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Monday, November 16, 2020

'Not too late to cancel Thanksgiving': your risk of having guest with covid-19 at your holiday

What’s your plan for Thanksgiving? Americans caught between the dire reality of an out-of-control pandemic and a desire to celebrate the national holiday with family may be tempted to believe that maybe they can manage the risks.

I’ve been thinking through my own planned turkey day gathering, an outdoor event in a rural setting with perhaps 15 people, including several older people and a couple of teenagers whose social distancing has been unverifiable at best. To me, being outdoors mitigates most of the risk of coronavirus transmission, yet as the day approaches I am having second thoughts. I think I might cancel Thanksgiving.

So what’s the actual risk? A helpful dashboard from the Georgia Institute of Technology, the Event Risk Planning Tool, shows estimated odds that a member of your holiday party will bring the covid-19 virus to dinner. That chance depends on where you live and how large the group is, and the model assumes all visitors are locals, but not already in your pod. What’s plain is no matter where you are in the US, the risk isn't zero.

I ran some numbers, as others have, and here’s what I found. For a party of 20 neighbors in Brunswick, Maine, near where my family lives, there’s a 5% chance someone will have the virus, based on that state’s background rate of infection. A gathering of just 10 people in the hot spot of Sioux Falls, South Dakota, meanwhile, brings a 67% chance. Dinner for 50 residents near New Orleans? A 28% chance. For a gathering of five in San Francisco, which has managed to suppress the pandemic fairly well, the odds are lower: about 2.5%.

These models assume people at your gathering aren’t already in the same household—eating with the people you see every day wouldn’t change your risk. Yet like it or not, Americans will be moving and mingling by the millions, and taking the virus with them. Kids are coming back from college, and other people are going forward with long-delayed visits to relatives.

The AAA, which every year makes a prediction of holiday travel, projects a drop of at least 10% from 2019, to about 50 million travelers, mostly making car trips. That’s a lot people, but it’s the biggest year-over-year decline since the recession of 2008. And AAA has put also an asterisk on its projection, saying travel could dip even more steeply with last-minute cancellations.

The travel group itself suggests “staying home” as the best way to protect against getting sick. (If you do travel by car, as most Thanksgiving travelers do, it says to “be sure to pack face masks, disinfecting wipes, hand sanitizer, and a thermometer to help protect and monitor your health.”)

One problem for Thanksgiving decisions in the US is an absence of clear messaging from Washington, DC. Instead of pardoning a turkey on the White House lawn, maybe President Trump should give us some advice on getting together. But so far, he hasn’t mentioned it. According to MSNBC anchor Chris Hayes, “Right now, if we had [an] administration that cared one whit about protecting Americans, there would be national coordinated messaging all over the place about making Thanksgiving virtual this year (or outdoors where weather permits)!”

Local ordinances and rules also vary widely, and in many places were tightened this week. Maine still permits outdoor gatherings of up to 100 (and up to 50 indoors). In Maine, most out-of-state visitors are supposed to quarantine for two weeks on arrival, while in California, LA County has recommended that its citizens not travel out of state. If they do, they’re supposed to quarantine for 14 days on their return. Both Boston and New York City have introduced evening curfews on bars and restaurants. New Mexico yesterday introduced a tough, two-week stay at home order.

But in the end, it’s mostly up to you. “I think each family is going to have to make a risk assessment about the risk and benefit of what we all feel is such an important tradition,” said Anthony Fauci, the nation’s chief infectious disease doctor. He said he was planning dinner at home with his wife, and a visit with his three daughters over Zoom. “Make your own decision. What kind of risk are you willing to take?” he said.

I ran a poll online about my own Thanksgiving plan, and most people thought it was too risky. While there’s scant evidence of coronavirus transmission out of doors, some said being outside wasn’t a magic bullet, while others felt the group was too big. 

To me, gathering in an open, outdoors space is the best way to hack the Thanksgiving conundrum. Even if one of your party has the virus, there are few examples of the virus being spread outdoors.

The jury is still out on whether cold weather, per se, makes the virus easier to transmit, although dry, heated indoor air may assist the spread—and enclosed spaces definitely do. It’s being inside with other people for an extended time—which is more likely in cold seasons—that’s the largest risk factor. So far, November has been unseasonably warm in much of the US, making outdoor gatherings easier to pull off.

If you do want to manage the risk, one way is to combine various precautions, using what the virologist Ian Mackay, at the University of Queensland in Australia, calls the “Swiss cheese” model of prevention. While no single precaution is perfect—each slice of cheese has holes—taken together, steps like wearing masks, hand-washing, and keeping rooms well ventilated will push down the risk.

Testing and quarantine is another strategy. It’s time to start this procedure for Thanksgiving if you haven’t already—avoiding contact with other people for several days gives you a chance to see if you get symptoms (which usually, but not always, develop within five days). Since many infected people have no symptoms, getting a test is also important. Tests can still be hard to come by, though.

Another fact to bear in mind is that the chances of someone having covid at your holiday event, as projected by the Georgia Tech app, are in constant flux. Given how fast and widely the virus is spreading, those risks are going to be substantially higher by Thanksgiving. Coronavirus cases are in the red zone throughout much of the country, with more than 160,000 infections counted yesterday. By Thanksgiving, two weeks from now, that figure could conceivably rise to above 250,000 cases per day.

With so many people infected, and smaller gatherings propelling the pandemic, it’s easy to see how Thanksgiving could turn into a nationwide superspreading event that just makes things worse. And that creates an extra negative you may not have thought of.

https://www.technologyreview.com/2020/11/14/1012128/its-not-too-late-to-cancel-thanksgiving/

Philadelphia announces new “Safer at Home” restrictions to fight rising COVID

In response to rising COVID-19 cases in Philadelphia, the City and Department of Public Health have announced changes to restrictions on businesses, events and gatherings, and other activities to help flatten the epidemic curve, prevent hospitals from becoming overwhelmed, and reduce the number of COVID-19 deaths.

The new “Safer at Home” restrictions are effective November 20, 2020 through January 1, 2021. An extension of these restrictions and/or the implementation of additional restrictions is possible depending on trends in the spread of coronavirus in the city. 

Businesses with questions about how to comply with the new restrictions should contact the Department of Commerce’s Office of Business Services at business@phila.gov or 215-683-2100.

To report a business or other institution that is not following the City’s COVID-19 restrictions, residents can call 3-1-1 or submit a request on Philly 311’s website.

The following businesses and activities are not allowed:

  • High schools and colleges must move to online instruction only, with the exception of clinical instruction for students in health sciences. 
  • Indoor dining at restaurants and other food service businesses. (Takeout, delivery and outdoor dining may continue. Additional restrictions on outdoor dining are detailed below.) 
  • Theaters, including movie theaters, and other performance spaces. 
  • Bowling alleys, arcades and game spaces.
  • Museums.
  • Libraries. (Those serving as Access Centers may continue to operate. Curbside dropoff and pickup services for patrons are allowed.)
  • Casinos.
  • Recreational activities and sports for youth, community groups, and schools. 
  • Gyms and indoor exercise classes. (Exercise groups and classes may continue outdoors.)
  • Senior day services (senior centers and adult day care centers) remain closed.

Changes to events and gatherings include:

  • All indoor gatherings and events involving people from more than one household are prohibited, in public or private spaces. This includes private events such as weddings and showers, listed as “celebrations” in previous guidance, as well as funerals. 
  • Religious institutions are permitted to have people indoors, but density must be capped at 5 people per 1,000 sq. ft. or 5 percent of maximum occupancy. 
  • Outdoor gatherings and events are limited to 10 percent of maximum capacity of the space, or 10 people per 1,000 sq. ft. for venues with an undefined maximum capacity—not to exceed 2,000 people in any outdoor space. In addition, all individuals at outdoor gatherings must wear masks at all times, and—to reinforce mask use—neither food nor beverages may be served.

Additional changes to capacity limits and other precautions will be instituted for businesses and activities that are able to continue:

  • Restaurants offering outdoor dining must reduce table sizes to four people. Guidance will make it clear that groups dining outdoors should be household members only, because mixing different households promotes community-wide spread.
  • Retail stores and indoor malls may continue to operate, but with a maximum density of 5 people per 1,000 square feet. The City will require these stores to enforce mask use and distancing of customers and staff.  
  • Offices are permitted to have only employees that cannot work remotely.
  • Barbershops, beauty salons, and similar personal services may continue to operate, but all staff and customers must wear masks at all times. These businesses cannot work on the face or otherwise perform services that require that masks be removed.
  • College sports may continue if their plan is specifically approved by the Department of Public Health and no spectators are present. 
  • Zoos may operate only their outdoor areas. 
  • Parks, trails, playgrounds, and athletic fields will remain open for individual use only. (No group sports.) 

The following businesses and activities can continue to function under current guidance from the Department of Public Health:

  • Grocery stores and farmers markets.
  • Pharmacies.
  • Banks. 
  • Construction.
  • Landscaping.
  • Home-based construction, renovation, repair, and maintenance.
  • Manufacturing and warehousing.
  • Real estate operations and transactions.
  • Health care services.
  • Home-based support services, such as home health services.
  • Taxis and ride share services.
  • Transit.
  • Outdoor mobile food carts and trucks.
  • Hotels.
  • Drive-in events in which people remain in their vehicles.
  • Child day care and early learning centers.
  • Elementary and middle schools.
  • Access Centers for children in elementary and middle school.

In every permitted setting, be sure to follow our Safety Checklist to help reduce the spread of COVID-19:

  • #MaskUpPHL to block the virus from spreading and require others to wear them.
  • Use barriers such as sneeze guards or plexiglass screens. 
  • Keep people who may be infected away from others (ideally at home).
  • Practice social distancing (6 feet!).
  • Reduce crowds. 
  • Frequently wash your hands with soap and warm water for at least 20 seconds.
  • Keep surfaces clean (don’t forget your cell phone!).
  • Communicate with staff, customers and others taking part in permitted activities and ensure everyone understands and follows this Safety Checklist. 

Delegates urge AMA to rescind policy discouraging HCQ for COVID-19

Despite the evidence that has shown that hydroxychloroquine and chloroquine aren't effective for patients with COVID-19, a frustrated group of physicians are urging the American Medical Association (AMA) to rescind its March statement that discouraged physicians from prescribing the unproven drug for that purpose, even as an early-stage treatment.

This resolution, led by Atlanta rheumatologist John Goldman, MD, an alternate delegate representing the Medical Association of Georgia, was considered at the AMA Special Meeting of its House of Delegates. He said the March statement, issued jointly by the AMA and two pharmacists' organizations, was hurting physicians' ability to help patients infected with the virus.

The AMA shouldn't make statements that interfere with what a physician thinks is best for his or her patients, Goldman and several of his supporters said.

"The combination, if used early, is effective, safe and not expensive, and I've had it work in my patients," Goldman told members of an AMA reference committee on science and public health. "But I've had problems getting hydroxychloroquine because pharmacies refuse to dispense it."

He also has been faced with having to fill out pharmacy prior authorization approval requests "for any use of it" because "the AMA said it was inappropriate to prescribe it and joined the pharmacists against us."

"Believe me, if you get COVID-19, no matter what is said, you will want the combination of a therapy early," he said.

Goldman's resolution contains four resolves. The AMA should:

  • Rescind the March statement calling for physicians to stop prescribing the drugs until there's conclusive evidence that the harm outweighs the benefit during the early stage of the disease course
  • Replace that March statement with one that notifies patients "that further studies are ongoing to clarify any potential benefit of hydroxychloroquine and combination therapies for the treatment of COVID-19"
  • Reassure COVID-19 patients receiving these drugs that their physicians prescribing them do have the ability to prescribe for off-label use
  • Take actions to require pharmacists to fill valid prescriptions issued by physicians, consistent with AMA policy.
Goldman acknowledged that the data do not show HCQ's benefit for COVID patients in the hospital, nor is there evidence that it prevents infection, but he believes the drug or drug combinations may work very early during the course of the disease.

After the drug was publicly touted in March by President Trump, who said he would take HCQ himself despite little to no evidence it was effective, doctors who had been regularly prescribing the drug for FDA-approved uses, such as for patients with rheumatoid illnesses like lupus, found it in short supply or much more expensive because suppliers and others were stockpiling it.

But Goldman's proposal was met with fierce opposition during much of the hour devoted to discussing it.

PubMed and Cochrane Library reviews of 4,900 COVID-19 patients "found no benefit from hydroxychloroquine in moderate to severe hospitalized patients," said Amish Dave, MD, a Seattle rheumatologist and alternate delegate from the Washington State Medical Association. He added that a large-scale randomized controlled trial from the University of Washington, presented at the Infectious Diseases Society of America meeting in October, found "there was no benefit of hydroxychloroquine for post-exposure prophylaxis."

"I have seen hundreds of patients with lupus, rheumatoid arthritis, Sjogren's syndrome, and other rheumatic conditions that have needed hydroxychloroquine and have not been able to obtain it during this COVID-19 pandemic, and it's caused them significant harm, including flares and adverse events," he said.

'I'm Angry'

"I'm angry that we have to spend our time responding to this and many other statements and distractions that have been made during this pandemic," said Alan Klitzke, MD, a Buffalo nuclear medicine specialist who represents the American College of Nuclear Medicine.

"Let's put this in the context of the political environment," he said, listing President Trump's claims that hydroxychloroquine works and that he would take it, despite lack of evidence, and other "daily public comments coming from the federal government ... blaming a lab in China for releasing an engineered virus, blaming the World Health Organization for failing to stop the virus coming to the U.S. ... a widespread U.S. conspiracy about the number of COVID cases that were being reported ... (and) claims that hydroxychloroquine would treat this, and doctors could also look into injecting bleach and inserting light sources into the body."

Not all doctors wanted to toss Goldman's resolution. A few said that the AMA had no business telling doctors what they should or shouldn't prescribe.

Robert Frankel, MD, a cardiologist representing the Medical Society of the State of New York, spoke as an individual. He said the AMA's March statement discouraging doctors from prescribing HCQ was "an extremely slippery slope" -- one that undermines the doctor-patient relationship and the ability to prescribe what he or she believes is best for the patient.

"All of us have used FDA-approved drugs and devices in off-label conditions for the benefit of our patients," he said. He added that physicians have had just 6 or 7 months of experience using the drug for COVID patients, and noted that researchers have rushed to publish those articles, only to retract them later. The FDA also has given emergency use authorization for certain therapies believed to be effective, which were then revoked a few months later.

"We have not exhausted the possibilities of this drug in various different populations and subpopulations for the AMA to determine what is -- quote-unquote -- appropriate," Frankel said. "For the AMA to single out this drug was clearly political and inappropriate and I speak strongly in support of this resolution."

Several speakers suggested that the support for the proposed legislation and/or the opposition to it was influenced by politics, not science.

The AMA Would Look Bad

Some of the three dozen speakers argued that not only was the AMA's original statement on solid ground, but rescinding it or changing it without evidence doesn't look good for doctors or the AMA.

"Changing the statement that has been made by the AMA will not enhance our credibility or help the public better understand what their options are," said Richard Frankenstein, MD, an internist in Tustin, California, and a delegate representing the American College of Physicians.

Parag Mehta, MD, a delegate from the Medical Society of the State of New York and a COVID-19 survivor, said that when little to nothing is known about treating an illness, "we're allowed to do anything, whatever's possible. But when we start knowing something about it which is not working, or harmful, it is the job of the leadership to inform the people. Please, respect the science."

https://www.medpagetoday.com/infectiousdisease/covid19/89705