Lessons From COVID-19

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 December 2021, there have been more than 51 million Americans infected with COVID19 and over 800,000 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. Additionally, chronic covid patients, also known as longhaulers can experience mild to severely disabling symptoms. 

The diagnosis is made by PCR testing of a nasopharyngeal swab for the SARS CoV-2 virus. A PCR test detects viral gene fragments and is very accurate if it is positive. However, the false-negative rate of the test can be 20% or more depending on the timing of the test with symptoms. It is also possible to test with a rapid test or home kit. This type of test detects viral proteins and is appropriate for anyone who is without symptoms or is testing to confirm safety for indoor group activities or travel, or does not have access to a PCR test. It is possible to also make the diagnosis of Covid clinically while awaiting test results. Check-in with your physician for a televisit if you have symptoms or a positive test. Antibody testing may be done to confirm the 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 and other anti-virals, and for Bamlanivimab, Sotrovimab, and other monoclonal antibodies. There are many studies that are ongoing to determine the possible effectiveness and timing of convalescent serum (anti-SARS-CoV-2 Antibodies); anticoagulants; modulators of the immune system. 

Safe and effective vaccines have been released under Emergency Use Authorizations since December 2020. These vaccines are remarkable in that they are 72 to 95% effective in preventing disease, and 90 to 100% effective in preventing hospitalization and death from Covid. Also impressive is that they 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 RNA vaccines at this time. An RNA vaccine prompts your cells to make the spike protein that results in proper Antibody formation. Messenger RNA is just that: a messenger; it does not get incorporated into your DNA. It is important to understand that there have been the normal independent medical reviews of 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 the US Department of Health and Human Services must review the recommendation and make the final approval. Only then may vaccines be distributed for the immunization of the public. Once these details are understood, this process should be reassuring to all of us. Initially, there was group prioritization for receipt of the Covid Vaccines. Currently, all individuals age 12 and older may receive Covid vaccination. 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. The occurrence of more severe adverse events was generally balanced between vaccine and placebo groups (cdc.gov). There was a pause in the distribution of the Johnson & Johnson Covid vaccine due to a few cases of cerebral clotting noted within a large group of over 8 million vaccinated people. With an extended review, The CDC decided that the benefits outweigh the risks. People with other risk factors for clotting should seek other vaccines. Vaccinations provided to the public with the oversight of ACIP and phase I, II, and III trials have provided control over many fatal and disabling conditions such as Polio, Measles, Rubella, and Smallpox, to name a few. The Covid infection rate had dropped steadily as the percentage of Americans vaccinated had increased steadily; however, with the Omicron variant, a much more contagious variant, the infection rate has been on the rising age. Protection from the vaccine takes time; no vaccine works immediately. You are considered protected when it has been 2 weeks from your second dose, or 4 weeks if your vaccine is a single dose. When you are more than 6 months from your second dose, It is now recommended to have a booster. It has been shown that vaccine effectiveness was clinically lower at the 6-month mark, and substantially improved with the booster (3rd dose). Also, the CDC recommended in December of 2021, that individuals seek the Moderna or Pfizer vaccine exclusively given data supporting effectiveness against Omicron.

We continue to gather data on the potential impact of Covid-19 upon pregnant women and their fetuses, as well as 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. However, pregnant women with Covid have a substantially higher death rate than healthy pregnant women. Transmission of the virus to the fetus through the placenta may occur, but at a low rate by current data. A study from Sweden documented a transmission rate to the fetus of less than 1%. There does seem to be an up to a four-fold higher risk of pre-eclampsia, and a higher risk of prematurity, and cesarean delivery. This same study from Sweden noted a 12% risk of the newborn being admitted to Intensive Care if the mother had  Covid at the time of delivery. Prematurity may be associated with a temporary or permanent disability. 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 that are expected to gather more information over time. It is reasonable to postpone conception until one is vaccinated and boosted; 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 has recommended that pregnant women be provided vaccination. (link: ACOG Clinical/Practice Advisory/Vaccinating pregnant and Lactating Patients Against COVID-19). 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). There is ongoing data surveillance for post-vaccine adverse effects (vaers.hhs.gov). All vaccinated individuals are encouraged to participate in symptom surveillance post-vaccination.

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. An additional study of men who died of severe Covid found testicular damage that was thought to be due to the severe inflammation and oxygen deprivation of severe Covid. Another study found no change in sperm parameters for a small group of healthy men analyzed prior to vaccination and 2 months after the second dose. 

Measures to prevent COVID-19 are highly encouraged for all individuals; and especially for pregnant women:

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 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.

Dumitriu, Dami, Gyamfi-Bannerman, Cynthia, “Understanding Risk for Newborns Born to SARS-CoV-2- Positive Mothers, “ JAMA, 2021; 325(20):2051-2052

Gonzalez, D, et al, “Sperm Parameters Before and After Covid-19 mRNA vaccination,” JAMA, 2021.9976 online June 17, 2021

Author
Maureen O'Brien Moomjy, MD, FACOG

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