David J. Holcombe, MD
Louisiana Public Health Association Member
As COVID-19 ravages the land, the elderly must pay special attention. As we have reached the dreadful milestone of 100,000 deaths in the U.S. we should remember that the elderly, especially nursing home patients, represent a disproportionate number of deaths.
When we consider Louisiana, there has been close to 40,000 cases recorded in all age groups as of May 25, 2020, with over 2,500 deaths. The median age of death is 74 years old, meaning most of the cases fall in this elderly age group. While numbers of deaths peaked around April 4, 2020, they continue to occur at this time, albeit at a slower pace. Most deaths occur in the hospital (83%), but 14% occur in nursing homes or long-term care facilities, while only around 3% occur at home in Louisiana.
When older Louisianans contract COVID-19, they are much more likely to die. That chance of death is called the Case Fatality Ratio (CFR) and represents the percentage of individuals that will die if they get any particular disease. The CRF increases dramatically with age for COVID- 19: 7.88% for 60-69, 19.62% for 70-79, 29.86% for 80-80 and 32.93% for 90+. In plain English, your chance of dying if you are above 90 is four times greater than if you are in your 60’s and 44 times greater than if you are 30-39 (when the CFR is only .74%).
Chances of death are also greatly increased with underlying conditions, not necessarily related to age. Of Louisianans who die, 58% had hypertension, 35% had diabetes, 20% had heart disease, 19% had either kidney disease or obesity, 13% had congestive heart failure and 11% had COPD. Over 50% of elders are likely to have one or more of these underlying problems. Since these conditions are more common in African-Americans, they pay a higher mortality price than their white counterparts. In fact, 55% of Louisiana deaths are in Blacks (who represent around a third of the population), while only 43% are in whites.
When we look at Central Louisiana, the statistics are roughly the same. At our Drive-Thru testing sites, we have tested over 2,500 people. Around half are Black and half are white, but in the positive cases, which represent about 10% of those tested, around 70% are African- American. Deaths in Central Louisiana (OPH Region 6) have been 50% in Blacks and 40% in whites, much as in the state at large. In our region, the underlying conditions are roughly the same, with a pronounced increase in COPD (around 20%) as opposed to the state numbers (only around 10%).
We are seeing a slow but steady increase in COVID-19 cases in CENLA, sometimes related to increases in testing and sometimes related to decreased vigilance. Most nursing homes are now engaged in regular testing of all residents and staff, revealing a distressing number of asymptomatic patients and staff members. “Asymptomatic” means that they have no symptoms at all, but are still carriers of COVID-19 who are capable of transmitting it to others. Nursing homes, much like prisons, have a “captive population.” Once positive cases within the facility are managed, the best practice becomes regular testing of staff who are the only ones who may bring new infections into the facility.
Aging is not for wimps. The challenging of aging can be health related, economic or psychological. COVID-19 has added another challenge to the elderly in these troubled times. Adequate testing, wearing of masks and social isolation will all go a long way to reducing the morbidity and mortality burden of this novel virus. Let us hope for the early development of an effective vaccine, the only real way out of this viral nightmare.
David Holcombe, MD
Member of the Louisiana Public Health Association
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Almost nothing has caused more controversy and consternation, besides the disease itself, than the issue of COVID-19 testing. First, there is not just one test, but multiple tests. The most common is the PCR (polymerase chain reaction) test that detects the presence of the virus. This test usually requires a nasal probe that is placed far back into the nasal cavity (very much like the flu test). It is being performed at various facilities in Central Louisiana and usually must be sent off to a reference lab, either commercial labs or the state lab in Baton Rouge. This means that there is a waiting time anywhere from one day to five days depending on how much of a backlog is experienced by the lab. (At one point, one reference lab had a backlog of 160,000 tests.)
There is also a variation of this viral test that is a quick test (known as “point of contact” testing) that can be run in anywhere from 5 minutes to less than an hour, depending on the equipment.
These “rapid” tests are not available in many locations, although the machinery to run them is becoming more available. The biggest problem has been the scarcity of the reagents (the ingredients to run the tests) and concerns about reliability. It is hoped that more machines and reagents will become available in the weeks and months to come.
Viral tests should not be confused with “serological” or “antibody” testing. These names, serological and antibody, are used exchangeable for blood tests that measure the amount of antibody a person has produced. When infected, people develop an immune response with antibodies, both IgM and IgG. The IgM antibodies signify the first response to a recent infections and the IgG levels denote the longer term response. If someone has neither one nor the other present, they are either very recently infected (and should be viral positive) or not exposed at all. It is hoped that the widespread availability of antibody testing will be able to separate the population into those who have already had COVID-19 and those who remain susceptible.
Once again, the serological tests are new and not all are entirely validated. Although they are probably very accurate and reliable, it is simply too early to tell. More complicated is the fact that all the antibody test (IgG) tells you is that you have had COVID virus. No one really knows if the presence of antibody alone offers protection from future infections and, if so, for how long. Someone with a positive antibody test still needs to continue social distancing and mask wearing since they may get re-infected at some time.
There have been conflicting reports of the availability of testing in the U.S. Some sources say that they are widely available and everyone can be tested. Other sources claim that this is not true and that many areas lack the equipment and reagents to perform the tests. The Office of Public Health questioned 42 local providers during the week of April 6-12, 2020 and found 22 of them reported inadequate numbers of testing kits. Testing capacity still remains a problem, especially given the goal of 4% population tests.
So who has to be tested and how? The answer has evolved rapidly and depends on the institution and the availability of tests. At this time, those who need testing are those who have developed fever, cough, and shortness of breath, muscle aches, sore throat, headaches, and loss of smell or even diarrhea. Although the cutoff for fever was 100.4 F or above, some people will develop a low grade fever or none at all. There are also numerous underlying conditions such as pregnancy, old age (above 65), diabetes, kidney disease, cancer, immunotherapies, and living with someone with these conditions that can merit testing. Those who have had prolonged, close contact with a known positive are also encouraged to be tested.
Generally, just being exposed to someone with documented COVID-19 does not mean you will necessarily become infected, nor does it mean you must be tested. You will only need testing if you develop symptoms yourself or if you have had prolonged (greater than 15 minutes close contact with a known positive case). Remember, there are a significant number of people who will be infected and not develop symptoms (asymptomatic spreaders), but at this point, everyone should be exercising self-isolation and wearing masks in public to minimize transmission in any case. Always assume the person in front of you is infected and you may be, too.
The complicated topic of the COVID-19 pandemic continues to occupy the airways and interpersonal conversations. We have flattened the epidemic curve, thus sparing lives and medical resources, but the relaxing of home isolation and the failure to wear masks and respect social distancing make a second or third wave probable.
There are some similarities between COVID-19 and the Spanish Flu epidemic of 1918 which killed 50 million people worldwide. It, too, was new, deadly and spread rapidly as documented by public health professionals. It, too, responded to social distancing and wearing of masks.
Neither viral nor antibody testing was available at that time, but hopefully we will soon be in a position to test everyone who needs or wants one. We should also have an effective vaccine and COVID-10 specific treatments in the future. In the meantime, maintain your social distancing and wear a mask in public.
Remember, around 30,000 Americans die from the flu in a bad flu season. We are already approaching 100,000 deaths from COVID-19, thus making it already three times as deadly as the flu. It is hoped a vaccine may be available in the late fall or winter, but it surely will not be in quantities sufficient to give to all citizens. Since flu season will be upon us in the fall, and it will surely be complicated by COVID-19, at least get your flu shot when it becomes available to avoid a double, deadly whammy.
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