No, We will not have Herd Immunity by April

Dr. Marty Makary is a brilliant physician and communicator. I am a fan. However, he just wrote an Opinion piece for the Wall Street Journal entitled, “We’ll Have Herd Immunity by April.” He could not be more mistaken.

He points to the significant decline in cases, his projection that 55 percent of Americans have natural immunity from past infection and an assertion that 15 percent of Americans have been vaccinated.

So, let’s understand why we are nowhere near herd immunity:

  1. Yes, cases are down. They are down following an all-time high surge that just two months ago was threatening to overwhelm our health care system. Cases always come down after a surge, and holidays are notorious for creating surges in cases due to travel and extended families and friends getting together.

So, are the cases down at a level that would suggest the pandemic is coming under control? No. Our current 7-day moving average of daily new cases per 100,000 in the U.S. is at 23.9. We have had 3 spikes or waves in the U.S. of cases. Our first was in March of 2020 at the onset of the pandemic. You might recall that cases were so alarming back then that many states implemented stay-at-home orders or lockdowns. So, what was the 7-day moving average of daily new cases per 100,000 in the U.S. at the peak of that first spike or wave? 9.8.

Our second spike or wave of cases was far greater and occurred during the summer. Well, what about the second spike or wave? What was the 7-day moving average of daily new cases per 100,000 in the U.S. at the peak of that wave? 20.4.

As you can see, cases have not even come down to the highest point they previously were with our first two waves. So, it seems premature to be declaring victory. We have all become a bit numbed to the numbers. We are currently at levels of disease transmission that last year would have been quite alarming. But, with each higher wave of cases, hospitalizations and deaths, we have become so conditioned to the large numbers that we think when cases are coming down from an all-time high that we must be on the home stretch.

So, how do we put these numbers in perspective? The Harvard Global Initiative sets 25 daily new cases per 100,000 as the level at which lockdowns, stay-at-home orders, etc. are indicated. Remember the White House Coronavirus Task Force chaired by Vice President Pence? The number they used for when transmission was out of control and required significant restrictions – 14. So, I think Dr. Makary is painting a far rosier picture of where we are than what the data shows.

Here’s additional perspective. Remember back at the beginning of the pandemic when our objective was to avoid community spread? Community spread was when there was so much spread within a community that we could no longer identify the source of infection for people who tested positive for COVID. Translated into daily new cases per 100,000, community spread is 1 – 9. Over 9 is accelerated community spread. That is where the U.S. is now.

So, if we were to get to herd immunity, what level of daily new cases per 100,000 would that be? Answer – less than 1. As you can see, we are nowhere close to this.

  • Dr. Makary projects that 55 percent of the American population has been infected. The problem is there is no way to prove or disprove that assertion. No serologic survey in the U.S. would lead us to that conclusion. Dr. Makary rightly points out that people may have immunity even without measurable antibodies due to T-cell mediated immunity. This is true, but again, doesn’t help us get to the number of people who have immunity, because we cannot routinely test for T-cell mediated immunity.

The CDC has made its own projections about how many Americans have been infected (and then presumably are immune, however, we are not inclined to believe that everyone who has been infected does have persistent immunity). Their projection is 83,111,629. Using the most recent U.S. population number, that would mean 25 percent of Americans have been previously infected and might still be immune – less than half of what Dr. Makary projects. We can’t know who is right.

But Dr. Makary goes on to make a statement that we know is incorrect. He states, “Herd immunity has been well-demonstrated in the Brazilian city of Manaus, where researchers … reported the prevalence of prior COVID-19 infections to be 76%, resulting in a significant slowing of the infection.” You may recall that Brazil did have a massive explosion of COVID cases at the beginning of the pandemic in the spring of 2020. Manaus was hit particularly hard. In less than 10 days, the health care system in Manaus was overwhelmed. Patients were turned away from hospitals bursting at the seams with COVID patients. Many who died of COVID were placed in mass graves.

Mathematical projections of the numbers of people who would have to be immune in a population (a herd) to make it difficult for the virus to circulate in the herd and infect those few who are vulnerable was 60 percent and virologists and our own public health experts anticipated that the actual threshold for herd immunity might be 60 – 70 percent. When scientists determined that 76% of the population of Manaus had been infected, the highest prevalence of any place in the world that I am aware of, it is true that we certainly presumed that Manaus likely had achieved the level of infection necessary to achieve herd immunity. But, where Dr. Makary is mistaken is his assertion that herd immunity was “well-documented in the Brazilian city of Manaus.” In fact, subsequent events disproved herd immunity in Manaus.

Recently, Manaus went through a new surge in COVID cases overwhelming their hospitals, not in 10 days as previously, but now in 24 hours. This is a strong argument against herd immunity. Hospitals quickly ran out of oxygen. Some hospitalized patients died because there was no supplemental oxygen to administer. Many more people died at home due to the lack of hospital capacity. This second wave was greater than the first. This is not consistent with herd immunity.

Now, one could argue that perhaps Manaus had reached herd immunity, but people’s immunity from previous infection with prior variants had waned, and they no longer maintained herd immunity. True, that may be the case. However, if true, that should also cause us concern in the U.S. that not all the people Dr. Makary believes have previously been infected remain immune. One could also argue, well the people of Manaus probably developed herd immunity to the D614 or D614G variants that were common at the time, but they just were not immune to the new variant, P.1. Also, very possibly true. But, in either case, what good is herd immunity, then? In the U.S., we have at least four new variants of concern (more variants than that, but I am just referring to the variants that have us worried). And, in either case, then why should Dr. Makary convince us that the U.S. will achieve herd immunity by April and all will be fine?

  • Dr. Makary asserts that 15% of Americans have been vaccinated. However, based on the latest numbers reported by the CDC, only 5% of the American population has been fully vaccinated, and with the most generous interpretation of the percentage of Americans “vaccinated” to include those who have only received their first dose, it would be 12.7%.

I am sorry to tell you that I don’t perceive any situation by which the United States achieves herd immunity by April of this year. The previous mathematical projection of 60 – 70% of people needing to be immune in order to achieve herd immunity has been revised upwards to perhaps 85% because models predict that a far more contagious variant will become dominant in the United States in March. In calculating the percentage of population necessary to achieve herd immunity, everyone who can be infected and transmit the disease must be included in the denominator. It is estimated that 24% of the American population is under the age of 18. There currently is no approved vaccine for children under the age of 16 and it is unlikely there will be until at least summer. If the percent of the population under 16 is 20%, then already, if everyone else in the country over the age of 16 has been infected and/or received a COVID vaccination, we would only get to 80% immunity. But, then again, we know that surveys tell us something on the order of 30% of Americans are either vaccine-hesitant – they want to wait 6-12 months before they get vaccinated or they are telling us that they will not get vaccinated.

Let’s march on. We will get there; we just won’t get there by April. Please don’t let your guard down. Stay home if you are sick. Get vaccinated if and when you can. Avoid gatherings of people other than those you live with, particularly indoors. Wear a mask when you are around people you do not live with. Wash or sanitize your hands often and every time after touching surfaces that are in public spaces. Keep a physical distance from others of at least 6 feet.

I haven’t posted many blog pieces lately, and that is because I am writing a book. But, I worry that you are hearing and reading a lot of false or misleading information right now, so I am going to try to write more often. As the co-author of the book we are working on often says, “Stay positive and test negative!”

Commonly Asked Questions about the New (Pfizer) COVID Vaccine

Should I get the vaccine?

For most people, the answer is yes. For this first vaccine, you will have to be at least 16 years of age. Those who have had severe allergic reactions (e.g., anaphylaxis) to any components of this vaccine in the past will not be eligible to receive the vaccine. We don’t yet have enough data to know whether the vaccine is safe for pregnant or lactating mothers.

When will we be able to vaccinate young children?

We don’t know yet, though I would anticipate that we may be able to do so sometime between the end of this school year and before the start of the next.

How many shots do I have to get?

Two shots separated 21 days apart.

How long until I have to get the next set of shots?

We don’t know yet, but we are anticipating that it may be as soon as a year or as long as three years. We will know better before you will be due for next year’s shots if it is a year.

Is the vaccine safe?

Yes, no serious safety concerns have been identified in the clinical trials thus far. With that said, side effects with vaccines are common, and often are evidence of the body mounting the desired strong immune response we are seeking. The most commonly reported side effects were pain at the injection site, fatigue, headache, muscle aches, chills, joint pain and fever.  These side effects are generally short-lived and typically resolve within several days of receiving the vaccine. These side effects tend to be very mild with the first shot and more severe with the second. Interestingly, older recipients of the vaccine tended to have milder symptoms with both shots.

How effective is the vaccine?

The vaccine is highly effective appearing to prevent COVID in 95 percent of those vaccinated, and in those few who still got infected despite getting the vaccine, they appeared to have significant protection against getting severe disease that would result in hospitalization or death.

When can I get the vaccine?

Because of demand and the fact that the vaccine is being manufactured and distributed, each state will get their vaccine in allotments every month, with the first shipments being received in mid-December. People will be divided up into priority groups that will determine when you will be eligible for vaccination. The first priority group is health care workers and residents of long-term care facilities. They will be able to be vaccinated starting this month. We don’t know the schedule for when additional groups will be eligible to receive the vaccine, but we would expect that high risk individuals may be able to be vaccinated as soon as February and the general population perhaps as early as April. However, watch your local news for public service announcements as to when it is time for you to be vaccinated.

Where will I go to get vaccinated?

Your primary care provider, local hospital and local pharmacy may be offering the vaccine. Information as to vaccination sites will be made available before the time you become eligible.

Is there a cost for the vaccine?

The vaccine is free, though there may be an administration fee charged by the provider. Be sure to check ahead of your appointment for vaccination whether you will need to pay anything at your visit or whether they will bill your insurance.

Once I get the vaccine, do I still have to wear a mask? Yes, we will all have to continue following all of the public health advice about staying home when we are sick, washing or sanitizing our hands frequently, covering our coughs and sneezes, keeping a distance of at least six feet from others with whom we do not live, and wearing masks anytime we are outdoors and cannot maintain the six feet of separation from others or indoors anytime we are with individuals who are not part of our household regardless of distance until a sufficient number of Idahoans and Americans have been vaccinated for us to achieve herd immunity (likely next fall). It is not yet known whether people who are vaccinated and are exposed to the SARS-CoV-2 virus might be able to transmit that virus to others even though they themselves are protected from infection so these infection control measures remain important for now.

How to Have a Virtual Thanksgiving

As we approach the Thanksgiving holiday, people long to get together with extended family, and surveys indicate that more than half of all Americans plan to travel for this Thanksgiving. However, we are also seeing record numbers of COVID cases, hospitalizations and deaths.

Given this uncontrolled disease transmission throughout most of the United States, the beginning of influenza season, and the fact that extended family get togethers are one of the most common transmission events for COVID, the CDC and many public health experts have strongly advised people against travel and spending Thanksgiving with those with whom you do not live. Canada had their Thanksgiving in October and experienced significant transmission of COVID within extended families. I have no reason to believe we will not have the same experience in the United States.

So, if you want to protect yourself and your family, let me suggest a virtual Thanksgiving. Given that gatherings are one of the riskiest settings for disease transmission, I reached out to an event planner to find out how they were helping clients do virtual events. I didn’t have to look far. My daughter, Lindsey Pate is a professional event planner with Bliss Events here in Boise. She has helped clients create virtual birthday parties and other events, so I asked her for her advice as to how people who want to spend time with family for Thanksgiving could do so safely and virtually. Lindsey is also a certified nursing assistant, who has participated in the care of COVID patients at a medical center here in Boise, so she is acutely aware of how severe this disease can be. Here was her advice:

Celebrating Thanksgiving From a Distance

By Lindsey Pate

Since you are following my father’s blog, I’ll wager we’re cohorts in understanding this virus is real and our behaviors are a contributing factor in the control of its spread. With the holidays approaching, those of us with a similar mindset may be considering how we can honor the season through responsible, festive celebration. As a professional event planner and a healthcare worker, I have been pivoting since March to work with clients and my own family on how to celebrate while avoiding unnecessary exposure.

By now, we know the short list of guiding principles until a vaccine is readily available– distance socially, wash our hands, avoid touching our faces, and if gathering, do so outside, in well-ventilated areas– but what does this mean for holidays centered around gathering and togetherness? Here’s a short list of ideas to acknowledge the holiday and inspire feelings of closeness, while adhering to the distancing recommendations of medical experts.

Together at a distance:

Most families I know will choose to join as a household to celebrate the Thanksgiving meal tradition. To keep the sense of celebration intact, consider plans to meet with extended family afterward, in a socially distanced setting. Just as Covid birthdays saw the rise of drive by parades, the same idea can be applied for the holidays: decorate your vehicles and plan a caravan for immuno-compromised or elderly relatives. If you’re ready to usher in the Santa season, pre-purchase tickets for an event such as Idaho Botanical Garden’s Winter Garden aGlow; the venue will be implementing social distancing and safety protocols to alleviate precaution pressure.

Going virtual doesn’t have to be awkward:

The year has taught us the ins and outs of the proverbial Zoom meeting and it’s likely some of us are planning an online dinner session. Avoid the silent pauses and over-talking with some pre-planned activities. Activities like a costume contest (can ugly Thanksgiving sweaters please be a thing?), turkey themed “Minute to Win It” contests, even a household scavenger hunt can be fun to break up the lulls. Gift bags can be porch-delivered ahead of time and include conversation starters (pieces of paper with topics to encourage discussion), game activities, and even slices of Mom’s pumpkin pie to enjoy simultaneously. Appoint a moderator (kids love this role!) to facilitate a talking order and award speaking privileges when multiple relatives pipe in at once.

Remember, it’s about reflection and gratitude:

So, gratitude pumpkins are a thing and they’re pretty great. Buy pumpkins for every person within a family unit and write a name on each gourd (or squash… fruit?). This can be a real pumpkin, but I also love the foam pumpkins that can be kept forever. If you’re a large family, consider a Secret Turkey and draw names ahead of time for the family with which you will share your admiration. Use an indelible pen to write directly onto the pumpkin the things you love and are thankful for about this individual, then deliver to their respective doorsteps. Let the comments be positive and anonymous – you may be wonderfully surprised by what others appreciate about you! If not everyone is interested in a little leg-work, have someone create a slide show of family photos to be shared digitally or virtually.

Ditch the cooking:

There’s nothing typical about 2020, so why not turn the whole thing on its head? Skip the cooking this year and dine at home with food created by a talented, local chef whose business could use your support. For more traditional continuity, have every household in your family place an order and eat together virtually, while sharing the same meal.

Go for it:

As gatherings dwindle to ten or fewer, the opportunity arises to create that spectacular, Pinterest-worthy event you’ve always wanted to host! Throughout the pandemic, we event planners have seen attention paid to the smallest of details, since the guest counts are manageable and budget friendly. For your family, maybe this means breaking out Grandma’s special dishware and linen napkins, or creating place cards and a beautiful centerpiece, or cooking your green bean casserole because it’s delicious and Aunt Sally always volunteers to bring hers first! Whatever this looks like for you and yours, 2020 is the year to simply go for it.

However you choose to celebrate next week, Thanksgiving still remains a day worth dedicating to gratitude and reflecting on the year’s blessings. Beyond the fact we are all grateful this year is approaching its conclusion, enjoy the special time with your loved ones and make the most of the lemons we’ve been stockpiling since Spring.

From our family to yours, we wish you a very Happy Thanksgiving and a beautiful holiday season.

School Operational Plans

Some of you are aware that I am helping some schools with their pandemic operational plans. In my work with one school district, it became clear that we needed to rewrite their operational plan. We have taken a unique approach to this plan. First of all, most plans are written for school leaders, staff and teachers. But, if we are going to be successful, we need to have the help of parents. So, this is the first plan that I have ever seen that also includes parents and their role in the pandemic operations. Further, plans that I have seen tell people what to do, but I have never seen a plan that explains why. It is my view that if we want people to do things that are above and beyond their normal duties/responsibilities, we have to explain why. So, I thought that an excerpt from the plan might be helpful to everyone, whether you are a principal, teacher, or parent. So, here you go:

  1. What is SARS-CoV-2 and how is it transmitted?

The Severe Acute Respiratory Syndrome – Coronavirus 2 (SARS-CoV-2) is the name of the virus that causes COVID (coronavirus disease) or COVID-19 (the 19 refers to the fact that this disease was first recognized in 2019).

The SARS-CoV-2 virus is very contagious and the challenging thing for managing the spread of this virus is that people often are contagious in the day or two before they develop symptoms, and others are infectious though they may remain asymptomatic for the entire duration of their infection. Therefore, until the spread of this disease can be brought under control, children will show up for school infected and contagious even though there may be no sign that these children are ill. The safest thing is to assume that you may be contagious and should therefore avoid close contact (six feet) with persons with whom you do not live and that everyone else apart from those with whom you live that you interact with during the day are potentially contagious.

The virus is transmitted in three different ways:

  1. Droplets – This is the most common way the virus is transmitted. Droplets refer to the secretions that come out of our nose or mouth when we speak, cough, sneeze, yell or sing, and if you are infected, virus will be contained in these droplets. This is why it is important to COVER YOUR COUGHS AND SNEEZES. No doubt you have noticed at times when talking or when observing someone else talking, that you can see small amounts of what you may have called spittle or spit come out of the mouth while speaking. This is normal and common, in fact, it is happening even when you don’t notice it.

We call this spittle or spit droplets, and these are secretions from your nose mixed with mucous or your throat mixed with saliva. If someone is infected with the SARS-CoV-2 virus, this virus resides for a period of time in the nose and throat and therefore is likely to be present in those droplets.

As droplets come out of our mouth and nose, they travel for a distance and either land on a surface or fall to the ground. If you are sitting at a desk, some of these droplets will land on your desk. If you are working on a computer, droplets will land on the screen and the keyboard. If you are talking on an iPhone, droplets will collect on the screen. This is why we must WASH OR SANITIZE OUR HANDS FREQUENTLY and CLEAN SURFACES that are touched or in close proximity to teachers and students AT LEAST DAILY AND ESPECIALLY BETWEEN USE by different teachers or students.

The droplets travel various distances, depending on their size, weight, the humidity in the room or outside, and what barriers are in their way (like a laptop computer or another person). The largest number of droplets will be in the air and in surfaces close to the person who is talking, coughing, sneezing, or singing, generally falling to the ground or evaporating by a distance of six feet. This is why we ask that everyone try to MAINTAIN A DISTANCE OF SIX FEET BETWEEN YOURSELF AND ANYONE YOU DO NOT LIVE WITH. This includes walking to school, riding the bus, arriving at school, in the hallways, in your classroom, at recess, while you are eating, and when you are in PE class or playing sports.

When a person is close enough (within six feet) to another person who is infected, and may not even realize that they are infected, then these droplets can land on the other person’s face, eyes, nose or throat and the virus in the droplets can infect that person by the person touching their face and then introducing it into their eyes (by rubbing their eyes), their nose (by rubbing or picking their nose or by simply breathing the droplets in) or their mouth (by the droplets landing in the mouth or by droplets on the lips being introduced into the mouth with licking their lips or with eating or drinking).

DISTANCE IS OUR MOST EFFECTIVE WAY TO SLOW DOWN AND PREVENT THE SPREAD OF THIS DISEASE. This is why we ask everyone, whether in school or at night or on the weekends, please avoid large gatherings. Large gatherings increase the likelihood that someone in that gathering is infected and contagious, even if they feel perfectly well and appear well, and large gatherings make it difficult to maintain your distance of six feet at all times.

Along with keeping our distance, the other most important thing we can do is to WEAR PROPER FACE COVERINGS PROPERLY. The main thing face coverings do is serve as a barrier to collect the majority of these droplets, and by doing so, blocking virus in those droplets from getting onto someone else’s face, eyes, nose or mouth that could then infect that person.

One can still be infected by droplets outdoors, though air and wind currents tend to impede the distance droplets will travel outside. Nevertheless, when outdoors, we should continue to KEEP A DISTANCE OF SIX FEET FROM ONE ANOTHER and WEAR PROPER FACE COVERINGS PROPERLY when there is a risk that distancing cannot be maintained at all times.

  • Airborne or aerosols – This is the next most common way to transmit the virus and likely the cause of transmission when you hear about “super-spreader events.” Aerosols are smaller than droplets. If you think of droplets like spittle, think of aerosols like the mist of hair spray or deodorant spray, although these can be even smaller. It may be confusing to call this airborne transmission when we talk about droplets, above, that also travel in the air. The difference is that droplets travel in the air only as far as they are expelled with force. For example, droplets will travel a shorter distance when we are speaking softly than they will when the teacher is projecting her voice in the classroom so her students can hear or when a coach is yelling or cheerleaders are cheering. Similarly, coughing or sneezing expels droplets a further, but still limited, distance.

To better understand airborne transmission, think of a time you were entering a room after someone was smoking or even when you were outside walking behind someone who was smoking. Could you smell the cigarette or cigar? Or, recall a time when you entered the locker room after people were exercising and sweating. You were smelling odors that were not projected into air by droplets, but rather carried in the air streams in the room or outdoors. That odor could just as well be virus particles carried in aerosols. And, if you were breathing in those odors and able to identify the smell, you would also be breathing in virus particles if they were circulating in aerosols.

Droplets travel a finite distance, in most cases, little more than six feet due to being pulled down to the ground by gravity or evaporating in air. In airborne transmission, the aerosols are small enough and light enough to travel on air streams, generally those created by indoor ventilation systems. They can travel the entire distance of a room or open area on these airstreams as they move to wherever the air return is.

“Super-spreader events,” namely those events where numerous persons are infected by a single person, tend to be large gatherings held indoors. While some people in attendance in close proximity to others may be infected by droplets, it is likely that many are infected by these aerosols traveling on air streams. These aerosols are created the same way that droplets are, but appear to be produced in larger amounts and with higher amounts of virus in them when people raise their voice, yell, cheer, or sing.

There are ways to mitigate the risks of airborne transmission:

  1. If weather allows classes or other activities to be held OUTSIDE, the risk of airborne transmission is reduced greatly.
  2. WEARING A PROPER FACE COVERING PROPERLY has been shown to reduce the number of aerosols a person emits into the air by 65 percent, because these, too, can be blocked to some extent by a face covering.
  3. COVER YOUR COUGHS AND SNEEZES to reduce the number of aerosols ejected out into the air.
  4. If indoors, increase the number of air exchanges per hour. Four to five air exchanges per hour would be good. The higher, the better. In addition, air in school buildings should not be recirculated when possible. It is always best to exhaust the air to the outdoors and circulate fresh air.
  5. If indoors, look for the air return in the room. Because air streams move towards the air return. Make sure that the teacher’s and students’ desks are not placed directly under an air return because the air streams that might contain virus will be directed right at that student or teacher.
  6. If indoors, consider opening the classroom door or the classroom windows, if the weather permits.
  • Contact – Of all the modes of transmission, this appears to be the least common. This mode of transmission would involve touching a surface where droplets have landed or touching items in the household recently used by someone who is ill with COVID where virus that remains on the surface might get on your hands and then you might touch your eyes, nose or mouth and introduce the virus where it can cause infection.

For these reasons, we recommend that everyone:

  1. WASH OR SANITIZE YOUR HANDS FREQUENTLY. Washing hands is always preferred when a person has visibly soiled hands due to dirt, blood, secretions, or vomitus. Otherwise, washing and sanitizing are, for our purposes, equally effective. When washing, use soap; warm, but comfortable water; and ensure that you rub your hands vigorously, lathering the soap and getting water and soap over the entire hands and between the fingers for 20 seconds. When sanitizing, similarly get the sanitizer rubbed over the entirety of the hands and between fingers. Allow the sanitizer to air dry rather than wiping the hands dry.
  2. CLEAN SURFACES DAILY but more often if the surface is frequently touched, e.g., doorknobs or sink faucet handles, and clean desks and keyboards between each student’s use.
  3. DO NOT SHARE drinks, food, snacks, gum, writing utensils, tissues, face coverings, make-up, chap stick, eating utensils, musical instruments or personal items.
  4. When students leave at the end of the day, tables, keyboards, chairs and other surfaces that were frequently touched by students need to be cleaned with ______.
  5. If there is equipment that will be shared by students (e.g., weight machines, free weights, kilns in art class, music stands, or mats), these should be cleaned in between each student’s use with ____ by the teacher or by the student with the teacher’s supervision.
  1. What are the most important things for me to know to protect myself, the staff and teachers at my school and the students at my school?
  1. Get a flu shot for yourself and everyone in your family if you have not already done so.
  2. Restrict visitors and non-essential persons in the school building.
  3. If you do not feel well, stay home, and if a student feels ill, please keep your child home from school. There are many contagious viruses that circulate in our communities during the fall and winter. Regardless of the cause of a staff member’s or student’s illness, it will help us manage the health and wellbeing of our staff, teachers and students if we can limit the transmission of all viral illnesses, especially since it can be very difficult to distinguish COVID from other common viral infections simply based upon symptoms.
  4. If you suspect that you or a student or someone you know has COVID-19 or has come into close contact with someone who has COVID-19, visit Coronavirus self-checker. This online tool will help you decide when to seek testing or medical care for you or the student.
  • Notify your child’s school that your child is sick, and staff notify your school if you are sick. Also inform the school if a staff member or student has had a COVID-19 test and what the result is, if available.
  • If anyone in your household is determined to have a confirmed or a probable case of COVID, everyone in the home should remain at home in quarantine for 14 days, while the infected family member is isolated. There is substantial transmission of the virus in the home when anyone is infected, whether an adult or a child.
  • The risks you subject yourself and your family to outside of school will impact the risk that a staff member or student could be infected and unknowingly take the virus with them into the school and infect others. Therefore, follow the recommendations below at school and outside of school.
  • Wash or sanitize your hands frequently. Washing hands is always preferred when a person has visibly soiled hands due to dirt, blood, secretions, or vomitus. Otherwise, washing and sanitizing are, for our purposes, equally effective. When washing, use soap; warm, but comfortable water; and ensure that you rub your hands vigorously, lathering the soap and getting water and soap over the entire hands and between the fingers for 20 seconds. When sanitizing, similarly get the sanitizer rubbed over the entirety of the hands and between fingers. Allow the sanitizer to air dry rather than wiping the hands dry.
  • Cover your coughs and sneezes.
  • Avoid attending events or activities where there will be large gatherings. With the high degree of community spread that we have, the chances that people in that gathering will be infected, even without realizing it or appearing ill, and contagious increase with the number of people in the gathering. Currently, in Idaho, we see many cases of COVID from attending weddings, backyard barbeques, sleepovers, car-pooling, or get-togethers with friends or extended family members.
  • If you will be out in public, attempt to maintain a physical distance of at least six feet from anyone you do not live with, and if indoors or if outdoors and keeping the distance cannot be assured, wear a proper face covering properly.
  • Proper face coverings can include cloth masks with two or more layers of washable, breathable fabric, surgical masks, or gaiters with two fabric layers or that are folded over to make two layers. Masks with an exhalation valve or vent are not appropriate face coverings because they allow virus to escape through the mask. A face shield is not an acceptable face covering, except in very limited situations as approved by the ­­­­­_________. That is because face shields provide little, if any protection for the face shield wearer or those around her from droplet or aerosol transmission. For those students or teachers who have the need for their lips to be seen, e.g., interpreters, special education teachers or teachers teaching young children how to sound out letters or words, the Clear Mask or the Rafi Nova Mask are acceptable face masks when engaged in activities for which a cloth face covering or surgical mask is not practical. The advantage to the Clear Mask is that the plastic window does not fog with speaking.

Wearing a face covering properly means that the face covering completely covers the mouth and nose and the mask does not have significant gaps at the sides where it does not fit well against the face.

Showing our Appreciation to Health Care Workers

There is no doubt that the coronavirus pandemic has been a divisive issue prompting political, ideological and medical debates. No matter our views and beliefs, though, one thing that we should all agree on is that our hospitals, doctors, nurses, respiratory therapists, laboratory scientists, pharmacists and all the many health care workers that it takes to be there for us when we need them, every day, night, weekend and holiday are heroes.

There were many visible demonstrations of our support for these health care heroes early on in the pandemic. Since then, these health care workers have continued to do their jobs every day, despite the fact that they know that they are putting themselves and potentially their families at risk of infection.

Many of us know someone who has had COVID and chances are they recovered with relatively mild illnesses. But, these health care workers see the most severe cases of COVID every day. They see the desperation in some of these patients’ eyes. These are not just “patients” to these health care workers, they are people who are scared, struggling for breath and often, alone. Despite the pressures on these health care workers due to the large numbers of severely ill patients they must care for every day, they often take time to hold a patient’s hand and provide the reassurance that family members are unable to. It is impossible to care for these patients days or weeks on end and not become attached to them. The recoveries are extremely gratifying and professionally rewarding; the deaths are huge emotional losses for which there often is no or little time to adequately process and grieve because there is another patient who needs attention.

Health care workers are going on nine months treating these patients and exposing themselves to the risks, and they will likely continue to have COVID patients for the foreseeable future.

As we approach the season of Thanksgiving, I call on Idahoans and people across our country to once again show our support for these health care workers and our local hospitals by turning out to applaud health care workers at the change of shift during the week leading up to Thanksgiving Day. At a time when our communities are divided about many issues, it is a tremendous boost to our health care workers to know that we are united in our support of our local hospitals and health care workers, the important work that they do and the sacrifices that they make. Please join in expressing your support and appreciation.

I also call on our Governor and those of other states to identify a day during that week leading up to Thanksgiving as a state day of Thanksgiving for health care workers.

The President of the United States has been hospitalized with COVID – What are the Lessons for us and What should we do?

Last night, the President and First Lady were diagnosed with COVID, and today, the President was flown to Walter Reed National Military Medical Center in an abundance of caution and for closer observation and monitoring.

Today, the President reportedly received at least one, and potentially two, therapies that are neither FDA-approved or authorized under compassionate use in order to do everything possible to help prevent the President’s illness from becoming more severe.

This is a time for the President to be hospitalized and quarantined and for the nation to reflect on where we are and what we need to do now.

  1. Unbelievably, after eight months, over 7 million cases of COVID in the US alone, more than 200,000 deaths of Americans, endless news coverage, numerous world leaders and celebrities infected, messages of acknowledgement of COVID by both major political parties, and acknowledgment of COVID by every medical, nursing and public health association or agency, there are still individuals calling COVID a hoax. This needs to stop. There was a time at the beginning of this pandemic where one might be excused for being suspicious of what was actually happening, but there can no longer be a justification for believing this to be a hoax other than willful ignorance or foolish denial.
  2. There has been a disturbing rejection of science and expertise that is dangerous and unfounded. Scientific advancements have saved lives and made our lives better. One need look no further than the improvements and efficiencies gained in farming and agriculture, the developments in computing, and the development of new medications and treatments. This rejection is not sincere; it is politically motivated. Before the President was infected, it was politically expedient for him to reject science and advice from leading experts. But, once infected, President Trump did not turn to Dr. Atlas, the highly controversial White House adviser for coronavirus; the MyPillow CEO who pitched an unproven COVID-19 cure of oleandrin made by a company in which he had a financial interest; nor to Dr. Stella Immanuel whose video asserting unbelievable and unsubstantiated claims about curing COVID President Trump retweeted with approval. Instead, he turned to the leading physicians and scientists in our country and the prestigious Walter Reed National Military Medical Center and to medications that were being scientifically studied when his own life was on the line. I suspect this would be true for the majority of those who are rejecting science and medicine. It is easy to deny science when it does not personally impact them or their family. However, in all my years of practice, I did not have a patient for whom I diagnosed a life-threatening condition in them or a loved one who did not want to take advantage of the best that science and medicine had to offer. So, let’s stop this. If you don’t want to follow the advice of experts, fine, don’t. But, own up to your decision and don’t cause confusion for others by trying to influence others to reject science and public health advice.
  3. Similarly, there are those who are promoting false and misleading information. I don’t know whether they understand the risks that poses to others or if they do not care. I hope it is the former. It is time for this to stop as well. In the most recent days, President Trump admitted that he had nothing against masks. However, he and his family did much to undermine the public health guidance on this. Mistakenly thinking that they were protected from COVID by the testing they get daily that most other Americans do not, it was easy to down-play the need for masks, which, after all, are a constant reminder that we are in a pandemic, but this has back-fired, resulting in exactly what the President did not want – significant increases in cases, deaths exceeding early projections, the closure of businesses, the loss of jobs and increasing unemployment, a huge hit to the economy, school closures and only a gradual re-opening and cancellation of some sports. It is time for us to stop perpetuating myths and unsubstantiated falsehoods and come together to reduce the spread of this virus, which is the best way to get back to some semblance of normalcy. So, if you are spreading this false and misleading information, please stop and realize that you are only making it more difficult to achieve the objectives you say you want.
  4. There are those suggesting that testing is our way out of this pandemic. There is no doubt that testing is important, but the White House indicates that the President was being tested every day, as was everyone coming into close contact with the President. It didn’t work because of the limitations of our current testing and because testing alone will never be able to control a pandemic – changing our behaviors and taking public health precautions will decrease our risk and slow down the transmission of the virus to the point where testing then can be a valuable tool in controlling the pandemic.
  5. Leadership matters. Leaders often are confronted with unpleasant, inconvenient, and on occasion, very difficult problems that can have a great impact on their organizations, customers, employees or communities, and great personal risk to the leader. In my experience, rarely do things turn out better by denying them, minimizing them, or avoiding them. Thus, I would always advise the leader to study the problem, seek out expert opinion, and then devise a plan to address the problem, realizing that you may learn more with time that will cause you to tweak your solution, you may discover that there are unintended consequences of your solution that will cause you to tweak your plan, or you may discover failings of your plan that cause you to change course. But, in this pandemic, I have seen numerous examples of leaders unwilling to come up with a plan or make a decision because they fear that no matter what they decide, someone will be unhappy with that decision. In some cases, that fear is amplified by potential loss of employment or failure to be reelected. On more than one occasion, I have given my advice to those leaders. If your assessment is that no matter what your decision, half of the people are going to be upset by it, then make the right decision – do the right thing, because if you are going to lose your job or not get reelected, at least be able to hold your head up when you apply for your next job or run for your next office, knowing that you did the right thing, and having history remember you for having done the right thing, rather than what you thought would please your most vocal critics. Keep in mind, those critics are not going to come to your defense when others now try to fire you or remove you from office because you did not do the right thing. Further, most potential employers are not going to want to hire someone who got fired for doing the wrong thing, and most of the electorate are probably not likely to support for office someone who history has shown mismanaged a major problem.

So, as our President fights this infection, let us fight the behaviors that have divided us and contributed to the spread of this virus. We can do it. If you don’t want to do it because it is the right thing, at least do it because the internet and social media will leave a lasting record of our words and deeds and history will judge us accordingly. It is time to restore the values of American exceptionalism and the spirit that when our country faces a challenge, we all roll up our sleeves and do what it takes to preserve our country, to protect our fellow countrymen, and to preserve the values of our democracy. God save our President and country and God bless America.

Is it Safe to Fly on Commercial Airlines?

I have been asked this more than once. And, I don’t actually know the answer, because I don’t know of any good studies that address this question. There is little debate that in some cases, there do appear to be infections that can be traced back to flights. But, I have no idea how many and exactly what any particular person’s risk is. However, this doesn’t help people who have to make decisions about travel in the next couple of months, so I will at least share with you what my own decision is and why.

Personally, I will not be flying for at least the next six months. Why?

  1. Cases of new COVID infections are increasing in the majority of the US states and in many of the countries that I might be attracted to as tourist destinations and that others might be likely to travel to for business.
  2. I believe that cases are going to continue to increase over this fall and winter, and in fact, may be worse than anything we have seen so far. Why? We are seeing a confluence of new epidemiologic risk factors – more K-12 schools opening every week with in-person classes, colleges and universities holding classes in-person, the resumption of sports, the re-opening of bars, more and more examples of large gatherings in defiance of public health recommendations (and many infections from extended family get togethers, neighborhood bbqs, weddings, etc.), the movement of gatherings indoors due to air quality in the western US or due to colder weather, the upcoming cold and flu season, the projections that at least 90 percent of Americans remain vulnerable to infection and the increasing evidence that the D614G mutation, which is more contagious, is likely the predominant SARS-CoV-2 strain in the US and Europe.
  3. The reason that 1 and 2 above are so important to my analysis is that the greater the number of cases in the community, the greater the odds that you will encounter one or more infected persons during your travel – the taxi or ride-sharing service to the airport or from the airport to your final destination, the shuttle bus or train between terminals or to or from parking lots, the hotel you will be staying at, etc.
  4. In my personal observations, it seems that people may be more likely to stay home from work sick than they are to cancel travel plans. I recall vividly a flight last year where the person across the aisle and one row back was coughing incessantly during the flight. Two days later, guess what? Yes, I had a nasty cold with an annoying and persistent cough!
  5. While airplanes do generally seem to have excellent air circulation, air exchanges and filtration, that is during flight. Probably all of us can remember boarding flights when it was hot outside and desperately fiddling with the air flow control valve above your head trying to get some cold air only to find out that the engines are not on fully and the air conditioning system will not turn fully on until beginning the take-off process.
  6. When up in the air, people will be taking their masks off to drink, snack and eat meals. There is also the issue of someone taking their mask off and then falling asleep or someone taking it off and refusing to put it back on. Are the flight attendants going to awaken the passenger in order to have them put their mask back on? Are flight attendants going to insist that a passenger wear their mask if they refuse? Certainly, we have seen many businesses that require the wearing of masks, but do not enforce it in the store.
  7. One must consider all the associated activities with any event. So, while the actual flight may or may not be safe, does the airport require everyone to wear masks at all times? Is there physical distancing at security? At baggage claim? At the taxi or ride-sharing stand? At the gate? During the boarding process?
  8. During the time I practiced medicine, I had patients get ill while out of state. Arranging care under those circumstances can be less than optimal, but generally doable. On the other hand, I have had patients get ill over seas and this is far more complicated.
  9. Lastly, given my concerns about significant increases in cases this fall and winter, one does have to consider the actions various states may take (travel restrictions or quarantining requirements) and restrictions the US or other countries might put in place that might require you to quarantine or might interfere with your ability to travel.

So, for all these reasons, I do not intend to travel for at least the next six months. Others might come to different conclusions, and of course, that is their prerogative. It is merely my hope that these factors may be helpful to you as you think through the risk/benefits of travel for you and your loved ones and make your own decisions in the next few months. If you do decide to travel, be extra careful about your adherence to all the safety precautions we have been promoting to reduce your chance of being infected. And, if you do become ill before your flight, please do everyone a favor and stay home!

Reopening Schools Safely

I have been an outspoken critic of school boards making decisions to reopen schools for in-person classes in areas with high degrees of community spread of COVID without giving due consideration to public health advice and medical input and without articulating their reasoning when choosing not to follow this advice.

I do appreciate that the decision about whether to reopen schools entails more considerations than only medical ones. That is the reason that I have stated publicly that doctors should not be the ones to make these decisions.

But, if the board’s decision is to open schools for in-person classes against the public health advice, then, as Dr. Jim Souza, Chief Medical Officer for St. Luke’s Health System told a number of the boards, the likelihood of success will be directly related to the strength of their schools’ operating plans.

I totally agree. I believe that the schools with very well-thought-out operational plans with clear responsibilities and accountabilities will be the ones with the best shot of keeping infections under control and preventing an outbreak. Because if there is significant community spread, these schools will have cases, almost certainly during the very first week of school, and very possibly the first day.

While this is great advice, the few operational plans I have seen at the school board level have not qualified as the kind of well-thought-out, detailed operational plans that I think about, nor what I suspect Dr. Souza had in mind. I realized that the boards were likely expecting the individual schools to come up with more detailed plans, but I felt very sorry for those principals and teachers, few of whom, if any, have public health, infection control, or virology expertise.

Certainly, the schools have access to the excellent guidance put out by the CDC and the state public health departments, but seldom is that guidance understandable to these education professionals in terms of the application to the specific circumstances and challenges they face in operating a school.

So, in an effort to help, I have volunteered my assistance to schools that want a review of their operational plans and suggestions as to how to improve them, and then further offered to do walk-throughs to identify issues that you really can’t be aware of until you see the facility and hear what normally happens from the principal and teachers who work there. In addition, it gives me an opportunity to answer the many questions teachers have. I should point out that this blog piece is about K-12 schools. Colleges and universities have many more and, in many cases, different issues and concerns.

The following may be of interest to schools that have not yet re-opened. My hope is that what I have advised the schools that have taken me up on my offer may be of help to you in strengthening your own plans and that my framework for doing the walk-throughs might enable you to do think about issues that I raise on those walk-throughs.

So, the first step when a school does ask for my help is to ask them to send me a copy of their operational plan. This allows me to look through, identify elements that are not up to date or correct and identify missing elements. I then mark the plan up, return it to them for their review and they can accept whichever of my changes and suggestions they like.

What I often find is that the plans usually offer very little detail. The plans often include guidance from public health authorities, but the plans seldom indicate how that guidance will be applied in the setting of school, how often it will be done, whose responsibility it is to do it, and how it will be accomplished in settings outside of the classroom. (I’ll provide examples below in my discussion of the walk-throughs). The detail is important, because this is likely to be the biggest factor in whether you have contained, isolated infections or an outbreak in the school.

I also find that the plans generally have little information on informing teachers, students and parents on necessary preparations before they show up for the first day of class; education of teachers, staff, parents and students about COVID and their responsibilities under the operational plan; a detailed communications plan; and the safety precautions that need to be implemented on the school grounds before a student even enters the door of the school.

Finally, I seldom see the amount of detail necessary to address non-classroom activities safely – physical education, choir, band, cheerleading, athletics, cafeteria, etc.

With this said, let me state that I think the schools that I have reviewed did a really amazing job at putting these plans together. They are educators and not public health experts, and to have done what they did shows a tremendous amount of thought and care. But, the critiques I have made are a reflection that to create a really good plan requires the partnership of educators who know how things happen in the school and the issues they face everyday with public health or medical experts who can offer fresh eyes and identify areas of risk that are less likely to occur to non-medical experts.

So then, with my comments in hand, the school can decide if they want to do a walk-through. If so, I generally ask the principal, a note-taker, the building maintenance expert, a classroom teacher and each of the teachers of the non-classroom areas – PE, music, coaching staff, etc. – to meet with me outside the front door to the school.

We start off with a discussion of what is going to undermine the success of the plan? For example, if the plan has not been well communicated to everyone who has a role in the plan, then there is little chance the plan will be successful. Has the plan been circulated? Is the plan easily available? Does everyone understand it? Do teachers have incentives to come to school sick – e.g., loss of pay, lack of availability of substitute teachers? Do parents have incentives to send their children to school sick – e.g., consequences under the attendance policy, inability for the student to keep up on their school work from home, challenges accessing or paying for a doctor’s visit and note to return to school?

Then we move on to what are the issues and concerns on school day, before students even enter the front door. How early can students arrive? If there is a significant amount of time students could be on campus without oversight, we could have problems. This could result in congregating outside in close proximity without masks on and children seeing their friends that they may not have seen in six months. There may be hugging, high-fiving, and all kinds of high-risk interactions. As I told one school, you have a great plan for when students are in the classroom, but they may end up being infected in the parking lot before they even walk through the front door.

We then need to discuss how students arrive. Will they come by bus or by car? Buses pose threats of their own. Buses generally do not have as good of air circulation as we would like, so we need all students and the driver in masks, extra distancing and the windows open when weather permits.

There is also the question as to whether the school is going to do temperature checks and/or symptom screening. Some argue against this because only a minority of children have fevers and/or symptoms when infected with COVID. Thier concern is that teachers and others may develop a false sense of security or complacency if they know the children have passed the temperature screening and/or symptom screening. My position is different. First, even if we only identify a few cases this way, it is worth it to keep them out of the school building. Second, with cold and flu season coming, we are not just screening for COVID, but also colds and influenza. We don’t want any of that in the school because all are contagious and we seldom can tell these conditions apart without testing, so I would argue we should do everything we can to keep everyone who is ill, including those who may not realize it yet, out of the school and from contact with others. Finally, I think it is easy enough to educate teachers that they should assume that every person they interact with at school is potentially contagious, and temperature and symptom screening has only identified some of those who pose a risk.

Here is what the largest study to date of signs and symptoms of COVID in children showed us:

  • 30% will have a temp >100.4
    • 39% will have a temp 99.5 – 100.4%
    • 22% of kids will be truly asymptomatic
    • 8.5% will be symptomatic with characteristic symptoms.
    • 66.2% have symptoms, but not those that are commonly recognized as COVID.
    • 25.4% of kids developed symptoms after diagnosis.
    • Kids that were symptomatic were symptomatic from 1 – 36 days. (61% still symptomatic at 1 week; 38% at 14 days; 10% at 21 days)
      • 60% had respiratory symptoms – cough, rhinorrhea
      • 18% had gastrointestinal symptoms – abdominal pain, diarrhea
      • 16% had loss of taste or smell

So, the reason I go into this at this point is that ideally, we want to screen children if we are going to screen them before they get on the bus and before they get out of the parent’s car. Obviously, once the kid is handed off to the school, it could be some time before we get a parent back to the school to pick their child up and we really don’t want a potentially infectious child hanging out at the school. So, can someone go on the bus to screen temperatures and symptoms before the child gets on the bus? Can we have staff screen children in their parents’ cars in the parking lot before the child gets out of the car? And, if they are going to do the temperature check, what are they going to use for the temperature cut off? Guidance commonly states 100.4, but in light of the above, and to keep it simple for screeners, I recommend just using 100.

The other thing we need to do is ensure that before the child gets in the bus or out of the parent’s car, they have an acceptable mask on and are wearing it correctly. If they don’t have a mask or forgot it, we need to have masks there and available to give the child. It is important to note that face shields are not an acceptable alternative.

At one school, as we were doing this review outside the school building, I noticed a half dozen building contractors going in and out of the school without masks on. It was a great opportunity for me to remind them that everyone who goes in the school building must wear a mask, even contractors and visitors. In fact, I calculated the incubation period for them to demonstrate that if one of the teachers was infected by a construction worker, they would likely be at their peak infectiousness on the first day of school!

We are ready to begin the walk-through. I turn to the building maintenance staff. We discuss the difference between droplet and airborne transmission and discuss strategies to increase air circulation and ensure that air is exhausted to the outside rather than being recirculated. In addition, in cases where we cannot get a sufficient number of air exchanges per hour, we discuss options of opening windows, opening doors and having classes outdoors.

While on the subject of airborne transmission, we check the bathrooms out. Many of the newer restrooms do not have lids on the toilets. I discuss the aerosolization that occurs with flushing toilets, the benefit of closing the lid of the toilet before flushing if there is one, and the need to restrict the number of students using the restroom if there are not lids. Further, we discuss the implications for virus to contaminate all surfaces in the restroom – the floor, the stall doors, the counters, the faucets, the paper towel dispenser, the door to exit the bathroom, etc. Therefore, in addition to washing their hands, I recommend placing a sanitizer just outside the bathroom for a final hand-sanitizing after exiting the restroom.

That leads to the next point. Sanitizers. Schools have done a good job of placing sanitizers near the classrooms, however, many of the ones I have seen do not give a visual cue that the sanitizer is empty. Therefore, I stress that it is important that someone has it in their workflow to make periodic rounds to fill sanitizers. Unfortunately, when empty, rather than finding another, kids will often just forego sanitizing their hands.

I then look at classrooms and ask the teacher to tell me all the movements in the classroom a child might be expected to make. It turns out that while they do a great job of distancing desks, there are places in the room where books or other resources are kept and where many students may go at once to get or return something. That then compromises our distancing. So, we talk about other ways to accomplish it by the teacher handing them out or staggering the students as they go to the area.

Speaking of airborne transmission, an important feature to look at in the classroom is the air return. Sometimes it is over the door at the entry way, but on other occasions, I have seen them right over the teacher’s desk (this is the worst possible location) or sometimes over a student’s desk. Given that aerosols will follow the airstreams, the virus will travel in a directed manner right over the teacher’s or student’s head. I always suggest that the teacher’s desk be moved if that is the case, or if it is over a student’s desk, then I advise moving the desk as much as possible (to reduce the risk of airborne transmission) while still maintaining distancing (to reduce the risk of droplet transmission), but if it is going to have to be near that airstream then keep that in mind and don’t put a vulnerable student under it or a student who for some reason is unable to wear a mask or unlikely to be compliant with mask wearing.

I also take this opportunity to discuss the need for cleaning – desks, chairs, keyboards, etc. I advise them to be clear in their plan who is responsible for cleaning what and how often. In addition, we discuss whether there are special education teachers or teachers or interpreters for the hearing impaired. These teachers often want to use face shields. I explain the limitations of face shields and the need for even greater than 6 feet of distancing when they are going to be used, but pointing out the likelihood that they provide little, if any, protection to the teacher or student for airborne transmission. Therefore, I suggest that they at least try to use face masks that have a clear area over the mouth.

Then we discuss movements of students in hallways between classes, for recess, lunch, or fire drills. I recommend that they stagger hallway movements (other than for fire drills, or obviously, a real fire) to minimize contacts that one class has with any other class. This will help contain isolated infections from becoming outbreaks. Teachers often express that they have no idea how to maintain distancing during these hallway movements. My suggestion is for teachers to assign students an order in which they will walk single-file out of the room, down the hallway and to their destination. For example, Jimmy is to follow Susie. Then, tell each student (except the first one) to extend their arm out in front of them, but not to touch the person in front of them. While not six feet, this distance will be sufficient for people while walking to ensure adequate distance to minimize the risk of exposure. Of course, all students should be wearing their masks, as well.

We then finish up with special risks – those not in a traditional classroom. Many schools are having students eat outside or in their classroom. This is great. However, for those who will be having students eat in the cafeteria, we discuss the need to stagger lunch periods so that we reduce crowding in the cafeteria, the need for distancing being even more important because masks come off to eat and drink, the risks of the meal time not being structured and supervised (students sharing food/drink, visiting friends and getting too close with their masks off, or yelling, shouting or cheering which expels greater amounts of virus in respiratory droplets and transmits them further than six feet.

Another activity with increased risk is choir, for the same reasons that students may not be wearing masks, and singing expels greater amounts of virus in respiratory droplets further than six feet. There is also risks of airborne transmission with singing. So, we discuss options for choir to convene outside or if indoors, with good air exchanges or alternatively doors and windows open, and with double the physical distancing. The same thing goes for cheerleading. Yelling and cheering will increase the amount of virus in respiratory droplets and spread them further.

Band has similar issues as a number of band members cannot play their instruments with masks on. Worse, all of the brass instruments I can think of have spit valves and players have traditionally emptied their spit valves by blowing hard into the instrument with the valve open and allowing the spit to fall to the ground. This could be problematic if a player is infected. Obviously, the best solution is to practice outside. Marching bands will be used to this. This can be more of a challenge for concert bands or orchestras. If the practice is going to be indoors, everyone who can wear a mask should. While all band members should be spread six feet apart, brass instrument players may need to have this distance doubled. In addition, it may be best to use a pee pad or similar floor covering below the player for emptying their spit valves. The pads should generally be picked up and disposed at the end of the practice by someone who knows how to handle potentially contaminated materials and dispose of them and that person should wear gloves. If students are going to dispose of them, then there is a need for careful hand washing or sanitizing afterwards. Since we don’t know whether emptying a spit valve may be an aerosolizing event, it may be best to have a trash receptacle, tissues and hand sanitizer at each brass instrument player’s seat so that as they open the spit valve, they can put tissues up to the opening and collect saliva into the tissue rather than allowing it to fall to the ground.

Physical education presents some additional concerns. Like singing, yelling, shouting, and cheering, heavy and fast breathing associated with exercise will potentially spread more virus in respiratory droplets and for a further distance than six feet. Physical distancing at all times will be important. Also, it is likely that equipment will be shared among students, so there needs to be extra attention to cleaning balls, ropes, and gym equipment in between uses. Certainly, activities involving close contact (e.g., wrestling) or frequent passing of a ball (e.g., basketball) should be avoided if possible. Special consideration to physical distancing must be given to locker rooms and showers. Locker rooms tend not to have high efficiency air circulation. One quick test – if you can smell the odors of sweaty kids in the locker room, then you are breathing enough stagnant air that you could also be breathing in the virus.

Finally, I often get asked about sports. Each sport needs to be examined with particularity, and I will not go through every sport here, but let me take one sport and give you an example. Swimming. Swimming should be a relatively safe sport from a COVID point of view. A swimmer swimming in a lane is going to be distanced and we are not aware of any risk that a swimmer could contract this virus from the pool water. However, while the act of swimming might be very safe, associated activities could be very dangerous. For example, swimmers obviously shouldn’t wear masks while swimming. But, if the teammates who are not swimming are congregating on the side of the indoor pool, without masks and are cheering their teammate on, this may be a very high-risk situation. Similarly, for all sports, we have to know how all the associated activities are going to be handled. Are there going to be in-person team meetings? Will distancing be possible? Will everyone be required to wear a mask? What about away games? Will students carpool? This would be risky given the close proximity students would be in in a car and likely without masks. Will they be travelling by bus? (See the concerns I mentioned above about school buses).

Well, this is how I am trying to help schools have detailed operational plans and be the best prepared they can be for the beginning of in-person classes. I hope that this can be of use to other schools that have not yet opened and that you might consider some of these risk points and questions as you do your own assessment of your plan, and hopefully a walk-through. But, I encourage you to engage someone who is knowledgeable about this virus, but not an educator to do your review and walk-through. Fresh eyes are very important. Good luck. I am hoping that we can keep students, their families, teachers and your staff safe.

Myocarditis Due to COVID

I have long been frustrated that people tend to lump the effects of COVID into two buckets – (1) infections in young persons that tend to be asymptomatic or mild and (2) infections in the elderly that may land them in the hospital or even result in death. Both extremes certainly exist and are common outcomes, but there is so much more in the middle. There are children and young adults who die and there are young adults who develop very severe illness and may suffer disabling complications including heart attacks, strokes and residual lung disease, deconditioning and PTSD following prolonged mechanical ventilation. Further, there is another set of people with an average age in their late thirties or early forties that develop long-term, disabling effects long after they appear to have recovered from their COVID infection called “long-haulers,” who I have previously written about. We need to change he discussion of COVID from one of full recovery or death to one of a spectrum of disease outcomes, including many outcomes that we simply do not understand yet, nor have we had sufficient time to know the long-term effects. One complication of COVID on this spectrum is myocarditis.

The subject of today’s article is myocarditis, a complication of COVID that has been recognized since April, but has recently attained attention due, in part, to the occurrence of this condition in college and pro athletes and some attention-getting decisions about whether college teams would play football this season, in no small part due to concerns about myocarditis.

What is myocarditis?

Myocarditis is inflammation of heart muscle – the myocardium. It may be caused by many different things, but viral infections are among the most common. Among the most common viruses to cause myocarditis are adenoviruses (a group of viruses that cause cold-like illness, pneumonia, diarrhea and pink eye in people of all ages), coxsackievirus (the cause of hand, foot and mouth disease in children) and other enteroviruses (viruses that enter the body through the intestine and generally cause cold symptoms).

How does myocarditis present?

The classic presentation of viral myocarditis is a report of a viral-like illness with fever, muscle aches and upper respiratory symptoms followed by the onset shortness of breath, chest pain and/or palpitations, and fast and/or irregular heart-beats. Not everyone recounts a preceding viral-like illness, but in those that do, the symptoms of heart failure may present over a few days to a few weeks after the viral illness.

When these patients are evaluated, they may have abnormal electrocardiograms, an echocardiogram may be normal or may show a reduction in the heart’s pumping effectiveness, or a cardiac MRI may show areas of swelling or inflammation in the wall of the heart, or even scarring. In addition, a blood test for troponin, a protein in heart muscle, may be elevated indicating that the heart muscle cells have been damaged.

How does a viral illness cause myocarditis?

We haven’t been sure whether the virus actually attacks or invades the heart muscle cells or whether the inflammation associated with the virus or the immune response to the virus is what harms the heart muscle, or possibly both mechanisms could be at play. A recent study (Lindner et al, JAMA Cardiology, July 27) in patients with myocarditis from COVID who died showed that the causative virus, SARS-CoV-2 could be detected attacking and invading heart muscle cells.

What happens to patients with viral myocarditis?

We don’t yet know for patients with myocarditis from COVID. Before COVID, patients with viral myocarditis often recover on their own or with anti-inflammatory medications in a matter of months. Most will recover their full heart function. However, some patients can experience life-threatening arrhythmias and some patients go on to develop serious heart failure. A weakness in pumping of both sides of the heart is one of the main predictors of death in patients with severe myocarditis.

So, what do we know about myocarditis in COVID patients?

The first case of COVID-19 infection in a patient that resulted in fulminant myocarditis as a complication was reported on April 10 in a 63-year-old man with no history of heart disease or underlying hypertension. This patient had elevated levels of the heart muscle protein, troponin, in his blood, enlargement of part of his heart, low pumping movement of his heart muscle and the pumping effectiveness of his heart was reduced by 40 – 50 percent (LVEF 32%). In this particular case, the patient’s heart function largely recovered, however he died of secondary infection on the 33rd day of hospitalization.

Since then, we have seen heart muscle involvement in many cases of patients sick enough to have required hospitalization. But, myocarditis is not the only manifestation of heart disease from COVID. COVID actually produces a pro-thrombotic state, i.e., a greatly increased tendency of the blood to clot abnormally. This has resulted in some patients experiencing significant pulmonary embolism (blood clots to the lungs), which if severe can impair the functioning of the right side of the heart; myocardial infarction, i.e., heart attacks due to blood clotting in the arteries that provide the blood supply to the heart muscle; and clotting of stents in coronary arteries producing heart attacks in those who previously had angina, underwent a cardiac catheterization and were found to have a blockage in their coronary artery for which a metal strut of a sort is placed in the artery to open up the blood flow through that artery. In addition, some patients with COVID develop a shock-like state, and we know that the imbalance between the oxygen and metabolic requirements during shock and the lower supply can cause abnormalities in the heart muscle and a release of troponin into the blood, thereby making this condition difficult, if not impossible, to distinguish from myocarditis.

More recently, patients who recovered from COVID have been evaluated with cardiac MRI looking for signs of myocardial involvement. It should be noted that we have not generally screened asymptomatic patients recovering from other viruses to look for evidence of myocarditis, so we don’t know if asymptomatic myocarditis is a common occurrence with other viruses.

These recent studies showed that a significant percentage of persons who recovered from COVID, including those who experienced relatively mild illness were found to have cardiac MRI evidence of myocarditis, including athletes.

The long-term impact of COVID-19 myocarditis, including the majority of mild cases, remains unknown. In symptomatic patients, especially those with significant involvement of their heart and impairment to their heart’s pumping effectiveness, there is a risk of arrhythmia as well as progression to fulminant heart failure and cardiogenic shock. But, for those who are asymptomatic, whose myocarditis is being picked up incidentally on cardiac imaging, we simply do not know yet why they developed this complication, what the risks are, whether some will go on to develop significant cardiac problems, or whether all of these individuals will recover with time.

Perhaps it is not surprising that myocarditis can result from infection by the SARS-CoV-2 virus since its target, the ACE2 receptor protein, can be found in the cell membranes of heart muscle cells. But, a report in July garnered a lot of attention.

In a study in JAMA Cardiology published on July 27, Puntmann et al reported that in a cohort of 100 patients recently recovered from COVID-19, “cardiac magnetic resonance imaging revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%), which was independent of preexisting conditions, severity and overall course of the acute illness, and the time from the original diagnosis.”

53% of the patients were male and the mean age was 49 years. The median time interval between COVID-19 diagnosis and the cardiac MRI study was 71 (range 64-92) days. 67% of the patients were considered to have had mild illness and recovered at home, while 33% required hospitalization. At the time of the cardiac MRI study, 76% of the patients had elevated levels of the heart muscle protein, troponin, in their blood signifying heart muscle injury.

As of the time of the cardiac MRI study, 17% of patients reported atypical chest pain, 20% reported palpitations, 36% reported ongoing shortness of breath and general exhaustion, of whom 25 noted symptoms during less-than-ordinary daily activities, such as a household chore. The authors conclude their paper by stating, “although the long-term health effects of these findings cannot yet be determined, several of the abnormalities described have been previously related to worse outcome in inflammatory cardiomyopathies.”

Also recently, cases of post-COVID myocarditis have been reported in college and professional athletes. We are awaiting a medical publication that is rumored to show that approximately 15 percent of Big Ten football players who were infected with COVID demonstrated evidence of myocarditis in follow-up evaluations. However, until this paper is peer-reviewed and published, we don’t have any of the details we need to draw conclusions from this.

From everything we know thus far, the clinical presentation of SARS-CoV-2 myocarditis varies among cases. Some patients may present with no symptoms and the myocarditis is detected only because of a screening protocol for athletes, some may present with relatively mild symptoms, such as fatigue and mild shortness of breath, whereas others report chest pain or chest tightness on exertion. Some patients do deteriorate, showing symptoms of tachycardia (fast heart beat) and acute-onset heart failure with cardiogenic shock. In these severe cases, patients may also present with signs of right-sided heart failure. The most emergent presentation is fulminant myocarditis, defined as ventricular dysfunction and heart failure generally within 2–3 weeks of contracting the virus. This complication occurred in a beloved nurse practitioner who was in her 40s and cared for children at St. Luke’s.  

While the acute inflammation and injury to the heart are the current focus receiving attention, the long-term effects of healed myocarditis are completely unknown. We have seen in patients with other forms of myocarditis that in the process of healing, scarring of the heart muscle can disrupt the normal electrical pathways of the heart and result in life-threatening arrhythmias, even when the acute inflammation has resolved.

Post-COVID myocarditis in Idaho

I spoke to two experts here in the Treasure Valley to see what they were seeing and what their thoughts about this complication are. I interviewed Dr. Andy Chai, a cardiologist at St. Luke’s Health System who specializes in advanced heart failure and transplant cardiology and who serves as the medical director of St. Luke’s Clinic-Heart Failure and Dr. Nathan Green, an interventional cardiologist with St. Luke’s Health System who serves as the medical director of the Heart and Vascular Service Line at St. Luke’s.

Both doctors indicated that they are seeing cases of myocarditis related to COVID here in Idaho and while these patients have most often ranged in age from their thirties to their fifties, they have also had disease ranging from mild to severe, including patients who have died from their myocarditis.

Both doctors lament how little we know about this condition at this time. They certainly expect that those with myocarditis who have well-preserved heart function, limited areas of involvement of myocardium and low levels of troponin elevation are likely to do well. For others, who have more significant inflammation, we don’t yet know what to expect, but we are managing these cases much like other cases of viral myocarditis and following up with serial evaluations to monitor their progress.

I did ask both doctors about sports this fall and winter given the amount of disease transmission we have in the communities we serve, as well as this yet poorly understood risk of myocarditis in athletes who might become infected. Neither doctor felt that the threat of myocarditis should be the determining factor of whether sports are played. The risk of transmission of COVID among those who participate in sports and to their families, teachers and others is certainly worth consideration of whether middle schools and high schools hold sports events this fall. However, perhaps more important if a school is going to have athletic programs this fall is how strong the operational plans of each school are.

As for an athlete who has seemingly recovered from COVID and now has an abnormal result on a cardiac MRI screening, as to whether that athlete should sit out for the season was a much more difficult decision. One doctor pointed out that we simply do not have good guidelines as to how safe a significant amount of exercise is for someone with myocarditis. Pre-COVID, we were generally only seeing symptomatic patients with viral myocarditis, and we tend to recommend limited exercise such as walking until we see the myocarditis resolve. One doctor suggested that if the athlete’s participation is especially compelling – a professional athlete whose family’s income is at risk, especially when you consider the much more robust safety protocols they have in place and resources available to protect these athletes or a collegiate athlete with aspirations of going pro- it makes it more difficult to tell that athlete they must sit out the season if the myocarditis appears to be subclinical or very mild. However, for student athletes in middle and high school, it seems prudent to exercise more restraint until we know more about this condition.

I then brought up the long-haulers who have significant symptoms and/or disabilities months after supposedly recovering from COVID, some of whom have reported chest pains, palpitations, and/or shortness of breath with relatively mild exertion. I asked whether these individuals need to be evaluated for possible myocarditis and both doctors indicated yes, without any hesitation.

Finally, I asked the doctors a question sure to make any cardiologist cringe. I asked whether in light of the not infrequent occurrence of myocarditis following COVID and the potential for impairment of heart function and certain EKG findings known to place patients at risk, might this be one more reason why people should not take hydroxychloroquine or hydroxychloroquine plus azithromycin for COVID, and both immediately and emphatically agreed that these medications might be even more likely to cause harm in the setting of a COVID patient who has developed myocarditis.

So, I have told you most of what we know at this time about myocarditis in the setting of or following COVID infection. Perhaps it is equally important to tell you what we don’t know.

  1. We don’t know the prevalence of this complication. In other words, we don’t know what percent of people who are infected with COVID go on to develop myocarditis.
  2. We don’t know who is at risk for developing myocarditis and what determines who will develop myocarditis and who won’t.
  3. We don’t yet know the long-term effects of myocarditis. Do most of the people who develop myocarditis recover on their own in a matter of months? Do some have long term heart problems?
  4. Should we be screening everyone who recovers from COVID for this condition or are there certain individuals who should be screened? If so, when and how often should they be screened?
  5. For those who have mild myocarditis, is it safe for them to exercise? How much, how often and at what intensity?
  6. If someone with myocarditis following COVID gets re-infected with COVID, will they develop a recurrence or a worsening of their myocarditis?

No doubt, we will learn more about this condition with time. As we get important new information, I will be sure to share it with you.

The Long Term Effects of COVID

The most common misinformation that I hear about COVID is not “this is a hoax” or “masks don’t work” or “kids don’t get sick” or “kids don’t transmit COVID” or “this is no worse than the flu.” It is a statement that goes like this, “Opening schools must be based on decisions that balance the risks – we know that kids generally don’t get sick with this virus, but we know the risks of abuse, suicide and food insecurity if we don’t open schools.”

The problem is that while we do have a long history of understanding risks to some kids when they are not in school, school boards often convey that they have weighed these risks against the risks of COVID. They have not. I have not even heard very much discussion about COVID risks at school board meetings, and frankly, school board members don’t know what the risks of COVID are, because no one yet knows what all the risks of COVID are.

The risks of COVID are often presented as two potential outcomes – (1) you get infected and may either be asymptomatic or have a mild illness or (2) a few may get severe illness and have to be hospitalized, and some of them may die. This ignores a vast array of complications (including strokes) and long-term effects, which may be life-altering for those who get them. This group of patients is not being considered in our decision-making, our policy-making or our assessment of the costs of this pandemic relative to the impact on employers of absenteeism and loss of worker productivity, the incremental costs to their health plans or the costs related to long-term disability. And, with loss of employment, I have not seen any projections of the impact of this to state Medicaid plans or in the event of a decision by the U.S. Supreme Court to strike down the Affordable Care Act early next year (more about this at the end).

So, in this group in the middle that doesn’t get talked about, we are finding many young, previously healthy and active individuals who are describing disabling long-term effects of their COVID infection, often even though they described the infections as mild and certainly not requiring hospitalization, lasting for months, and in many cases, that have continued to persist to this point. There is even a name given to these individuals – “long-haulers.”

These patients have not yet been systematically studied, and there are challenges to understanding what is going on because not everyone had confirmed infection, many likely having been infected during the initial surge in cases when testing was difficult to obtain or when they had symptoms that were not on our early symptom lists having only been recognized later. Further, many of these patients do not have positive antibody tests either, which we know happens in some cases of infection, and perhaps has some relationship to the symptoms these patients are experiencing. Interestingly, in a study of 1,400 long-haulers, two-thirds of those who underwent antibody testing had negative antibody tests, including some who had previously documented positive PCR tests.

The symptoms being experienced by these patients are wide-ranging, and it seems as though no two patients are alike. However, what is common to many of these patients is what they describe as a marked change compared to their “pre-COVID” status, and oftentimes quite disabling symptoms. These have included:

  • Extreme fatigue, one patient describing it too exhausting to take showers. Some describe being unable to stand for long periods of time.
  • Awakening with shortness of breath
  • Burning sensations in the tips of their fingers and/or toes
  • Diarrhea
  • Discomfort with taking a deep breath
  • Hair loss
  • Hand tremors
  • Headaches – often throbbing
  • Heavy menstrual periods or loss of menstrual periods
  • Insomnia
  • Memory loss – “brain fog”- a combination of short-term memory loss and inability to focus
  • Nausea
  • Night sweats
  • Palpitations, tachycardia
  • Persistent fevers
  • Seizures
  • Sensitivity to light and/or sound
  • Shortness of breath, getting winded walking up stairs
  • Tendency towards bruising

Some patients have reported that their symptoms are resolving, while others continue to be plagued by them. It is hard to know exactly how many people have been affected by these “post-COVID” symptoms because there is no standard definition for their condition and no central repository for reporting of these conditions, but it is believed that this disorder affects more than 90,000 people in almost 100 countries, including the US, UK, India, France, Finland, Senegal, and South Africa. Some suggest about ten percent of those infected with COVID will develop long-term effects.

Interestingly, while most people consider those in their 30s and 40s to be of “low risk” for severe COVID and death, the average age of these long-haulers has been 38, and while men tend to have worse outcomes and more severe illness with COVID infection, these long-haulers have been mostly women.

NYC’s Mount Sinai Hospital is one of the first hospitals in the country to establish a post-COVID clinic. They have reported seeing this predominance in women and the average age of their patients was reported as 44. Dr. Putrino, who runs this clinic, has indicated that many long-haulers have symptoms that resemble dysautonomia, an umbrella term for disorders that disturb the autonomic nervous system, which controls bodily functions such as breathing, blood pressure, heart rate and digestion. It remains unclear whether the virus itself causes damage that results in these long-term effects, or whether these long-term consequences are a result of an over-active or exaggerated immune response, despite the failure to develop an antibody response or the loss of antibodies once produced.

More than 90 percent of long-haulers whom Putrino has worked withalso have “post-exertional malaise,” in which even mild bouts of physical or mental exertion can trigger a severe physiological crash. “We’re talking about walking up a flight of stairs and being out of commission for two days,” Putrino said. This is the defining symptom of myalgic encephalomyelitis, or chronic fatigue syndrome. 

The CDC has had little to say on this subject, but it acknowledges that 35% of COVID patients, even those with mild illness, do not recover even after 3 weeks.


There are few clinical studies on these patients. Here are results of some of the few studies that have been done.

  1. One report is from patients themselves. A patient-led research team of 640 patients  reported their own characteristics at

The most common symptoms reported were (in descending order) fatigue, muscle or body aches, shortness of breath or difficulty breathing, difficulty concentrating or focusing, inability to exercise or be active and headaches.

2. Study out of Germany

This study examined the cardiac MRIs of 100 people who had recovered from Covid-19 and compared them to heart images from 100 people who were similar but not infected with the virus. The average age of the study group was 49 and two-thirds of the patients had mild illness and recovered at home, while 33 percent were hospitalized. More than two months later (median time interval from diagnosis with infection to the MRI evaluation was 79 days), infected patients were more likely to have troubling cardiac signs than people in the control group: 78 patients showed structural changes to their hearts, 76 had evidence of a substance in their blood signaling cardiac injury typically found after a heart attack, and 60 had signs of ongoing inflammation of their heart muscle.

3. Italian study

87.4% of hospitalized patients (mean age 56.5 years) still had at least one symptom, and often a variety of symptoms, after two months since the onset of their initial symptoms of infection. The most common symptoms were fatigue and shortness of breath.

4. A researcher from the Indiana University School of Medicine in July surveyed 1,500 long-haulers from Survivor Corps, an online COVID-19 support group. They reported almost 100 distinct symptoms, from anxiety and fatigue to muscle cramps and breathing problems.

5. Cases of type 1 diabetes among children in a small UK study almost doubled during the peak of Britain’s COVID-19 epidemic, suggesting a possible link between the two diseases that needs more investigation. Thirty children in hospitals across north-west London presented with new-onset type 1 diabetes during the peak of the pandemic, approximately double the number of cases typically seen in this period in previous years, with clusters of cases in two of these hospitals. Twenty-one children were tested for Cobid-19 or had antibody tests to see whether they had previously been exposed to the virus.  In total, five children tested positive, either for active Covid-19 infection or previous exposure to the virus. However, antibody testing was not routine, and fourteen children were not tested for previous exposure to Covid-19. At the height of the outbreak in the UK, testing was not widely available and many of the children were not able to be tested during the time they may have been infected.

Karen Logan at Imperial College Healthcare NHS Trust and supervising author of the study, said: “It appears that children are at low risk of developing serious cases of Covid-19.  However, we do need to consider potential health complications following exposure to the virus in children. Our analysis shows that during the peak of the pandemic the number of new cases of type 1 diabetes in children was unusually high in two of the hospitals in north west London compared to previous years, and when we investigated further, some of these children had active coronavirus or had previously been exposed to the virus.”

Other studies/information:

There are several points that I want to close with.

  1. We have only begun to understand the long-term effects of COVID infection. In some, they may be annoying, in others they are debilitating, and in others, they may be life-threatening (e.g., insulin-dependent diabetes, if this is proven to indeed be a consequence of COVID infection). Some people appear to recover over a few months, others continue to be plagued by these effects nearly half a year since their likely infection. There is much we don’t know. Why do some people recover quickly, yet others have lingering symptoms? Who is at risk for developing prolonged effects from their COVID infection? Do these symptoms eventually resolve, or will there be some who are plagued by these symptoms or disabilities for the remainder of their lives? Are there treatments that can improve their wellbeing? What happens to these individuals if they were to become re-infected? Do they have more or less risk than others of becoming re-infected?
  2. School boards and public health boards have, for the most part, not paid enough attention to these long-term effects of COVID as risks when they balance the risks of opening vs. not reopening schools for in-person classes, and even more importantly in decisions as to whether to hold athletic events or not.
  3. We have not yet begun to contemplate the implications of these long-term sequelae on society. Will long-haulers impact workplace absenteeism and productivity? Given that some long-haulers are reporting changes to their menstrual cycles, will this impact the ability to conceive? Will long-term disability result in an increase in behavioral health issues such as anxiety, depression or even suicide? What will be the costs of caring for these individuals over the long-term? And, as I have said on many occasions and written on others, this is particularly concerning at a time when the Affordable Care Act is being challenged in the U.S. Supreme Court this fall with the request that the Court strike the law down. As far as we know, Republicans have no back-up health plan that they believe can be passed by Congress and enacted into law if the ACA is struck down.

A decision by the Court to strike the ACA down (see my earlier blog posts for a full discussion of this legal challenge) would eliminate guaranteed issue, community rating, Medicaid expansion and the public insurance exchanges, along with the advance premium tax credits and subsidies. So, if a person lost their job and with it their health insurance, they would have two possible alternatives to get insurance – Medicaid and the public insurance exchanges with the assistance of financial assistance from the government. However, if the ACA is struck down, there is no Medicaid expansion and the public insurance exchanges will be gone. If the person is able to purchase insurance on their own, without the restrictions of the ACA, an insurer could deny coverage for someone who has been infected with COVID as a preexisting condition, or if they were to offer coverage, they could do so by increasing the premium significantly.

There are many implications of post-COVID effects, and we don’t understand what most of them are yet. This is an area that requires much more time to see what develops and what the answers are to the questions I posed above, more research, and is just one of the reasons we all need to pay attention to the Supreme Court decision that likely will come out in the first part of next year.