Monday, May 18, 2020

Atul Gawande, M.D. writes articles for The New Yorker and has some excellent advice for all of us about how to re-enter the world after our weeks in seclusion.

The New Yorker reports and analysis on Covid-19 are free to all to read.

Here is the beginning of this article with the link attached below. As usual, Dr. Gawande offers a thoughtful analysis on the strategies that healthcare workers have undertaken that can be applied to all of us sitting at home wondering how safe it will be to venture outside to resume semi-normal activities as more non-essential services are added. I hope you'll read on...

Amid the Coronavirus Crisis, a Regimen for Reëntry

In places around the world, lockdowns are lifting to various degrees—often prematurely. Experts have identified a few indicators that must be met to begin opening nonessential businesses safely: rates of new cases should be low and falling for at least two weeks; hospitals should be able to treat all coronaviruspatients in need; and there should be a capacity to test everyone with symptoms. But then what? What are the rules for reëntry? Is there any place that has figured out a way to open and have employees work safely, with each other and with their customers?

Well, yes: in health care. The Boston area has been a covid-19 hotspot. Yet the staff members of my hospital system here, Mass General Brigham, have been at work throughout the pandemic. We have seventy-five thousand employees—more people than in seventy-five per cent of U.S. counties. In April, two-thirds of us were working on site. Yet we’ve had few workplace transmissions. Not zero: we’ve been on a learning curve, to be sure, and we have no way to stop our health-care workers from getting infected in the community. But, in the face of enormous risks, American hospitals have learned how to avoid becoming sites of spread. When the time is right to lighten up on the lockdown and bring people back to work, there are wider lessons to be learned from places that never locked down in the first place.

These lessons point toward an approach that we might think of as a combination therapy—like a drug cocktail. Its elements are all familiar: hygiene measures, screening, distancing, and masks. Each has flaws. Skip one, and the treatment won’t work. But, when taken together, and taken seriously, they shut down the virus. We need to understand these elements properly—what their strengths and limitations are—if we’re going to make them work outside health care.

To read the article, follow this link.

Friday, May 15, 2020

So Just How Effective Are Those Masks?

This article from The Annals of Internal Medicine appeared in my inbox this morning after being picked up by the National Center for Biotechnology Information/National Institutes of Health.

The question the authors wanted to answer was simple: Do surgical and cotton masks block the transmission of Covid-19?

The conclusion I found stunning - not only was the answer no (that didn't surprise me) but the outside of masks were more contaminated that the inside of face masks - counterintuitive right?

The study size was small: 4 patients and the study did not compare the use of these masks to N95 masks. Given that N95 masks are in short supply and a previous study showed that surgical masks were effective in preventing the dissemination of the influenza virus, the researchers wanted to know if surgical masks would also prevent the spread of Covid-19.

They had each of the patients cough 5 times on a petri dish that was 20 cm (approx 10 inches) away from their mouth. They coughed in this sequence: without a mask, a surgical mask, a cotton mask and then again without a mask.

The masks were swabbed in this order: the outside of the mask first then the inside side of each of the masks.

Here were the results: all surfaces on the outside of the masks were positive for Covid-19 whereas only one patient contaminated the inner and the outer surfaces of the surgical and the cotton masks.

So how is it that more virus was found on the outside of the mask - not the inside as one would suspect? Here's the reason postulated: Since the masks are not tight fitting, a turbulent jet of air is created at the edges of masks where the particles escape and essentially contaminate the outside of the surface. I think of it as a similar effect to how our glasses get fogged up and our breath rises up when we cover our nose and mouth.

But it doesn't explain the lack of virus on the inside of 3 out of 4 of the masks. As the authors noted, the velocity of the cough may have forced the particles straight through to the outer surface, but it doesn't account for larger particles coughed that would have been unable to penetrate.

Here's what the authors' say: "We do not know whether masks shorten the travel distance of droplets during coughing. Further study is needed to recommend whether face masks decrease transmission of virus from asymptomatic individuals or those with suspected COVID-19 who are not coughing.
In conclusion, both surgical and cotton masks seem to be ineffective in preventing the dissemination of SARS–CoV-2 from the coughs of patients with COVID-19 to the environment and external mask surface." 
Keep in mind that the authors were careful to point out that the study:
1. Did not include N95 masks.
2. Does not reflect the actual transmission of infection from patients with Covid-19 wearing different types of masks.
3. The study did not test whether masks shorten the travel distance of droplets during coughing. 
4. The study did not test if face masks decrease transmission of virus from asymptomatic individuals or those with suspected COVID-19 who are not coughing.
So there is still a lot more that would be helpful to know but for me, the takeaway is clear. Presuming my family and I don't have Covid-19, it still behooves us to:
  • thoroughly wash our hands after removing a mask, 
  • throw away disposable masks after single use or rewash the mask if it's reusable 
  • continue to maintain social distancing

To read the full study, follow this link.

Sunday, May 10, 2020

Who to Treat and When During Covid-19

The challenge for gyn/oncs during Covid-19 is deciding who should get surgery now, who can wait, which patient should start chemo and how to treat the patient who actually has Covid.

There is no road-map to follow and what is guiding these clinicians is the answer to this question: Is the treatment curative or not?

In addition, there is no evidence-based medical guidelines to follow during this time. Because of that, the Society for Gynecological Oncology has put together the SGO Covid-19 Task Force. The goal of the task force is to, "gather and disperse important resources regarding surgery, infusion clinical trials, resident and fellow education, patient communications and wellness during the pandemic." You can read more about this by following this link.

Wednesday, May 6, 2020

Answering Questions on Cancer and Covid-19

Thanks again to Betsy for alerting me to this website and the articles devoted to cancer survivorship.

The American Society of Clinical Oncologists and the National Coalition for Cancer Survivorship worked together to provide this information about Covid-19 and cancer. The article first appeared in March and was updated on May 3, 2020 and will hopefully be of interest to all.

Q1: Can you briefly describe what it means to be 'immune compromised'?

The term ‘immune compromised’ refers to individuals whose immune system is considered weaker, more impaired, or less robust than that of the average healthy adult. The primary role of the immune system is to help fight off infection. Individuals with compromised immune systems are at a higher risk of getting infections, including viral infections such as COVID-19. There are many reasons that a person might be immune compromised: health conditions such as cancer, diabetes, or heart disease, older age, or lifestyle choices such as smoking can all contribute to weakened immune systems. Patients with cancer may be at greater risk of being immune compromised depending on the type of cancer they have, the type of treatment they receive, other health conditions, and their age. The risk of being immune compromised is typically highest during the time of active cancer treatment, such as during treatment with chemotherapy. There is no specific test to determine if a person is immune compromised, although findings such as low white blood cell counts or low levels of antibodies (also called immunoglobulins) in the blood likely indicate an immune compromised state.

Q2: Does a history of cancer raise your risk for health complications from COVID-19 (SARS-CoV-2)?

It appears that patients with cancer and survivors of cancer may be at higher risk of health complications from COVID-19. This is not surprising given that this group of individuals is often immune compromised. There is also evidence from one study (Liang et al, Lancet Oncol, http://dx.doiorg/10.1016/S1470- 2045(20)30096-6) that reported patients with a history of cancer had a higher incidence of severe complications, including needing intensive care unit care, mechanical ventilation (being on a breathing machine) or death, compared with other patients who did not have cancer. This is just one study though, and the small number of cancer patients in that study (18 patients) cannot necessarily be generalized to all patients with cancer.

Q3: Does having received chemotherapy or radiation in the past raise your risk for getting COVID-19 or having a more serious course of illness?