The Covid-19 Pandemic has affected every citizen of this world. It has been a highly contagious and highly virulent virus that has a mortality rate up to 10 times greater than the typical flu! In this post, we aim to highlight lessons we can learn from Covid-19 and how we can take protective measures for ourselves, our families, and our communities.
As of January 2021, there have been more than 20 Million Americans infected with COVID-19, and over 350,000 deaths. This shocking death rate has disproportionately affected people with diabetes and obesity, and people of color, and people of advanced age. Respiratory droplets are the main cause of transmission of the SARS-CoV-2 virus. These droplets are released with talking, coughing, sneezing, and singing. Respiratory droplets usually reach the ground within 3 to 6 feet of the person of origin. There is likely some component of aerosolized spread indoors with limited ventilation, such that the virus may hang in the air for a period of time prior to dropping to the ground. Contact surface spread is another mode of transmission. The virus can be spread by asymptomatic, pre-symptomatic, and symptomatic individuals. The average time from exposure to symptoms is 5 days, with almost all people developing symptoms within 12 days of exposure. There is a great range of symptoms for infected individuals from no symptoms to respiratory failure, and multi-organ failure and death. For hospitalized patients, 20% will need intensive care. The most common symptoms are fever, dry cough, shortness of breath, fatigue, and muscle aches; and additionally, there can be symptoms of nausea/vomiting or diarrhea, headache, weakness, runny nose, and loss of smell or taste. Complications may include pneumonia, acute respiratory distress, liver injury, cardiac injury, kidney injury, clotting events, impaired consciousness, and shock. The diagnosis is made by PCR testing of a nasopharyngeal swab for the SARS-CoV-2 virus. As the false negative rate of the test can be 20% or more depending on the timing of the test with symptoms, it is possible to also make the diagnosis clinically. Antibody testing may be done to confirm previous infection. However, a positive antibody test does not necessarily provide protection against future exposures.
Treatment has been primarily supportive: supplemental oxygen, rest, symptom reduction. There have been recent randomized controlled studies that have shown benefit for Dexamethasone (a steroid, and immunosuppressant), and for Ramdesivir (an anti-viral), and for Bamlanivimab (monoclonal antibodies). There are many studies that are ongoing to determine the possible effectiveness of convalescent serum (anti-SARS-CoV-2 Antibodies); anticoagulants; modulators of the immune system; and other anti-virals.
Safe and effective vaccines were released under Emergency Use Authorizations in December 2020. These vaccines are remarkable in that they are 95% effective and have been developed and medically cleared in under 1 year. This amazing success has been possible as the DNA code for the virus was published for public use by China in January of 2020; as the US Government dedicated resources to Operation Warp Speed to parallel process vaccine production simultaneously with vaccine studies; and as there had been a decade of studies on DNA and RNA technology that permitted the development of these DNA and RNA vaccines. It is important to understand that there have been the normal independent medical reviews of the Phase I, II and III studies required of all vaccines. The Advisory Committee on Immunization Practices (ACIP) reviews all data on vaccine safety and efficacy. The ACIP is independent of the government. The ACIP is independent of the pharmaceutical companies. The goal of the ACIP is to protect the health of the American public. Once ACIP has reviewed all data on experimental trials involving 50, 000+ individuals, they make a recommendation to the CDC. Then, the directors of the CDC and US Department of Health and Human Services must review the recommendation and make the final approval. Only then may vaccines be distributed for immunization of the public. This process should be reassuring to all of us. Currently there is a list of group prioritization for receipt of the Covid Vaccines. Prioritization is based on factors that contribute to risk of exposure and/or risk of more severe disease, and are broadly based on occupation, age, congregant residential living, and medical history risk factors. Expected side effects from the vaccine include injection site pain/discomfort, fatigue, chills, muscle pain, joint pain, and/or headaches. These symptoms are related to the challenge to which your immune system is responding with the effect of making protective antibodies. Occurrence of more severe adverse events were balanced between vaccine and placebo groups (cdc.gov). Vaccinations provided to the public with the oversight of ACIP and phase I, II and III trials have provided control over may fatal and disabling conditions such as Polio, Measles, Rubella, and Small Pox, to name a few. The Covid Vaccines currently available and soon to be available will provide control over this deadly pandemic and will permit a return to normalcy that we all desire.
We continue to gather data on the potential impact of Covid-19 upon pregnant women and their fetuses, as well any potential impact upon fertility. Here is what we currently know as we continue to wait for larger studies. For pregnant women with COVID-19, there is almost a two-fold greater chance of an ICU admission; with an overall ICU admission rate of 1 per 68 infected pregnant women. Keep in mind that the overall infection rate in pregnant women is low. Transmission of the virus to the fetus through the placenta appears rare by current data. There does seem to be a higher risk of pre-eclampsia, prematurity, and cesarean delivery. One mechanism of disease of the SARS-CoV-2 virus is by causing micro-clotting. Given the vascular nature of the placenta, complications related to placenta dysfunction are understandable and need further study. There are data registries to try to gather more information over time. It is reasonable to postpone conception until one is vaccinated; if age and other factors are favorable for an individual or couple to make this choice. The phase I, II, and III studies did not include pregnant women. Given the science that is the basis of the vaccines, the American College of Obstetrics and Gynecology have recommended that pregnant women be provided vaccination. (link: ACOG clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-pregnant-and-lactating-patients-against-covid-19). If they are currently in a priority group for vaccination. There is an excellent decision-making tool for patients and physicians to assist with the decision to vaccinate in pregnancy Link: Covid vaccine and pregnancy decision making.
For patients undergoing fertility treatment, information from a recent basic science study concluded that the SARS-CoV-2 virus was not present in the semen or testicular tissue of infected men. The same research group had scare human ovarian tissue to study; and studied the ovarian tissue of primates with results showing a lack of receptors for the virus, suggesting that long term impact on ovarian function is unlikely.
Measures to prevent COVID-19 are highly encouraged for all individuals; and specially for pregnant women:
- Wear a mask in public
- Wash hands frequently and thoroughly
- Maintain social distancing of 6 feet or more.
- Limit contact with other individuals; avoid medium or large crowds
- Avoid indoor activities, such as restaurants, and the arts until proven very safe
- Maintain prenatal appointments
- Maintain a supply of preparedness resources including medications
- Avail yourself to a vaccine; after a discussion with your Obstetrician
- Wear personal protective equipment if there is potential for occupational exposure
Preventing disease is an individual goal and a community public health goal.
Through this pandemic, we have learned cough and cold etiquette, mask wearing, along with social distancing, and isolation of infected individuals, as simple and effective measures that can actually control the pandemic and save lives. We have a greater respect for the value of vaccines in preventing the burden of diseases. We have all learned to greatly respect the germ theory. We have also concluded that the real heroes of society are the healthcare workers, first responders, and other frontline workers. We applaud each and every one of them!
Wiersinga, W.J. et al., “Pathophysiology, Transmission, Diagnosis, and Treatment of the Coronavirus Disease 2019 (COVID-19), A Review”, JAMA, online, 2020.12839, July 10, 2020.
Novel Coronavirus 2019 (COVID-19), American College of Obstetricians and Gynecologists, Practice Advisory, July 1, 2020.
Stanley, K, et al, “Coronavirus disease-19 and fertility: Viral host entry protein expression in male and female reproductive tissues”, Fertil Steril, July 2020.
CDC.gov/Vaccines and Immunizations, Dec 2020.
ACOG clinical/Practice Advisory/Vaccinating Pregnancy and Lactating Patients Against COVID-19, Dec 2020
Baystate Health, and University of Massachusetts Medical School, “I’m Pregnant, Should I Get the Covid Vaccine?” Dec 14 2020.