, N95 mask.  Before the pandemic, not a lot of people outside of healthcare were familiar with it.  We healthcare providers kept our own N95s stored in a paper bag with our names scrawled on it, out of sight and usually out of mind. These masks had one sole purpose — to protect us from tuberculosis (TB) if we took care of a patient who had active TB. 

We were “fit-tested” once a year to make sure the mask would function.  The fit test was basically, well, weird.  You donned your N95 mask and the occupational health nurse would put a kind of plastic dome over your head.  Then they sprayed a chemical with a sickly-sweet floral fragrance under the hood.  If you could not smell it, you were good.  If you could, you needed a new, better fitting mask. And, we were cautioned, once the mask was used, particularly in a verified TB situation, it was to be thrown out. It was contaminated and should not be used again. 

For lack of a more nuanced reaction to this bit of history — Ha.  COVID made the lowly N95 mask a superstar, elusive and sought after.  Everyone wanted one. There were dire shortages.  People were stealing them and they had to be kept under lock and key.  And now apparently they could be used countless times even after contact with infected people. Just like that.  And we found that a properly fitting N95 was a very uncomfortable thing to wear all day.

But this post isn’t really about the N95.  It’s about public health and the role it still plays in mitigating another highly contagious disease in the community, the eroding concept of the common good, and vaccine hesitancy.

In the time before many vaccines were available, there were numerous outbreaks of dangerous diseases.  Typhoid, diphtheria and polio come to mind.  Health departments enforced quarantines, complete with signs nailed to front doors. No one questioned this because it was so obviously for the common good.  No one wanted themselves or their families to become sick and die.

Tuberculosis, while not as virulent or as lethal as the aforementioned diseases, was a bane nonetheless. Many people died of TB, including two of my grandparents, in the first part of the 20ieth century.  It was generally a disease that attacked people in poor health, living in crowded conditions, which then as now, unfortunately goes hand in hand with poverty. TB is just as contagious as COVID but here’s the big difference.  Most healthy people exposed will develop latent tuberculosis infection or LTBI, which does not make you sick or contagious. It will however, make a TB test positive, because the dormant bacterium that causes TB (mycobacterium tuberculosis) is still detectable, even though your immune system has walled it off and made it inactive.   

To this day, healthcare providers are tested once a year for TB.  If the test is positive, it signifies exposure but not necessarily active disease.  The next step after a positive test is a chest x-ray which would detect active, and thereby contagious disease.  I have known many providers who were exposed, some knew it, some didn’t, and their tests were positive, and remain so.  There is a treatment regimen advised for people with LTBI.  The reasoning is that that the disease lies dormant until the host weakens, whether from illness, old age or even pregnancy, and then reactivates, becoming a contagious and potentially fatal disease. The treatment for LTBI consists of daily meds for a few months and some of the medications are not well tolerated. If you are deemed young enough and well enough to take the regimen (some of the meds could be toxic to the liver), it is advised to do so in order to prevent reactivation in the future. While the incidence of tuberculosis has decreased in this country, the advent of HIV/AIDS produced drug resistant strains, which requires more discussion than feasible in this post.   

You might ask why I’m discussing tuberculosis at all when we are still in the midst of a pandemic of a much more dangerous disease. It has to do with my commitment to public health and my struggle to understand COVID vaccine hesitancy and anti-maskers. Public health authorities were instrumental to and successful at controlling TB.  And most people were grateful for it, which is so very different from what is happening today amidst a battle with much more dire consequences if lost.

There was a thought-provoking essay written by a community health physician (Anita Sreedhar) and a sociologist (Anand Gopal) in the New York Times last week (Behind Low Vaccination Rates Lurks a More Profound Social Weakness https://www.nytimes.com/2021/12/03/opinion/vaccine-hesitancy-covid.html?smid=url-share) that helped me understand that the points of view of some anti-vaccine and anti-maskers can be attributed in part to a number of factors, including: a distrust of a government which has not helped them in the past, a differing hierarchy of needs for people living on the edge vs the rest of us, and the rejection of the concept of the common good, which emanates from feelings of being abandoned by the powers that be. The resulting mindset is that everyone has to look out for themselves, and no one else.  Individual freedom above all else.  It makes sense as a rationale for this thinking but it doesn’t solve the problem.  Which brings me back to TB, specifically how public health departments handle TB to protect both the community and the individual.

If someone is diagnosed with active TB, they are mandated to take medication, and if they are not deemed reliable, they are brought in to a public health facility (or someone goes to their home) so they can be observed taking the medicine.  This is called Directly Observed Therapy (DOT).  It’s most definitely a thing as is the power of the health department to isolate contagious individuals and at times commit them to a facility until they have completed treatment (which is always a last resort and rarely happens.)  Ensuring that these individuals are treated is in everyone’s best interest.  It protects the infected by curing their disease and also protects the community at large from becoming infected.

So say one is anti-vax and anti-mask and anti-mandate and your next door neighbor who frequents all the public places you do and volunteers at your kid’s school has been found to have active TB. Would you fight for the individual’s right to sovereignty over their body even though they have the potential to infect the community and sicken the most vulnerable? Is it their right not to take the medication? If you are healthy, maybe you would only get LTBI if exposed, no big deal for now.  But what if you are still recovering from the flu (you don’t get the flu shot, after all) and your immune system is weakened.  What if one of your elderly relatives volunteers at the school too?  Now TB is not the scourge in terms of virulence that COVID is. It spreads in the same way as COVID, through airborne droplets, but is not going to cause a pandemic because TB is slow while COVID is fast, and in many cases TB can be cured with medication.  Also it can take a few weeks to become infected and contagious after a TB exposure, and as explained before, the latter might not happen if you are healthy.  Still it is a nasty, potentially deadly disease with drug-resistant strains and life-long effects on health. 

When I think of tuberculosis, I can’t help thinking of our public health departments and how important they are to the community.  Humans are drawn to community for protection and social interaction.  We naturally want to belong — to our families, our social groups, our local communities and yes, our country.  Today our country is so divided.  I wish more people could understand that the individuals working in public health, imperfect and strained as they all are, are doing the best they can to safeguard the health of as many people as possible, and this in the face of so many unknowns.  That essentially, is their mandate. That’s what the common good is, the best outcomes for the greatest number of people. It’s hard to argue with that.  Because if we are not all in this together, then what’s the point of being here at all?  #thecommongood, #vaccinehesitancy #N95s #WritingCommunity #weallwanttobehealthy #tuberculosis #LTBI #Covid #endthepandemic

Breakthrough

Posted on by writenp

My husband felt invincible after becoming fully vaccinated, but he got breakthrough Covid last month.  He thinks he caught it on a plane.  By then he was wearing a mask, just for show, really, and the comfortable cloth mask he wore was thin.  As was the mask worn by his seatmate who hunkered down in her hoodie during the two hour flight, refusing all snacks and beverages.  In retrospect, this was a huge red flag.  Because who turns down free Cheezits and Popcorners on Jet Blue? He had very little contact with anyone else before he became symptomatic three days later, so he is probably correct.

This is how it went down, with an onset that was slow and gradual: he started to get what he thought was a sinus infection, to which he is prone, followed by post nasal drip, some congestion and that was about it for a few days.  He began taking an antibiotic because of his long-standing sinus issues.  But unlike before, he didn’t get better after his third dose of Augmentin.  In fact he thought he might be feeling worse, more tired than usual.

I suggested testing and we kept googling (yes, even health care providers google, more than you’d think or maybe want to know) — sinus infection vs Covid symptoms, and Is it a cold or Covid?  Really it is impossible to tell because there are so many presentations and everyone is different.

I left, encouraging him to get tested but unaware that he was feeling progressively worse.  He bought a home Covid test and it was almost immediately, and very clearly, positive.  These OTC rapid tests are very reliable when the result is positive, especially in an area with high incidence.  (This was Florida.)  So we knew he had to self-isolate for 10 days from when he was first symptomatic. 

We kept in close touch and Facetimed.  I’d say he had about 2 ½ days of feeling quite miserable.  He had all the symptoms of a bad case of influenza: headache, fever, chills, fatigue, muscle aches, congestion and cough.  He never lost his sense of taste or smell nor did he have a sore throat.  He never experienced chest pain or shortness of breath but his pulse ox (which tells us how well the blood is being oxygenated) at the lowest was 92.  (Normal is 96-100, and we start to pay attention when it is heading down towards 90.)  When he started feeling better, his metrics improved accordingly.  We shudder to think what would have happened had he not been vaccinated.

At that time he was commuting to Florida about every other week for work and I spent an occasional weekend there.  I did not get sick even though we spent three days together unmasked indoors and in a car.  I took two OTC tests — one when I got home (three days past the first exposure) and one three days after that, both negative.  I never developed symptoms but if I had, and the OTC test was still negative, I would have gone for a PCR test. Of note, he had 2 Pfizer vaccines and I had 2 Moderna.

Having a background as I do in community health, it’s not lost on me that this breakthrough, likely caused by the Delta variant, will not become part of the data. I think this is the norm, unfortunately, rather than the exception and I’ll tell you why.  PCR testing is nowhere near as available and accessible as it needs to be. Really it should be on speed dial, 24/7, where someone will come to you and administer the test.  For free. Then we would have some real data.  But the reality is that, depending on the time of day, it can be difficult to get a timely appointment.  Plus going out is miserable when you don’t feel well and you run the risk of exposing other people.  

The next best thing is an OTC test for people who want to do the right thing and protect others.  Anecdotally I know of six individuals with breakthrough cases in my immediate familial, friend and professional circle.  All of them relatively young (well, under 65) healthy people. They all did the right thing.  To me it is apparent that breakthroughs are way more prevalent that the CDC would have us believe.  Maybe it’s because they don’t have the data but also likely due to a reluctance to say anything negative about the vaccines. Understandable given all the negative misinformation out there and the need to get more people vaccinated.  Sure it was always mentioned that the vaccines were not 100% effective at preventing symptomatic disease, but until Delta, people did think they were bulletproof. Maybe that’s just human nature.  And we were all very tired of masking and distancing.

But picture this.  I am flying home, double-masked (cloth over surgical) and notice many children with “colds” on the plane.  Lots of coughing and sneezing.  These families were returning home from vacation.  Were they going to have their child tested in Florida at the first sniffle and then isolate in a hotel room waiting for results and possibly a longer isolation?  No.  They needed to get home and get back to their lives.  Maybe they thought, ostrich-like, if there was no test, there was no Covid, or maybe they didn’t think about it at all.   I don’t know if the parents were vaccinated and of course, I don’t know if these children actually had Covid.  But they certainly could have, given the circumstances.  I wonder how many people on the plane later got sick.  

Would requiring a negative test or proof of vaccination decrease transmission during travel? Might a mandate like that also increase vaccination rates?  To me it’s clear that it would, but not without a great deal of pushback and negative impact on the airline and travel industries.  Apparently it’s hard enough to get some people to keep their masks on when traveling. It’s easy to imagine that such a mandate would simply transfer the disruptive behavior of anti-maskers on planes to the lines at the airport when the non-compliant are prevented from boarding.

There are no easy answers.  While some of us would do a great deal to end this pandemic, there are still some who doubt its very existence or have gone down the rabbit hole of misinformation, unlikely to surface.  For now, this much I do know: the fully vaccinated are not invincible and should continue to be careful when the situation warrants, especially when travelling or in areas with high incidence.  Stay safe out there, and do the right thing.

When Worlds Collide: Administering COVID-19 Vaccines at a Community Health Center

Posted on by writenp

Is it better to give than to receive? I wanted to find out if giving the vaccine was as gratifying as receiving it.  Since I already covered what it was like to get my shot, I am sharing my experience of administering COVID-19 shots, something I very much wanted to do, even though it’s not in my job description.  What I learned went beyond the comparison of giving and receiving, into the concrete disparities between private and public health care and the people served by each. 

But first, I got around the not in my job description part by volunteering (i.e., no pay) to administer the shots a few mornings a week. Instead of nice work clothes and a lab coat, I sported scrubs and white sneakers.  How liberating, how comfy.  It really took me back.  Actually the last time I wore scrubs professionally was on a medical mission to Guatemala, but that’s another story.

Here are the specifics on all three vaccines.  Skip to the next paragraph if you already know or are not interested in the nuts and bolts. All 3 of the COVID-19 vaccines are intramuscular injections into the deltoid muscle of the upper arm. At our clinic we have the Moderna which is a 2 dose vaccine, the second dose given 4 weeks after the first.  For a time we also had the Johnson and Johnson Janssen vaccine with is a one and done as they say.  Both are for people aged 18 and above, and the amount in the syringe is the same – 0.5cc. The Pfizer vaccine, which our clinic did not have, has to be mixed with a diluent (a special diluting solution) before being drawn up, and is 2 doses given 3 weeks apart.  The dose each time is a little less in volume than the other 2 vaccines – 0.3 ccs. That one is good for ages 16 and above.  The age ranges may change as the vaccines are undergoing testing for children. I won’t get into the efficacy of each one.  The studies were done in varying conditions. Each one works well enough to prevent the majority of people from contracting the disease, and is even better at preventing severe illness and hospitalization. And that of course, is what we were all most worried about.  Because if contracting COVID meant just a few days of feeling under the weather for everyone, it wouldn’t be a big deal.

As I began writing this, the Johnson and Johnson vaccine has been all over the news due to a rare clotting condition exhibited by 6 women within 2 weeks of getting the vaccine, one of whom died and one who is in serious condition. That’s 6 cases among around 7 million people who received the vaccine.  When I learned they were all women aged 18-48, I immediately thought of oral contraceptives, which can cause blood clots.  But apparently most of the women were not taking them.  CVST (cerebral venous sinus thrombosis) is a very rare and very serious clotting disorder, which causes both clotting and bleeding.  For now the vaccine is on pause but that reflects an abundance of caution, when you consider the numbers.  The odds of getting that rare side effect are about the same as getting Guillain-Barré Syndrome (GBS) from the flu shot.  According to the CDC, studies suggest a person is more likely to get GBS from actual influenza than the shot.  Just as it is far more likely to get blood clots (and die) from having the COVID-19 illness vs getting the Johnson and Johnson vaccine.

This post was intended to be about the experience of giving the vaccines, so I will circle back. Every one of the people I inoculated was grateful to be getting the shot and grateful that there was a shot at all.  Nobody cried although I’ve heard that it has happened — tears of joy and relief.  I think the pandemic has made us all more emotional.  When I received my first dose of Moderna in January, it was as close to a religious experience as I think I will ever get.  Being able to bestow that feeling through vaccinating others amplified the exhilaration, the hopefulness.  So yes, in this case, it is even better to give than receive.

As a vaccination site, we are open to the community at large, anyone whom the state deems eligible to receive the vaccine. This should be true at all sites who applied to be vaccinators,  but in the local private practices at least, when they did have supply, they sent emails to their own patients with very specific admonishments not to forward the email. Point made. Conversely, in addition to our own patients, our waiting room fills with people who have never set foot in a community health center before, although most likely their housekeepers and nannies and landscapers have.  There was a little sheepishness at times, about snagging the vaccine in a place like ours, but also, I hope, a new appreciation for what we do.  To a person, they expressed surprise about how “nice” our offices were, how clean and professional.  A little insulting, to be sure (what were they expecting, a MASH unit?), but I hope, as they sat (socially distanced and masked, of course) among our regular patients in the waiting room, their eyes were opened.  I hope they realized how important high quality health care is to the people they employ or who serve them at stores and restaurants and grocery stores.  How important it is that these people have a “nice”, clean, professional and safe place to go.  Because the state of their health affects the health of the community as a whole.  And never has this been truer, nor the stakes higher, than during a pandemic.