Canada has solidly launched into its second wave of COVID-19 and what most experts now consider the new normal. There is no going back to the world we once knew. It is indeed forever changed. But there are many silver linings and reasons for hope. Here are some thoughts on what our collective future will hold and an update from Dr. Pearlman on pandemic proofing for our tomorrow.
The Dawn of the Second Wave
As many countries across the world are facing resurging case rates and closures of non-essential business, so too are we here in Canada marking the start of the Second Wave. In Ontario, last week we saw the highest case rate recorded to date (1,042 on October 24th) with a cumulative case load of over 71,000 since the outbreak in March. But this surge is indeed just the start. The flu season has yet to begin introducing along with, multiple influenza strains, other respiratory infections that are common in wintertime, including the 4 coronaviruses that account for the common cold.
Furthermore, as the falling temperature and winter chill make outdoor gathering and dining more difficult, we will see increased transmission due to more time spent indoors. Due to these factors and the impact of exponential growth during a surge it is undoubtedly going to get worse before it gets better.
The Second Wave will be Different
The second wave looks markedly different than the first. To start, by far the largest group presently affected are those under 40 years of age. Though youth in itself does not ensure mild illness, COVID-19 tends to be better tolerated in this group not requiring intervention, hospitalization or ventilation. However, these mildly symptomatic or asymptomatic cases are a strong source of spread. As a result, while we continue to see rising case rates, the hospitalization rate has not been increasing in parallel (as of yet). We are also equipped with more, but still incomplete knowledge about COVID-19 compared to the first wave. We are able to identify COVID-19 through testing and tracing (though still greatly lacking in Canada) to enable early recognition and containment of hot spots and to prevent super-spreader events. We now understand that COVID-19 can present with a wide range of symptoms often mild or non-respiratory especially in the young and metabolically fit. We have yet to identify effective treatments, but management by healthcare workers in COVID-19 units has been enhanced and informed by the early experience of others in regions that experienced severe first waves such as New York City, Italy and the UK.
Mandate the Measures
Globally, governments and public health officials can and should mandate what we know works; masks, distancing and hand washing. These three low risk and low cost public health measures have been proven to be effective and are strongly recommended by most health experts.
As always, scientific thinking must prevail and no measure should be considered in isolation. Distancing and mask wearing must reflect other variables of a given situation. No, a mask is not needed when you are driving in your car alone. And yes, the 2 metre or 6 feet rule is arbitrary (based on dated science) and there are conditions that would make this distance inadequate if masks are not worn to protect from droplet transmission. So it is not masks or distance or hygiene or screening and testing but rather a combination of all of these measures. Factors that increase transmission and droplet spread include; indoors versus outdoors, low UV and humidity, poor ventilation, increased force of expulsion (ie. coughing, sneezing, singing, cheering, shouting), higher viral shedding rates (i.e. which vary based on the degree of symptoms of the spreader and stage of their infection), and increased susceptibility of an individual to infection. The graph below demonstrates the risk of transmission of SARS-CoV2 from asymptomatic people in various settings with or without a mask.
Testing and Tracing Explained
There are three types of COVID-19 test and each test provides different information which can be produced on a different timeline and with variable accuracy.
- Diagnostic PCR Test: The diagnostic gold standard test detects active infection and is usually administered by a nasopharyngeal swab (or throat swab) to detect viral RNA via PCR (polymerase chain reaction) amplification. It is labour intensive and dependent on costly and scarce equipment and at best provides a result in hours but more often takes several days. These tests are offered now with limitations across the province at testing centres and for asymptomatic patients by appointment only in a limited number of pharmacies.
- Antibody ELISA Testing: confirms immunity by detecting acute (IgM) or convalescent (IgG) antibodies from a blood test. This can be processed at a lab for more robust results via ELISA testing or as a point of care rapid test. Unfortunately the value of this test is limited as false positives arise due to cross reactivity with other coronavirus strains (like the common cold), inability to confirm that antibodies are neutralizing and actually capable of inactivating the virus, and the likelihood that these antibodies will not persist implying a lack of a durable immune response. An individual with known past infection can be found not to have antibodies and similarly someone with detected antibodies may lose this protection in the near future rendering them vulnerable to subsequent reinfection. We have been offering the antibody test in our clinic for some time now and I have tested several patients with confirmed prior cases of COVID-19 who turn out not to have antibodies. As such, I recommend this test with caution and ensure my patients understand the importance, regardless of outcome, of maintaining all measures.
- Rapid Antigen Test (RAT): This point of care test detects viral antigens or fragments as a proxy for an active infection. Accuracy of these tests is highly variable but the low sensitivity means that this test performs best when used in populations where the index of suspicion is high (such as in an outbreak). The relatively low sensitivity of these tests produces high false negative rates leading to missed cases if the prevalence is low. A negative test result on a RAT would require further confirmation by a PCR test. Thus, rapid testing is certainly not our silver bullet.
Regardless of the test method used to confirm active infection a robust case notification and contact tracing system must be in place. Due to substantial shortages of testing equipment and tracing personnel, the province has taken measures to restrict testing to individuals with symptoms or a known contact. The COVID Alert app has been developed by the Government of Canada as a notification system using bluetooth signals to identify possible contacts of a positive case. An alert will require and enable you to access testing preferentially and alerted contacts must self-isolate while awaiting their test result. I strongly recommend downloading this app to all of my patients and have required this step of all of my staff.
Vaccines: Facts versus Fantasy
Never before has there been a globally unified collective effort to develop and produce a vaccine as is the case with the race for a COVID vaccine. The WHO identifies over 100 vaccine candidates in development with several in the latest phase of human clinical trials. Experts expect to have a vaccine candidate ready for commercial production early in 2021. However, for vaccination to be an effective means to an end of the measures in place, we would need to have immunized over half of the entire world population. COVAX is a collective international group aimed to ensure equitable access and distribution of a future COVID-19 vaccine throughout even the most impoverished regions of the world. But it is important to note that not all viral illnesses are vaccine preventable. Not for lack of effort or funding, scientists have never come up with a vaccine for HIV. After SARS in 2003, scientists worked to develop a coronavirus vaccine without success. The lack of a durable immune response to prior infection suggests that vaccination strategies would require repeat dosing. Trust in public health figures and governments around the world is faltering in the wake of the pandemic with COVID fatigue setting in. As a result, it is likely that vaccine uptake even when available will be incomplete. I see it as a priority for our leaders to ensure clear messaging, actively counter the abundant false information spreading over the internet and social media and enlist the support of representatives of all communities to ensure that a future potential vaccine program is maximally successful.
In the meantime, I strongly recommend the annual flu vaccine which is now available. A high dose (four fold the potency) is available for those above the age of 65 years. Flu vaccination will prevent 3 strains of flu each of which could risk an immune and respiratory comprised state even in a previously healthy individual that would expose to a worse possible case of COVID if simultaneously or subsequently infected. Preventing the flu will also reduce confusion created by respiratory symptoms and the associated need for testing and self-isolation. Not to mention, that flu vaccines are well established to be safe and effective and every year prevent countless influenza related deaths. Simply said, this is the year to get your flu shot!
The Fallacy of Herd Immunity
The concept of herd immunity is based on the belief that infection can be eradicated when the majority of a population has been infected (or vaccinated). There are those that belief that by allowing the majority of the population to return to life as normal and let the virus run its course, herd immunity can be achieved. Over time, with infection rates rising about 55-65% it is thought that the pandemic may be contained. Controlled herd immunity allows those at low risk to resume life without protective measures in place while those at high risk are protected. A strategy to achieve herd immunity was recently proposed in a document called the Great Barrington Declaration put forward by a libertarian think tank. The scientific community at large opposes this notion due to the concern that loss of life and human suffering would be catastrophic and the risk of reinfection (as is the case with other coronaviruses) is unknown. In an opposing article published this month in the Lancet, scientists called the herd immunity approach a “dangerous fallacy unsupported by scientific evidence”.
The Short and Long term threat of COVID-19
Acute infection can manifest with a wide range of symptoms. Some have a mild case and some severe or even fatal. Severe illness may involve sudden acute respiratory distress (SARS), multi-organ failure, widespread clotting and systemic inflammatory reactions. SARS-CoV2 has a predilection for those that are metabolically unfit and the elderly and it is these populations that are at highest risk for severe acute illness. But healthy and young individuals may inexplicably have severe COVID or even die of related complications. Most report more mild symptoms including fatigue, shortness of breath, cough, fever, headache, diarrhea, muscle aches, loss of taste and smell, and difficulty concentrating. Women tend to be at lower risk of contracting severe acute infection but higher risk of developing symptoms that persist beyond 3 to 4 weeks. Long COVID is a term now used to describe persisting symptoms and chronic cardio-respiratory complications of infection with SARS-CoV2. Notably, long COVID may follow a relatively mild acute infection. Women between the ages of 50 to 60 years are considered to be at greatest risk of developing long COVID and may complain of profound fatigue, ongoing breathlessness, body aches and mental fog (referred to as the COVID concussion). Women in this age bracket were shown to be 8-times more likely to have lasting symptoms than those aged 18 to 30 years. This pattern is similar to that seen with auto-immune disease suggesting that an immune dysfunction may underlie the chronic phase of COVID-19.
From Pandemic to Endemic
With vaccination an unlikely remedy to return life to normal and herd immunity an unacceptable solution doomed to fail, it is likely that the COVID-19 pandemic will be transformed into an endemic infection- one that never truly goes away. This is exactly what I envision. A slow reversion back to a near normal but with continued low level, hopefully controlled and maybe predictable outbreaks of COVID-19. As with common coronaviruses that account for the seasonal cold, we will become more resilient in the face of an ongoing risk of infection and reinfection.
I was a medical student during the HIV epidemic. At the time, new measures were introduced to prevent transmission of blood borne infection and reduce the risk of needle stick injury including glove wearing and safety engineered needles. These were novel measures at the time but they have never gone away. We never regressed our practice to allow the risk of a blood borne pathogen to emerge again. Similarly, we will not return to the normal we once knew in which we were continuously exposed to airborne and droplet transmission of disease. I for one would feel somewhat relieved that during future flu seasons, it would be acceptable to avoid hand shaking and ask that those in line behind me keep their distance. So a silver lining we can appreciate is the notion that we will be better protected from this second wave of COVID-19, future waves and future potentially more dangerous airborne or droplet based infectious disease.
Pandemic Proofing PearlMD
Robust safety, security and infection control measures are and always have been in place at PearlMD. As a frontline healthcare worker through SARS in 2003 and again (while pregnant) during H1N1 in 2009, ensuring the highest standard of infection control from clinic design, to work flow, to environmental controls has always been a priority. Through the early weeks of quarantine in March, I began the plan to reopen. I approached and partnered with Panasonic to secure first in market access to their best in class COVID inactivating air and surface sterilizing Nanoe-X technology. In addition to our stringent protocols, screening and triage, these devices have been installed in each and every treatment room and throughout the clinic. By releasing electrified ionic water particles that entrap and remove bacteria, viruses, fungi, mould and odour from the air, Nanoe-X has been proven effective in inactivating SARS-CoV2. As well, when distancing and masks are not possible, we have sourced breathing tubes with anti-microbial filters and nasal clips to prevent transmission during treatment. In advance of the second wave, we have again stepped up our measures and optimized work flow to allow increased sterilization time and distancing. You can learn more about our protocols and review our screening tool here.
Building Resilience from Within
As always we must focus on what we can control. There is much uncertainty. The path forward will be long and difficult. Steps to build resilience of mind and body will prove effective to bolster immunity in the months ahead.
Here are my top ten tips to improved health and wellbeing in the era of COVID-19:
- Set a schedule: Be consistent with your daily routine. Start the day right with a morning work-out and nutritious meal. Stay consistent with daily exercise, eating plan, work schedule and sleep pattern to build much needed structure within our daily lives and support our natural circadian rhythms.
- Find Security within: Let your body be your sanctuary. Breathe. Meditate. Connect with your deep self. Be kind and allow yourself to express deep emotions and take time to enjoy even the simple pleasures of life. Security can be achieved even when you feel stressed. In times like these, we must remember that safety and security can be found from within.
- Breathe: Pause. Draw in a deep belly breath. Eyes closed and breathe in through your nose (smell the rose). Fill your belly with oxygen (as the diaphragm descends your belly expands). Hold in the inhaled air to fill your lungs with oxygen and find mental clarity. Exhale through your mouth (blow out the candles) to release the carbon dioxide from the base of your lungs. Let it carry out your negative thoughts and emotions. Use your breath as a tool to regulate your nervous system and gain control of the fight or flight response. Nervous system regulation is the path to your cognitive clarity and improves immune function.
- Sleep: Set a consistent schedule for sleep. Prepare with a nightly ritual and routine and defend your sleep like a warrior. Try an Epsom salt bath with essential oils like lavender and a scented candle and feel free to improvise. Dim the lights and ensure darkness for sleep. Shutting down screens, avoiding negative news or stressful thoughts. Set a to do list for the next day so that your mind is not busily planning in the midst of the night. During sleep your brain resets, restores and allows for optimal function of mind and body. A good night sleep is key to immune health, emotional wellbeing and your cognitive vitality.
- Be Active: Stay active doing what you love. A daily work-out routine is possible even from your own home now that gyms are again closed and cooling weather may make outdoor activity more difficult. Challenge both your body and your mind. Push through physical discomfort and take on a new mental challenge or problem. Daily exercise is key to a healthy mindset and strong immune system.
- Let Food by thy Medicine: Eat your superfoods for optimal immune health. Vitamin C rich foods like kale, red peppers, kiwis and tomatoes are particularly important for immune health. Zinc can be found in foods like oysters, lentils, hemp seeds and eggs. While foods and nutrients will not prevent, treat or cure COVID-19 they are steps to improve your metabolic fitness. You can find further health and nutritional tips to help bolster immunity here.
- Immune Boosting Nutrients: There are certain vitamins, minerals and anti-oxidants that may provide additional support immune health and reduce inflammation. Vitamin C, zinc, elderberry (sambucus), ginseng, and astragulus are a few examples. Our proprietary formula was developed based on the best evidence supported nutrients that may help protect from coronavirus infection.
- Keep Informed and Stay Vigilent: Combat COVID fatigue with an conscious effort to remain vigilent. As described, protective measures including masks, physical distancing and hand washing work. Reduce or eliminate your exposures by limiting outings to those which are essential and keep close contact only with those within your household. For those living alone, keep a tight social bubble of 2 or 3 trusted others. Follow public health guidelines, as our leaders are setting policies and guidelines to ensure our collective wellbeing. Staying informed is essential in these dynamic times.
- Resilience: Our ability to transform, adopt to new circumstances and innovate to solve the challenges imposed upon us will define our recovery. Resilience is key to our success. To be resilient in times of trouble takes an open mind to change and a hopeful eye to the future.
- Hope: Hope for a better tomorrow. Switch your mindset to optimism to help you plan for better days ahead. Positivity and hope can help you navigate daily challenges as you pivot to the other side. Mindfully count your blessings with gratitude for what we have and stay optimistic for better days ahead.
Consider these 10 tips to help you navigate through the second wave of this pandemic and challenging times ahead. Together we will see it through to a new normal. The journey will require resilience and innovation to help ensure we are stronger and more secure for our future.
Dr. Jennifer Pearlman
Dr. Pearlman is a medical doctor in Toronto, Canada. She is owner and Medical Director of PearlMD Rejuvenation a Precision Integrative Medical Clinic offering expert medical care, leading technology and treatments to help patients achieve Ageless Vitality. Dr. Pearlman is an internationally recognized expert in Women’s health, hormones, aging and cosmetic medicine.