HIV and ID Observations

Mickey Mantle and fan, 1956 (with permission)

A few weeks ago, I got a text from a long-time ID colleague here in Boston:

Hey Paul want ur opinion … this is for an interview with MLB radio, and no one knows less about baseball than I do, but as an avid fan and wise ID doc, do you think the season should continue?

Confession — it took me around 3 milliseconds to respond, if that.

And my answer was yes.

But, some no doubt are thinking, we’re in the middle of a pandemic. It’s hardly under control. A bunch of players had already tested positive, proving it’s not safe.

And — let’s remember — it’s just sports. Sports don’t matter.

But here, in all its tarnished, selfish, complicated, and ultimately messy way, is why I still think it’s worth trying to play professional sports in 2020.

These professional leagues have extraordinary resources — and the motivation — to control outbreaks. The NFL alone boasts annual revenues of $25 billion. You think this might motivate the owners to play the games safely?

The players’ careers don’t last forever. The average professional football player’s career length is only 3-4 years, Major League Baseball 5-6 years. That’s the brief time most of these supremely talented individuals make the bulk of their life’s earnings.

The slowed reflexes, loss of muscle strength, decreased vision, accumulating injuries, and other changes brought on by aging loom as opponents that no athlete has ever beaten. A fast, hungry young rookie is always coming up to take their place — especially if they’re not superstars.

The clock ticks down on these brief careers even during a pandemic.

Sports have already taught us something about disease control — and can teach us more. With coordination well beyond what our government appears willing, motivated, or capable of doing, they have deployed extraordinary strategies that, so far, have been remarkably effective.

Can anything be more of a success story than the NBA? Who could have predicted that they would have zero COVID-19 cases when they placed hundreds of young men into Florida during a surge of cases?

Their strategy of frequent testing, creating a limited “bubble” of exposures, and importantly getting buy-in from both the ownership and the players now is being emulated by other industries.

Not only that, they helped validate a new technique for using saliva for COVID-19 testing.

I’ve made no secret that I don’t like football, and confess I prepared myself to reject whatever plan the NFL came up with to play the games safely. The decades of denials the NFL tossed out about the hazards of the sport gave me no confidence they could possibly go forward with a legitimate plan.

But no! After listening to this Freakonomics podcast, I was frankly blown away at their thoughtful and highly detailed approach. This includes frequent (daily!) testing, active participation of the players’ union and the league in civilized negotiations about policies, reliance on science rather than emotion or politics to do the right thing, wow — this is how to bring an epidemic under control!

Professional sports give many of us something we need right now — a distraction. Pandemic. Fires. Violence. Racial tension. The death of an inspirational public figure. Raging political discord.

Yep, 2020 has it all. Why not enjoy a few moments away from these nightmares to watch Naomi Osaka storm back and win the US Tennis Open, or LeBron James fight Father Time in the NBA playoffs, or Mike Trout continue a career that looks like he could become one of the greatest baseball players of all time?

With echoes of FDR’s advice to proceed with the baseball season despite World War II, again sports can give us a well-needed reprieve from the grind of daily existence, both as fans and as participants.

One of my patients, mostly very isolated since early March due to COVID-19, kindly shared the above picture with me since he knows we share a fondness for baseball. (Ok, “fondness” = obsession.)

It’s a promotional photo taken with Mickey Mantle in 1956, the year he (Mantle) won baseball’s Triple Crown. (I’m sharing it with my patient’s permission.) Take a look at that kid’s face! And thinking about sports still gives him pleasure today.

Some might argue that these professional leagues’ safety measures divert resources (especially testing) away from schools, nursing homes, and other settings that need them more. Fair enough.

But is there any indication that if pro sports didn’t start up again, that the tests would have flowed to the schools? As noted by Will Leitch, “All of us should be able to get tested easily and quickly! But that fact does not inherently mean that what leagues are doing is wrong.”

So let’s play ball — and hope we learn something from these professional leagues about how to control the pandemic by getting buy-in from all involved.

And, most importantly, by following the science.

As we learn more about transmission of SARS-CoV-2, the news for restaurants goes from bad to worse.

And while there’s a long list of sad things about this pandemic, the decimation of the restaurant business for owners and the people who work there is right up there. The loss of the restaurant experience for us diners is pretty sad, too.

Importantly, restaurant dining isn’t one of those hypothetical risks for COVID-19, such as surface contamination of groceries and delivered packages. It’s a real, well-documented concern with strong supporting evidence.

In a CDC study conducted at 11 healthcare facilities and just published last week, investigators queried 154 people with symptoms consistent with COVID-19 and positive tests, along with 160 control individuals testing negative. They asked about various activities in the two weeks prior to the onset of symptoms — eating out, shopping, going to an office, visiting a hair salon, taking public transportation, attending a religious service, and others.

People with positive test results were more than twice as likely to have reported dining at a restaurant than were those who tested negative. No other activity conferred significant risk.

It’s a small study, and the authors note several potential limitations, but they amplify the message that crowded settings, close contact, and lack of mask wearing indoors increase the risk of COVID-19.

The vagaries of restaurant ventilation — so exquisitely detailed in this investigation of a restaurant outbreak in China — add to the hazards of indoor dining.

Here, one presymptomatic person infected nine other diners, all of whom sat under the the same air conditioning vent that recirculated “old” rather than fresh air.

www.medrxiv.org/content/10.1101/2020.04.16.20067728v1.full.pdf

None of the 68 diners in other areas developed COVID-19, nor did any of the 8 waiters — likely because transient contact is much lower risk.

Meanwhile, Harvard epidemiologist Professor Miguel Hernan compares epidemic curves in New York and Madrid in this fascinating thread:

1/
Look at the shape of these curves.

New York and Madrid had similar epidemics until they spectacularly diverged.

In March, both cities were caught by surprise and shut down because of #COVID19.

In September, the situation is under control in NY and alarming in Madrid.

Why? pic.twitter.com/VF0BCl0xyt

— Miguel Hernán (@_MiguelHernan) September 11, 2020

What does this have to do with restaurants?

In New York, indoor dining is CLOSED. Indoor dining in Madrid was OPEN at 60% capacity in June. Bar service opened too. Protocols weren’t aggressively enforced. Since June it has been easy to find crowded bars and tables. The contrast with NY was striking as anyone spending time in both places can tell you.

Is it too far fetched to extrapolate from these cross-city comparisons and conclude that opening restaurants played a role? Not really, when you consider how cases in the southern US spiked when bars and restaurants opened in regions that still had significant community transmission.

(And having had the pleasure of dining late — and I mean late — into the evening in Madrid, I can assure you that these meals are the very opposite of transient when it comes to potential exposure time.)

As noted above, all this information about restaurants and COVID-19 risk makes me very sad. Having grown up in New York — arguably one of the world’s great restaurant cities — I love the way a top restaurant experience provides more than just excellent food. The atmosphere, the conversational buzz, the decor, the rituals, and of course the intermingling of so many different cultures enhance our lives in countless ways. Certainly I’m not alone in missing this colorful aspect of life from the Before Times.

Not only that, but my mother worked as a food writer, and for years wrote a weekly column in the New York Daily News on hidden restaurant gems in the city. If a new Ecuadorian restaurant opened in Queens that generated some buzz, you can be sure we’d soon be sampling some empanadas ecuatorianas or llapingachos.

Meanwhile, awaiting a vaccine and other preventive strategies, what can we do now to support these hurting restaurants?

Dine outside while we can. Tip heavily. Order take out. Buy merchandise. Other ideas here.

But skip the indoor dining in restaurants for now. And while we miss it, it might help to remember that eating out isn’t always so great.

https://youtu.be/K_q4S7lZeik

For us ID doctors in most of the northeastern United States (and Chicago and Detroit and some other northern cities), March and April hit us like a giant wave of never-ending calls, pages, emails, and crises.

With COVID-19 case numbers increasing every day, the challenges crashed down on us in an endless torrent of hospital needs and responsibilities.

The emotional toll of seeing so many critically ill patients for whom we didn’t have any proven therapies was only part of it. We were also the group to whom everyone turned for help — everyone had questions.

We know you must be swamped right now, but … started many a query.

No surprise. This is an Infectious Disease, after all. “It’s what you signed up for,” as one of my friends, a lawyer, put it succinctly with a shrug.

But it’s also something none of us had ever seen in any of our lifetimes. No one is old enough to remember the 1918 influenza pandemic. No one really knows what to do, or how to do it.

Which is why the work of handling COVID-19 can be endless.

Want an example? Someone tallied what one of my extraordinary colleagues — she ran our “biothreats” response team — gave to the COVID-19 effort, which started for her in early March:

Wow.

Needless to say, it came as an enormous relief when case numbers started to drop. For Boston, this started in early May.

Here’s what Dr. Stephen Smith, writing in late June, said about his experience in northern New Jersey (reprinted with permission):

In my private ID practice in northern NJ, 18 miles west of New York City, we have treated over 200 hospitalized COVID-19 patients, many in the ICU. We peaked in early April. Then in early May, it was as if someone turned off the spigot. Since then, we have been consulted on only 20 patients who tested positive for SARS-CoV-2, but only a minority was admitted with COVID-19 symptoms. We have not intubated a patient with COVID since early May.

We are hesitant to use the “A” word (attenuation). Like the reverse of saying Lord Voldemort’s name, we are worried that if we say the “A” word, it won’t happen.

To what do we owe this lessening of the COVID-19 burden, especially now that cases are increasing in most of the rest of the country?

While herd immunity might play some role — I remain hopeful, despite discouraging reports on low seropositivity in hot spots — much more likely is that we’ve been adherent on a societal level with implementation of various low-tech strategies.

Social distancing. Banning communal indoor activities. Closing bars and restaurants. Asking religious institutions to worship over Zoom, or outside. Wearing masks in public, especially indoors.

These things, you know, actually work.

While we ID doctors in the northeast bask in this much-needed reprieve, our ID colleagues in much of the rest of the country — initially relatively spared — now have to deal with rising case numbers.

And they must be truly exhausted. Really.

Because it’s not as if they weren’t gearing up for this in the winter. When CROI (the most important national HIV meeting) converted to a “virtual” meeting in early March, many ID doctors from the south and west had already cancelled their plans to come to Boston — COVID-19 already loomed very large nationally to all us ID specialists, and preparation for it was underway everywhere.

Plus, note I wrote that they were relatively spared — they’ve also been seeing some cases right from the start, if not as many we initially did.

So to all ID docs out there in Arizona, Florida, Texas, California, Alabama, South Carolina, Tennessee, Georgia, Louisiana, and all the other states experiencing a COVID-19 surge, I’m thinking of you.

And so hoping that your community will get it together, and turn off that spigot soon.

Because when it happens, it brings a relief the likes of which you won’t believe.