by Dora Anne Mills, MD, MPH, FAAP, Saturday, November 27, 2021

Dr. Paul Farmer, who has dedicated his life to bringing lifesaving tools of modern medicine to those who need them the most, has remarked optimistically about the COVID-19 pandemic: “When you settle on a problem, devote the resources to it and have at least some ability to incorporate new information, every time, it gets better,” he said. “I don’t have any experience anywhere, where you just apply yourself, along with others and then do not see progress. My optimism has pretty honest roots.”

Emerging news about the Omicron variant

Although the emerging news about the Omicron variant detected in southern Africa is unsettling and concerning, it is also not a reason to lose hope. As Paul Farmer reassures us, many others are working on this, and we have the ability to incorporate new information. But that’s actually understating the situation. The world’s best scientists are working on this, not just a few “others”. And because of the focus on the pandemic, we are able to quickly identify and incorporate new information, as happened with this new variant.

The news about Omicron is also not surprising. The Delta variant taught us that this virus can significantly mutate. So long as there continues to be widespread transmission around the world, the virus is likely to continue to mutate. Omicron at this point in time doesn’t change our current strategies. And if a new vaccine is needed, the mRNA platforms provide very quick mechanisms to develop new ones.

Unlike in 2020, we can currently go about our lives safely and not in fear, so long as we adhere to the major strategies of:

  • Vaccinating
    • Make sure you and everyone you’re in close proximity with who is eligible for COVID-19 vaccine (age 5+) are fully vaccinated, including boosters (anyone 18+), as well as fully vaccinated for influenza.
  • Masking
    • When indoors or in crowded outdoor venues and in close proximity (within ~6’) with people outside of your household, mask.
  • Distancing
    • Keep you distance, especially when unable to mask, e.g., when eating, then distance (again, when with people outside of your household).
  • Ventilation
    • When gathered with people outside of your household, meet outdoors when possible, or if indoors, increase ventilation (air flow, air exchange) by opening up windows and turning up the heat.
  • Testing
    • When gathered with people outside of your household, especially if for an extended time (e.g., for a retreat meeting or holiday gathering), consider rapid antigen testing of everyone upon arrival, if you can afford and find these tests.
  • Hygiene
    • Wash hands frequently and cover your mouth and nose when sneezing or coughing.
  • Reducing density
    • Keep the numbers of people you’re gathered with low.
  • Staying home
    • Everyone should stay home if they have any symptoms of illness, including fever, runny nose, cough, and sore throat or are just not feeling well, even if they’ve tested negative.

These strategies work. One recent example is that these strategies have been used by college campuses very successfully this fall and as a result, students are able to enjoy a fairly normal semester.

I’ve now been able to use these strategies several times for gatherings or long-duration meetings, and they’ve worked well. While most have expressed gratitude for these assurances of safety, it’s been a bit awkward to ask some to verify their vaccine status or take a test, especially if they’re not used to doing so. Those who have traveled to big cities or Europe are very used to this since vaccine passports and on-site testing are routine there; they’ve just not become part of our culture yet here in Maine.

Lessons learned

Some lessons I have learned:

  • If people know ahead of time what’s expected of them, they’re mostly fine with it.
  • Some have arrived saying they tested themselves earlier that day or a day or two ago. I think in many settings, it’s important that people know they’ll be tested upon arrival and that prior tests do not count. In general, it’s better when everyone tests upon arrival, including because the test is done at the same point in time (someone could have tested negative a few hours earlier and be positive upon arrival); and there is some assurance as to the quality of the test used and the testing techniques.
  • I’ve found that some believe if they test negative, they can toss the other layers aside. For that reason, I think it’s helpful to let people know that while testing is a layer of protection, it’s not the only layer needed since testing, vaccination, masking, distancing, ventilation, and hygiene all work synergistically. None of these layers is foolproof, but when all are activated to the extent that is practical or possible, everyone is safer.

How to communicate about expectations

In terms of letting people know ahead of time, below is a sample text anyone is welcome to use (and edit) to send to expected guests:

During this current pandemic surge, we are taking some additional precautions for all those visiting (or attending our holiday gathering or meeting) in order to protect the health of all attending. Therefore, we ask that:

  • you not attend if you have any symptoms, e.g., fever, cough, sore throat, runny nose, or are not feeling well, even if you test negative;
  • you are fully vaccinated against COVID-19 and influenza, including a booster shot against the former;
  • everyone mask when you are indoors and in close proximity to others;
  • people distance as is possible when unmasked, such as when eating;
  • you take a rapid antigen test upon arrival (we will provide). Additionally, if weather permits, we may have people sit outside or may open a window, so please wear warm clothing.

We greatly appreciate your help as we all learn to move forward and find joy in gathering together in COVID-safe ways!

Additional precautions

If you or someone you’re close with is immunocompromised or you are high-risk for severe disease and just want to take extra precautions, here are some suggestions. More information on these strategies can be found in the resource section below.

  • N95/KN95: wear a well-fitted N95 or KN95 when in close proximity (i.e., you may be breathing shared air) with those not in your household.
  • Eye protection: wear goggles or face shields while in close proximity with those not in your household.
  • Air purification: buy a portable HEPA air cleaner for rooms that you may commonly gather with others or for situations that other forms of ventilation are not practical.

Which over the counter tests to buy?

The FDA has very recently approved several new rapid antigen tests for at-home use in order to ramp up production and their availability. They mostly use lateral flow technology, which means if you’ve used a pregnancy test in the last ~25 years, you’re familiar with this (though the COVID tests use nasal swabs, not urine). Because they have been around the longest and are commonly sold, the accuracy may be a bit more reliable for the following at-home tests:

  • Abbott’s BinaxNOW
  • Quidel’s QuickVue
  • BD Veritor At-Home, (needs to be used with a smartphone)
  • InteliSwab
  • Ellume (needs to be used with a smartphone).

All but Ellume come in a 2-test kit. It’s increasingly easy to find these kits, especially at chain pharmacies, big box stores, or online (including big box stores’ websites), but you may have to search to find them.

I’ve found it easier to buy one brand, learn how to use it, and keep buying that brand so as to assure the testing technique is the same. Since Abbott’s BinaxNow tests are made in Maine and are fairly easily available, I’ve been buying them. A quick scan of websites this weekend shows they’re available for $14 for 2-test kits at some local chain pharmacies as well as Wal-Mart online. [Others generally charge about $24.]

Questionable test results

What if you test positive on a rapid antigen test but don’t have symptoms? Or if you test negative, yet have symptoms? You should follow the US CDC guides found in the resource section. Basically, in either case, you will likely want to obtain a PCR test to confirm the results, especially if you’re at high-risk for severe infection (see a link to a list of such conditions in the resources section below). You can also test a second time with a rapid antigen test, in case there was a false positive or false negative with the first test. It’s also best to quarantine/isolate as is recommended by US CDC.

If you test negative but have symptoms, consider testing for influenza, since we’re seeing more of this. Unfortunately, there are not easily available at-home influenza tests, though I hope that changes. If you have COVID-19 and you’re well enough to stay home but are in a high-risk category for severe disease (age 65+ or have one of the conditions listed in the resource link), then you should let your PCP know so you can be considered for monoclonal antibodies (MABs). These are synthetically-made antibodies that if given early in the course of the infection can reduce the risks of hospitalization by at least 70%. They are administered by an intravenous infusion or four different shots. It’s often challenging to find a site that administers them, but one link below is to a list of the Maine sites and the other has a national location finder (though I notice this finder doesn’t seem to be frequently updated). One major note, it is critical to start monoclonal antibodies as soon as possible (preferably within the first five days of symptoms), since they’re not nearly as effective as the illness progresses and are not indicated for those who are 10 days or more from the onset of symptoms.

Record-breaking cases

The news headlines in Maine continue to highlight the breaking of records for COVID-19 hospitalizations and cases. It’s understandable since those are the numbers most readily available. However, healthcare systems in Maine and across the country are really facing three concurrent crises:

  • COVID-19 pandemic
  • Rise in other health issues
  • Workforce shortage.

Rise in other health issues

Since last spring, across the country, we have seen very large increases in patients with a variety of health issues as well as increases in the severity of these illnesses. Some of this may be due to delayed care due to the pandemic. Much of it seems directly and indirectly caused by stressors related to the pandemic. For instance, we’re seeing surges in behavioral health issues, e.g., drug overdoses at record-high levels and mental illness crises. The Federal Trade Commission reported in October that in 2020, U.S. sales of cigarettes rose for the first time in 20 years. A report from the Kaiser health system shows that the average American adult gained 1.5 pounds per month, equivalent to 18 pounds, during the first year of the pandemic. With increases in smoking and weight gain, it’s not surprising to see ripple effects, such as escalations in diabetes, heart disease, and cancer.

There is a history of growth in a variety of health issues after disasters. Several studies on the after-effects of the Scud missile attacks on Israel and Hurricane Katrina show increases in a number of health issues, including for several years after Katrina.

Workforce shortage

Like many industries, healthcare is experiencing an exacerbated workforce shortage. The reasons are numerous, including those nearing retirement age leaving and others quitting because of emotional and physical exhaustion. Regardless of the causes, as of this last summer nearly one in five health care workers had left the field during the first 15 months of the pandemic. And unlike many other industries, healthcare cannot shut down.

These challenges are not just felt in Maine, but also across the country and across the globe. Dr. Paul Farmer’s work is built upon the principle that the only real nation is humanity. This pandemic has taught us that the virus looks at humanity as one nation. It does not see our borders as it slithers across them quickly and silently. In some ways, many in our world – its scientists, its business people, its political leaders – have come together as one nation to solve so many of the pandemic’s challenges, from vaccine development, genetic sequencing and surveillance, supply chains for personal protective equipment, and learning from different nations’ responses. I hold hope that as they come together to address the new Omicron variant, they will find answers.

Haitians have a saying, “Beyond mountains there are mountains”. The author Tracy Kidder used this in the title of his book “Mountains Beyond Mountains”, a biography of Dr. Paul Farmer. The pandemic has also taught us that beyond one challenge, one mountain, is another challenge, another mountain. The Haitians also believe that mountains are not just challenges, but opportunities. I believe our hope is to find the opportunities in these challenges, and I believe we will find them. Working together as one world, there is no mountain we can’t climb.


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