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The Rabbit Hole of Fear

April 4th, 2020

Historically, we have had staff meetings every week at Four Seasons Pediatrics.   This continues with huddles, emails, and communications occurring several times a day.   Our meeting room now has reservations for 5 people to join me.  The rest of the staff connect by a video device to see the slides and meet.   More about that below.

I have always been a physician who practices with a strong confidence in using evidence to drive what I do.  Dr. Elmer and I have surrounded ourselves with providers who also feel that way (Joyce, Dr. Lange, Dr. Apruzzese and Dr. Sohn).  As this COVID-19 crisis has evolved, I have seen fear become a bigger driver of what we do, with less and less consideration of robust evidence.  Social distancing – especially in large populations will have and is having the biggest impact on spread of this virus.  The next most impactful behavior is staying at home with any of the following symptoms: coughing, sneezing, fever, sore throat, diarrhea or vomiting.  If you must leave the home, covering the mouth with a mask, tissues or as a last resort your elbow will protect those around you.   

More recent fear surrounds COVID-19 patients not having symptoms, but spreading it to others.  It is true that this can happen.  It has been studied and has been proven to occur with other viruses such as influenza.   Studies previously showed we can spray droplets when we speak.  Therefore we can spread a virus by speaking with others.   I am not going to downplay this as a possibility.  Let us focus on the known ways viruses have proven to be spread.  If it were of any significance, we would see major outbreaks beyond the crowding of the hotspots that have occurred in major cities in New York, New Jersey, Michigan, Louisiana, Washington and California.  Many of these outbreaks occur after big social events like religious community gatherings, Mardi-Gras, Mass Transit etc.

This week, modeling showed the deaths that are predicted to occur over the coming weeks to months ahead.  New York was hit early and will come to a peak early.  Other parts of the country will be peaking later, leading to a slower spread.  This will occur in smaller communities as we relax our social distancing.

In the beginning of the month, there was an editorial in Lancet regarding people wearing masks in public.  This was picked up on news outlets.  Studies showing that we can have saliva leave our mouth during talking was added to the discussion.  Our mind naturally puts together two items – someone with COVID-19 may not have symptoms and they can give it to me by talking.   This fear, along with the number of anticipated deaths, can lead us to go down the Rabbit Hole of Fear. 

Now back to our staff meetings.  I pulled together all the well done studies about effectiveness of masks.  Even when the best masks are used (N-95 with proper fitting), we went over studies with no benefit.  Other studies showed no benefit of no mask compared with a surgical mask.  There are studies showing benefit, but most studies showed no or very little benefit.  That includes comparing the N-95 mask with a surgical mask.   Not all studies quoted are ones we should change behavior for.   I showed all the well done studies and then asked our staff to share their interpretation after the meeting.  Here are some of the statements emailed to me:

“masks are ineffective if being used to prevent getting an illness, especially if used incorrectly”

“only wear masks if you have symptoms”

“I thought it was very informative and I appreciate all the information you supply us with.  I also appreciate how much you and Dr. Elmer care about the staff here.  This is why I love coming to work every day”

“explaining to parents what the masks are used for (for ill patients to prevent spread to other people). The importance of PROPER handwashing”

“mass masking is not beneficial”

I explained to our staff – there is likely to be a recommendation to use masks in public.   I also showed other studies about how often a person touches their face (23 times per hour).  Looking at a study on hand washing:  only 9% wash their hands vs 84% apply hand sanitizer in an effective way as recommended by the CDC.  

What are the important strategies?  Maintain social distancing.  Do not go out in public when you are sick.  Wash your hands correctly.  The implications of infection spreading from those with very little or no symptoms is most important within our own home.  A CDC study showed the risk of infection for known COVID-19 cases is 10.5% in the home vs 0.5% for close contacts outside the home.  We take shortcuts at home because we feel safe.  We share food, we pick up our loved ones dishes, and we hug and love each other.    The number of cases in our area is low.   It will not rise to the level we see in New York City, but this is going to increase when we let our guard down.  We need to continue to take precautions for family gatherings and groups where we are in close proximity.  This will need to continue for as long as this virus is substantially circulating.   We need to fundamentally change our social approaches until we are able to have both medication to treat this virus and a vaccine to prevent it. 

Risk to Children

I know it was frightening to learn of a 7 week old who died this week.  The child tested positive, but there is still not a confirmation that COVID-19 was the cause.   Please continue to remember what we have been saying.  The risk for children is extremely low but is not NO risk.  To have over a million cases with 2 of those being children, continues to give us confidence about reminding you of the low risk.   In this year’s flu season, 162 children died in the United States.  That occurred with the flu vaccine and an effective drug to treat it.  Most of those were un-vaccinated children.   It is my strong belief that the Flu represents a greater risk to children this year, than the COVID-19 will.  COVID-19 represents a much bigger risk to our elderly population.  Each time there is an unexpected death, it will be reported in the press.  We need you to tamp down that fear and continue the strategies that are evidence based.    We will learn of more evidence based strategies and I will make sure you are aware of them.  The strategies that are in place are working.  Keep social distancing.  Don’t go out in public when you are sick.  Wash hands after touching high risk surfaces and touching your face.  Become more aware of touching the face.  Do not visit the elderly with your children.  Use social media to visit grandparents, friends and relatives.   (I toasted my Father in Law with a beer this week on face time).   Do a Video Visit with us when we recommend that you not come in the office (thank you for following this when you call).  Keep your well visits and get your protective immunizations.  A decline in vaccinations is not going to help this situation.    If the CDC recommends masking, you will see us all wear masks in order to follow the recommendation, not because we have symptoms.  Don’t go down the Rabbit Hole of Fear.  Take care, turn off the news and have a good weekend.   – On behalf of Dr. Miller and Dr. Elmer and all the staff of Four Seasons Pediatrics.