Author Archives: John Rensimer

Coronavirus Update

COVID-19 Update 9

Why Should I Do It If “Essential” Workers Don’t?

We are pounded on incessantly by medical experts, by government leaders, by media, from every video screen we stare at, from notices on doors, from the radio… exercise The Golden Rule and be part of something bigger than yourself… stay apart! The more SARS-CoV-2 spreads, the more it kills. Yes, the old people. Yes, medical workers and first-responders who put themselves at risk. And, at times, even someone in middle age. Someone’s wife, husband, brother, sister, father, mother, grandparent… a best friend. It gets real when it isn’t just a number. It’s that person 2 months ago with whom you were planning a dream trip. Or, grandpa whose only remaining life’s desire was to see your child, his coming grandchild, be born next Thanksgiving. Or, just your buddy you meet every Tuesday for some coffee, and a sandwich, and a piece of chocolate pie, to make sense of what your life was and is, now that you’re both retired. Plans, dreams, memories, hopes… lives.
So, for the most part, many are making a reasonable effort to keep to themselves, to be part of the solution.

Yet, Sunday, I stop by Kroger’s Supermarket to load up the fridge for the week. I’m 70 and I’m wearing a mask and using hand cleanser on the way out of and into the car. As I stroll toward the entrance, the majority of people entering and exiting this human funnel have no masks. Haven’t they TVs, radios, mobile phones? Have they not heard the message? Worse, as I get my cart inside, I see a few supermarket workers with masks, many askew, but clearly not more than 50%.
Geez, the aisles don’t allow 6-feet separation of shoppers passing each other. At checkout, you are maybe 4-feet from the cash register guy. Maybe 3-feet from the bagger.

Then it comes to me. I get it. Because this is an essential service (food delivery) COVID-19 knows this and doesn’t come in here. That’s why, when I suggest to the register guy that he needs to shave off his goatee and tight-fit a mask, he has a “caught-in-the-headlights” frozen stare.

I can see the white-space bubble over his head, like in the comics, “What the hell is that your business?” I pull my trump card, “I am an Infectious Diseases expert. You look like you’re about 70 and are probably exposing yourself to 100 people a shift. You are at serious risk to die if you catch this virus. If you don’t care about yourself, care about somebody else, like us,” I assert through my muffling mask. He stares an annoyed stare and hands me my receipt. See you.

Just considering, is the supermarket putting USDA failed, spoiled food out on the shelves? Might as well seeing how they run their show in a pandemic. We all need food, so, the one place you would want to have the highest infection control measure would be where the close-in traffic is. How about putting signs up to dissuade those 65 and older or with medical conditions to not come in; have a surrogate pick up the milk? Or, at least supply them with a mask if they must shop for themselves. How about one-way traffic down each aisle, enforced by monitoring staff? Hand cleansers at the entry-way.

I mean, these essential businesses get to stay open and rake in the cash while other businesses don’t know if they’ll ever reopen and people are buying groceries off savings or debt. Yet, market management is so arrogant as to ignore what everyone else is doing for the greater good.
Where else? Hospitals. Walk the halls of a hospital floor and you’ll see their staff chatting, unmasked, several feet from each other. No social-distancing here. We’re special. We’re healthcare professionals. When we enter this special building, we are exempt from the biological reality all those schlemeels out there follow. Well, we actually do it at home, but not here. We have uniforms, we’re different. Well, it is different, we think, because the hospital Administration doesn’t require us to be tested every 2 weeks to prove work-fitness, so we don’t pass SARS-CoV-2 to the patients. Oh, the patients- – forgot about them, because we do work under special rules. Let’s see. A hospital is a place where such people go. Really sick people. Old, serious medical conditions, weakened immune systems- with their bodies physically handled hourly by nurses, therapists, blood drawers, physicians. I mean, is this COVID-19 heaven or what? Masks for everyone? Are you kidding? Nurses have been fired and doctors threatened for insisting on such measures since it might upset patients and families that there is a contagion afoot. What’s more important, infection control or public relations?

However, hospitals got serious a couple weeks ago when they limited visitation to one person a day per patient. I’m still trying to figure out how they were sure which patients were COVID-19 clean? Oh, that’s it. They set up a table with several staff at the single entry point allowed. Taking your temperature with an unreliable forehead thermometer got it done. Except, what if I had a fever an hour before or an hour after they spot-checked me? You must know that no infection causes continuous temperature elevation. I asked the hospital nurses manning the screening workstation. Blank stares. Just doing what they’re told. Others must know what’s right or we wouldn’t be doing this. After all, they’re doing it at the airport with international travelers. Most usually, infections cycle fevers up 2-4 times in 24 hours. All of them… malaria, TB, typhoid, AIDS, pneumonia, COVID-19.
But, at least it “looks” like they’re serious. This is what “leadership” hands down as policy. This is written as if this is comical. You have to do that to avoid being preachy and to compel the reader to stick with it. But, far from humorous or entertaining, this is a criminal disgrace. And, I never thought I could join a hospital and a grocery store into the same class.

The point? How do you get the regular guy in the street who half suspects a lot of this is just an exercise in wielding power to create hysteria to comply with public health policy?
He looks at these societal “essential” services and what their take is on the true threat of the situation. He sees no consistent or serious measures taken. He sees these as places where bodies are concentrated, yet they’re sure not distancing and masking. Ah, it’s just a bunch of malarkey. I’ll go my own way, carve my own path through this, he thinks.
And that, my friends, is how you fill graveyards.

You have more time on your hands now than you have ever had. Contact management at the essential services centers and raise their awareness that you are watching and that you will not patronize them if they don’t get with the program, don’t join the team. If you don’t sense intent to change, call the media and see if you can get a reporter to put it on air. Post it on social media.
Where our lives and those or our loved ones are at stake, there are no exemptions, especially for the essential services.

Ironically, they should be held at the highest standard by the community.

Graveyards.

 

Ed Rensimer, MD

 

 

Michael Berry Show Clip

Please listen to this segment on the Michael Berry Show, KTRH 740 radio, 4/3/2020. Michael thought so much of my discussion of COVID-19 that he replayed the entire piece on his second show of the day to a national audience. I am sure you will benefit from the content.

Ed Rensimer, MD

CLICK HERE FOR THE RADIO CLIP

 

COVID-19 Update 8: What’s THE Critical Next Step In Return to Normalcy?

Answer: A SARS-CoV-2 Serology Test

What is that? A single test? Are you kidding? Let’s first discuss what such a test is. Once you understand it, you will see it is a game-changer.

Serology is the area of medical laboratory science that refers to the markers in our serum (the liquid fraction of our blood) from reactions of our immune system cells. After an infection such a footprint is an antibody (like an “anti-missile”); a protein in the serum that our immune system cells made to attach or neutralize the invader, to kill it and/or clear it from our body- like a sticky glue made to inhibit further replication of the pathogen invader until other weapons and support troops (cells) can arrive as part of the overall immune response.
Once the infection is resolved, most often these protein antibodies stay around for a long time, often times for life. The antibodies are entirely specific to the invader. So, having had measles or chickenpox, there would be measurable antibodies in the serum that could show that you had had that viral infection decades ago.

Wow, lots of basic medical science. Where is this going? What’s it got to do with my currently miserable life and this COVID-19 mess? We already have a test for the SARS-CoV-2 agent, why are we talking about this?

The current COVID-19 screening test is for the genetic material of the virus itself. It is positive when an individual is infested with the virus or clinically ill from it, and shedding the virus. But, you’ve heard that up to 80% of COVID-19 infections may have no or minimal symptoms. So, a huge number of infections will not be diagnosed – they are below the radar screen. Are they important if no one is sick and no one harmed? Yes, it is critically important to identify these people. Once you do that you understand the true nature and extent of the pandemic; where the virus has been, and is headed.
The data we have now are on actively ill cases. So, if 5 of 100 ill people die, the fatality rate is 5%. But, if 80% of COVID-19 infections are minimally ill or without symptoms, then the group the 5 deaths came from was 500, and the death rate is 1%. These real numbers can be found out once COVID-19 serological testing is applied to the entire population. 1% (usual flu is 0.1%) or lower fatality rate makes it much more acceptable for people to return to work (especially when we continue to shelter high-risk people until widespread infection abates) when comparing the true risk of death to losing your livelihood, your home, your retirement savings, your business or your country. We do not close down the country for a severe seasonal flu epidemic, which can kill 40,000-60,000 per year. We make a decision to concede that. Just like we conceded 406,000 mostly young lives to World War II to save our way of life.

If a large number of patients are not counted because they are barely or not ill, then the fatality rate would be much higher, which would increase the sense of pervasive anxiety and dread and reluctance to approve rejoining society, a by-product of incomplete information.
The value of such accurate information is undisputed, but where is the impact right now of serological test results of the population showing all who have been infected? What’s the practical benefit?

1. If you know who has and has not been infected and, in keeping with most viral respiratory infections, cards could be issued to those who are “post-COVID-19” and who would likely be partially or completely protected from infection, or at least severe disease, allowing them to go to work, go to school, congregate in public places like restaurants, visit hospitals, proceed with pregnancies, and on and on.

2. Personal protection equipment, like masks, would be conserved and directed to the highest need- -medical professionals and first-responders exposed at work.

3. A pool of people able to donate plasma with COVID-19 antibodies for treatment of extreme illness cases would be identified.

4. Medical workers with positive antibodies could attend their duties with impunity, allowing antibody negative individuals to stay on work-leave until the intense phase of the epidemic waned.

5. If and when a vaccine became available, surely in limited supply at first, it could be targeted to those not yet infected as indicated by a negative serology test.

6. Should there be resurgent waves of infection over the next 1-2 years, usual with novel virus pandemics, those identified as never yet infected could be advised against social contact and to continue quarantine, without mass evacuation of schools and businesses. The suppressive-mitigation infection control measures would be applied to a well-defined much smaller population, without the profound social and economic disruption.

Yes, this one type test, currently under development, applied broadly would change every aspect of dealing with this pandemic, minimizing loss of life (by concentrating resources on those at true risk) while restoring our societal order and economy. This, of course, assumes that COVID-19 confers significant protection against re-infection and endures past the 1-2 years of usual infection resurgence. This is an important detail, but it is reasonably probable that COVID-19 antibody gives some, if not complete protection. SARS virus, the brother of SARS-CoV-2/ COVID-19 produced protective antibody that lasted at least 2 years, long enough for COVID-19 to no longer be “novel” to the human race, just another virus, like flu.
Let’s keep our eye on this and hold it as reasonable position of hopeful optimism. We’re due.

Ed Rensimer, MD

Infectious Diseases

COVID-19 Update 7: Infectious Diseases Specialty Overview

FRONTLINE CONCEPTS

SARS-CoV-2 vs. Influenza 3/17/2020

Statements have been made that Coronavirus-19 (SARS-CoV-2) is just like the flu- that too much is being made of it. To compare them,

1. COVID-19 and influenza are both respiratory illnesses caused by viruses.
2. Virus Shedding,
a. Patients ill from flu shed virus (and so may infect others) for 24H prior to onset of symptoms and for 5-10 days after.
b. COVID-19 virus shedding has been seen 2-3 weeks before onset of illness (persons who are not sick, asymptomatic), and then for possibly 2-3 weeks after illness onset.
c. COVID-19 death rates are anywhere from 10-50X that of influenza (numbers subject to change as virus detection testing is more available and the extent of infection across the entire population is defined).

So, these are very different viruses, probably mostly because SARS-CoV-2 is “novel” – crossed over from the animal kingdom to humans with no immunity, whereas many people have at least partial immunity from prior flu infections or vaccinations. In years ahead, once SARS-CoV-2 has passage through millions of humans and there is broad immunity across populations, this virus will likely resemble other respiratory viruses in its behavior.

The Pandemic

The biology of SARS-CoV-2 and its behavior in interacting with humans will not be known for months, maybe a year or more. However, looking at the experiences of individual epidemics within the pandemic provides valuable information, useful for dealing with the US outbreak as it is accelerating at exponential speed.

1. There are dozens of countries with exponential growth; all of Western Europe, Scandinavia, SE Asia/ Malaysia, Africa, and S. America.
Italy: A model for us, as a western society. 3 ½ weeks ago, there were only 3 cases; now has the highest number of cases outside China- 15,000 cases and 1,000 dead by 3/13/20. 25,000 by 3/16.
By 2/20/20, all healthcare workers were on continuous work shifts.
By 2/23, there were 76 cases.
By 2/25, there were 229 cases. Officials were behind in testing 7-10 days.
By 3/3/20, 10% of medical workers in Lombardy were infected.
From 3/1-3/11, between 9-11% of hospitalized patients went to the ICU.
On 3/8, the extraordinary measure of mandating quarantine of 60 million citizens was imposed. On 3/16, the decision to not offer ventilator support to anyone 65 yrs-old or older was implemented.
In Italy, COVID-19 cases have been doubling each week.

Asia: China’s extreme societal lockdown stopped exponential growth by the end of January. Japan, Singapore, Thailand, Taiwan, and Hong Kong were hit by SARS in 2003, and so learned about exponential growth; so they did lockdown earlier with COVID-19, holding the epidemic below exponential growth.
Note, when Wuhan, China thought it had 444 cases, it had 12,000 (27X more).
With COVID-19, the case numbers are always far under-estimated because of asymptomatic incubation pre-illness onset.
80% of COVID-19 cases are mild. 20% will be hospitalized and 5% of cases will go to the ICU.
Average doubling time for SARS-CoV-2 is about 6-7d; meaning after 11 doubling times (about 2 months), 500 cases would become 1 million. We must appreciate the explosive nature of this virus over a short time.
With the average time from illness onset to death being 17 days, and if there is a 1% mortality rate, then when 1 person dies, he probably was infected 3-4 weeks before- during that time there were 99 other cases (as he is the 1%). With a COVID-19 case doubling rate of 6 days, the numbers compound and that one person’s death suggests there are 500-1000 cases along with him.

Containment/Mitigation

Containment is impossible. COVID-19 now is endemic to America- “community-based” cases, unrelated to travel or exposure to travelers. With the entire country involved and the Italian COVID-19 track-record, we can only POSSIBLY SLOW the inevitable progression through our populace.
Slowing the pace of the outbreak is the strategy of “mitigation”. It is described as “flattening the curve”- the graph of new cases emerging. An analogy would be taking a 50-ft high tsunami and breaking it up into five 10-ft waves, hitting the shore in spaced apart succession. The idea is to allow an orderly processing though our healthcare system within the staffing, hospital bed. and medical equipment limits of our medical system. Should the illness load hit over a short period, say a month, as in Italy, rationing would be the dreaded necessity- deciding who gets admitted to the hospital, access to an ICU bed, or placed on a ventilator… or dies. That has been happening in Italy.
This is why what seems like overreaction and drastic measures across our society are being put into action. The tsunami is visible on the horizon and the near beach water is being sucked out to sea. Leadership realizes to hesitate or equivocate is likely an incomprehensible disaster.
If people are separated (“social distancing”), infections will occur, but at a much more controlled rate as they return to their normal lives, spreading out the case load over 2-3 months. There is hope that SARS-CoV-2 will be harmed by higher ultraviolet light levels and warmth as we head toward April, as is the case with some other respiratory viruses. Also, some such viruses that spread by airborne aerosol droplets (coughs, sneezing) do not spread as easily with high humidity that carries the droplets to the ground in a shorter distance (6 feet for SARS-CoV-2). We can expect such humid Gulf of Mexico air to move into Houston by April.
If the transmission rate decreases by 25% by social distancing, the case curve would flatten and delay the epidemic peak by 14 weeks; decrease by 50%, and the peak delays by 3 months and is much smaller.
Social distancing used too late with the 1918 Spanish Flu in Philadelphia caused 260 deaths/100,000; used early on in St. Louis, 50 deaths/100,000.

Healthcare System

We have about 160,000 ventilator machines in the U.S. As a novel virus, if SARS-CoV-2 paralleled the 1918 Spanish (Novel) Flu Pandemic, about 740,000 would need ventilators to have a chance to survive the illness.
The U.S. has 2.8 hospital beds/ 1000 people-less than Italy (3.2), China (4.3), and S. Korea (12.3.) … all of which struggled with SARS-CoV-2.
The U.S. has about 45,000 ICU beds. A moderate epidemic, would require about 200,000 beds; a more severe outbreak, it could be 3 million. US influenza deaths avg 12-60 thousand per year. But pandemic flu in 1957-1958 killed 116,000 and in 1968 killed 100,000. Both of these epidemics would have needed 65,000 ventilators to rescue people from likely death.
And, with COVID-19 cases taking up all these beds and ventilators, there would be collateral loss of life (not counted directly in the epidemic mortality statistics)- others who need the ICU management and/or ventilator: evolving strokes, heart attacks, severe bacterial infections, vehicular trauma, etc.
As we all know, because of the economics of the medical business, our healthcare system is streamlined with only a bit of extra capacity; hospitals are often at full occupancy in normal times. You can see where a crisis across the society could require rationing of care as the existential reality. It is no different than medical professionals choosing who will live or die based on medical futility and best chance of survival on a battlefield.
Currently the U.S. has an estimated 1% of the respiratory masks needed to cover all healthcare workers. And, remember, 10% of Italy’s medical workers have become infected (some fatally) partly due to insufficient protective equipment supplies.
I think you now get it. We are not prepared and cannot make up for it in time to contain this outbreak- only spread out the contagion over time to more closely match medical need to resources–mitigation. Social distancing can show positive effects in 2 weeks.

Conclusions

We must realize what we face. Actions that make sense now (and for continuous review as circumstances change),
1. Serious Social Distancing
a. Schools out
b. Public entertainment and other large group gatherings delayed
c. Stay at home, except for life essential activities.
d. Minimize human contact with those at or above 65yrs-old and/or with serious underlying medical problems.
e. Minimize visitors to elderly care facilities and hospitals.
f. Minimize visits to any medical facilities-physician offices, labs, imaging centers, etc; only appointments out of critical medical necessity for the next 1-3 months.
g. Pharmacies should provide extended medication supplies and consider home delivery.
h. Only essential services open: grocery stores, transportation, pharmacies, medical offices.
i. All medical care providers to adjust workflow communications and operations to achieve rapid access and egress for patients- the goal little or no waiting time in common areas with other patients.
Ignorance and risk uncertainty are the parents of panic and anarchy, primed by unrelenting media exaggeration and, at times, misinformation.
What are the elements of coming through all this with the best possible outcome?

Concern: Yes
Attention/Focus: Yes
Compliance: Yes
Flexibility (course corrections): Yes
Information: Yes
Action: Yes

I am confident that this country can manage its way through this. But, it will be with credible leadership; information transparency; timely, targeted action; trust and resolve; and always, always focus on those for whom we are responsible, while also seeing ourselves and our families as part of and stakeholders in something bigger than ourselves. The Golden Rule always works.

Ed Rensimer, MD
Director
International Medicine Center

 

To Dine or Not to Dine? What to Consider Amid Coronavirus Concerns

Take a look at this article for which I was interviewed on aspects of eating out during a pandemic,

Ed Rensimer, MD

https://houstonfoodfinder.com/news/to-dine-or-not-to-dine-what-to-consider-amid-coronavirus-fears/

 

 

CORONAVIRUS UPDATE 6: FOR THE PROFESSION

Re: Medical Facility Procedures/COVID-19 Containment 3/11/2020

Colleagues,

There appears to be no commentary or direction for those of us on the front-lines of what is a US epidemic within a novel virus pandemic. Aside from my office’s protocol for my staff (attached), I suggest that it therefore is on us to think this through.

Operative word: proaction. Your patients and their families will see you taking measures to protect them as well as your practice’s viability while this outbreak runs its course, and they will be grateful. It is time for the profession to engage.

So, consider the following,

1. Limit all appointments to only those that are time-critical from a medical point of view, i.e. standard of care required and unavoidable in the interests of the patient.

2. Workflow Change: Though this will impact the business, consider the impact if a number of your staff require quarantine. At the intake of a call for an appointment, tell the patient to call your office on arrival so your staff can approve entry to your facility such that there is little or no waiting time in your lobby, shown quickly into an individual exam room. If they are not in acute medical distress, have them wait in the building common areas or their vehicle.

3. Upon entry to your facility, provide a respiratory mask and require hand cleansing with soap and water or hand cleanser with over 60% alcohol.

4. As much as medically advisable, try to keep those 65 yrs and older away from your facility; elective appointments to be put off until we see if the COVID-19 pace and pattern of spread diminishes with warmer weather.

5. Wipe with appropriate cleaning solutions surfaces of likely patient contact after each visit: arm rests on chairs, exam table edges, door knobs, stethoscope diaphragms, BP cuff, etc.

6. Staff to cleanse their hands after each patient encounter.

7. Check-Out: Staff to cleanse their hands, pens and counter areas after each check-out financial transaction and appointment re-scheduling encounter.

8. Staff to wear masks.

9. Advise patients to avoid crowded elevators, or to cover their nose and mouth (?handkerchief) when in one with others, on their way to see you.

Previously, the focus for isolation/distancing measures was on anyone with respiratory symptoms and/or fever. Now, knowing the incubation period from time of virus acquisition is up to 14 days, and that many will not be ill but shedding virus (as well as post-illness shedding of virus for another 10 days, or more), everyone is an exposure risk. Now that there have been “community-based” cases, travel history is irrelevant with respect to COVID-19.

The basis of these ideas are the facts on the biology of COVID-19 as they are emerging as well as the nature of our practices and how they interact with the community. From an epidemiological view, physician offices and other medical facilities (diagnostic laboratories, hospitals, surgery centers, elderly living facilities), congregate and concentrate the most at risk protoplasm in the society and those at most jeopardy for serious illness and death—those 65 yrs-old and up. How much and what you decide to do will be customized to your practice environment and services.

We need to be thinking this way and we need to look at our patient populations, our services, and our physical plants, and then be the professionals and leaders our patients and communities expect and rely on us to be. We treat patients, but, cumulatively, we treat society. Inarguably, measures taken by the medical community to diminish spread within their workplaces will be the most impactful on this epidemic because our clinics are where the rubber meets the road on contagion. We do not want to become Italy.

Feel free to share this and anything else I have written with your friends and colleagues and even patients (who might bring these ideas before their other healthcare professionals). My email list is limited,and I hope this information is disseminated. It is all posted on my websites:

traveldoc.com

rensimer. com

Call me anytime with questions or ideas that I would be glad to consider as part of future bulletins.
I hope this has been useful in getting all of us thinking about our personal professional circumstances. Cliché though it may be, we are all in this together.

Ed Rensimer, MD
Infectious Diseases
Director, International Medicine Center
Houston, TX

Coronavirus (COVID-19) Update 5: 3/11/2020

The epidemic is accelerating, as expected, and it will do so over the next 1-2 months, at least. We will find hospitals over-burdened, even possibly without enough equipment and other resources to treat the deluge of seriously ill patients if community-based containment measures fail.

The only thing that will after this trajectory (note what is happening in Italy), will be investment by each citizen and every medical professional in conscious awareness of and action on containment efforts.

Things for you to do,

1. Every family member cleansing hands (soap and water for at least 20 seconds of all hand surfaces, or a hand cleanser with at least 60% alcohol) every hour if possible when outside the home.

Even without human-to-human contact (within 6 feet of a coughing individual or direct physical contact), COVID-19 can be picked up from contaminated surfaces—elevator buttons, phones, credit cards, chair arm-rests, steering wheels, you name it.

So, we should all be carrying hand cleanser with us.

2. Avoid touching your eyes, nose, or mouth with your hands.

3. Avoid visiting elderly people or those with serious pre-existing medical problems or on immune system-compromising treatments.

4. Medical Appointments: See my piece on “Medical Facility Procedures/COVID-19 Containment”, 3/11/2020. Take action, as a patient, to follow the “Workflow Change” principles with your physicians’ offices.

In fact, copy and share this commentary with your medical professionals, or direct them to these updates on our websites, traveldoc.com or rensimer.com. Disseminating this information as widely and quickly as possible and putting the recommendations into action are critical to containment, the only game in town for the foreseeable future.

5. Respiratory Masks: Consider any mask you can get, optimally an N-95 mask, for any closed-ventilation spaces, when gathering with others is unavoidable, such as airline flights, business meetings, school classes, etc; certainly if anyone in your group exhibits respiratory symptoms (cough, runny nose, sore throat) and/or fever.

Note: Children, by the Chinese experience, comprised only 2.4% of all the COVID-19 cases, so they appear naturally resistant to infection. However, as with hepatitis A, they very well may not be usually clinically ill when infected, but may be an exposure risk for adults from their asymptomatic virus-shedding. With respect to hand cleansing, children need to be included.

Edward R. Rensimer, MD
Infectious Diseases
Director, International Medicine Center
Houston, TX

 

COVID-19 Update 4: 3/9/2020

Prudent Personal Actions

Well, as had been apparent, coronavirus (COVID-19) is here, in most US states, soon to be in all. The experience in other countries indicates we will see exponential spread and many who are not clinically ill are shedding and spreading the virus now.
So, what should you do? Listen to all your personal “wish-system” that it is really nothing? Listen to political leaders who always and in every country, including ours, withhold communicable outbreak information or spin it to soften the impact in order to keep public order and economic stability?
What is known?

1. COVID-19 is highly transmissible, both before and up to 2 weeks after clinical illness.
2. Risk for a deadly outcome is mostly in those over 65 yrs-old, especially with pre-existing medical problems.
3. Transmission is by aerosol (coughing) up to about 6 feet and acquiring the virus off contaminated surfaces with self-inoculation of the nose, mouth, or eyes.
4. It is unclear what is COVID-19’s ability to mutate—into worse or less worse form—but, as with all viruses, the more passages through humans, the more chance for mutation.
5. It is unknown whether seasonal warming will diminish COVID-19 activity and so its spread.

So, our goals should be to avoid the virus and to be part of killing this outbreak.
Common sense measures,

1. Become a homebody for at least the next month.
2. Wash your hands with any public exposure or activity at least several times a day, if not every hour—soap and water, thoroughly, or with a cleanser with 60% or more alcohol content.
3. Spend no time with anyone with respiratory symptoms and/or fever—runny nose, sore throat, cough.
4. Try to have business or other meetings by phone or other “distancing” methods.
5. Medical Appointments/Procedures:
Avoid them. Re-schedule unless an appointment is absolutely medically necessary. There should be no “wellness” exams.

Medical facilities, particularly physicians’ waiting rooms, are shared ventilation spaces where ill people congregate, sometimes for long periods. Obviously, the elderly are disproportionately present, often moving from doctor office to doctor office, through emergency rooms, through medical testing facilities—they are an intensely medicalized subculture. All of this, when you think of it, magnifies the risk of cross-pollination with COVID-19.

Our office has patients don respiratory masks and clean hands upon entry. Patients with respiratory symptoms or fever are shown directly to an exam room, not to sit in a public area.
a. If elderly, call your doctor’s office ahead so that you can go directly to an exam room on arrival (wait outside until they call you on your mobile phone).
b. Wash your hands on entry and at departure from the office.
6. Avoid visiting elderly people. Call them or see them through FaceTime. If it is necessary to physically visit, avoid physical contact, and wash your hands on entering their physical space.
7. Respiratory masks are probably overkill, except in medical facilities or in prolonged, close quarters in close-ventilated spaces, such as an airliner.

There is no reason to panic. But, that is not permission to disregard what is happening before our eyes around the world and which is about to rapidly escalate here. Denigrating concern, anxiety, and responsible action in an evolving, widespread epidemic is just a form of condescending arrogance, willful ignorance, and blowhard bravado in a situation about which there are serious gaps in important information. If we all take part in pro-action to thwart the spread of COVID-19 and it turns out to have minor impact on the US, then we acted responsibly for our community, our loved ones, and ourselves. For that, we should be commended, not criticized.

Edward R. Rensimer, MD

Director

International Medicine Center

 

Coronavirus (COV-19) Overview/ Update 3: 2/28/20

It’s Here. What Do I Do?

Yes, COV-19 is now in the U.S. Do I deal with the information, or just duck it and go about my life, obliviously? The immediate answer is based on your life’s pragmatic philosophy on how you choose to deal with the inevitable “rough water.” For me, information is everything. It allows me some sense of control and to assume my natural optimism – that I have always and will always get the best possible outcome for the circumstances. Maybe not what I had wished, but the best that could be had.
So, what’s the overview and the bullet-point facts?

1. In a totalitarian society (China), where people can be forcibly locked into quarantine, beaten and imprisoned for not wearing face-masks, and entirely restricted from public assemblage and getting around, COV-19 has spread at breakneck speed. So, it is highly and casually (no intimate contact) transmissible.

2. Though we think the time of exposure to onset of illness is about 2 weeks, we don’t know, because we are basing our conclusions on Chinese data, subject to the propaganda filters of that regime.

3. COV-19 infected individuals who are not overtly ill can spread it.

4. We have no idea how long people shed the virus after the illness subsides. Ebola virus has been found in survivors’ tissues months to a year after being well.

5. We yet have no idea whether having had COV-19 immunizes a person against future infection.

6. Again, we have no idea of the real death-rate from COV-19, because there have not been enough cases outside China to compile statistics on deaths vs. the total number of diagnosed cases that are reliable.

7. We do not know if COV-19 mutates or changes to weaker or stronger ability to cause disease (virulence) as it passes through more and more human hosts (as does flu).

Think about it. We are an open, free society where we take for granted our mobility and rights to congregate. However, in an highly controlled and restrictive Chinese societal model, COV-19 could not be contained.
Some are saying it is not inevitable that we will have a widespread outbreak, a U.S. epidemic inside a worldwide epidemic, i.e. a pandemic. With all the facts to date, this seems implausible, though I hope to be wrong. At least, if COV-19 is heat-labile, perhaps it, like influenza, will wane as we get to mid-April and warmer days. However, that is yet unknown. A rational person should count on at least an abbreviated, but serious, epidemic over several months.
So far, those at most risk for death are 65 yrs and older, usually with serious, pre-exisiting medical problems. Not so comforting for those of us up there.
Alright, I’ve given my overview. It should be apparent that, now that there has been one U.S. case not directly associated with or imported from an affected country, the cat is out of the bag. There must be a number of unsuspecting U.S. citizens incubating the virus, and then more and more. There is no public health measure that can effectively stop propagation through the populace when you cannot always know who is carrying and shedding the virus. And, without entirely closing entry to the U.S., COV-19 will be imported from France, Italy, Brazil, Russia… from everywhere and anywhere.

But, though we cannot prevent it, we can minimize it.
What, right now, should you do?

1. Keep up on announcements on COV-19 based on developing information from western societies (from which we will develop factual information on transmissibility, virulence, and mortality rate); but always be aware that public officials (regardless of political party) are prone to censorship in war and other national crises, to allay panic and societal disruption.(cdc.gov)

2. Minimize exposure to large groups of people.

3. Avoid anyone, family, friends, neighbors, co-workers, classmates with a respiratory illness.

4. Have no contact with anyone who has traveled overseas, for at least 14 days.

5. Wash hands frequently and thoroughly.

6. Avoid casual physical contact with others (handshakes, etc.)

7. Do not send your child to school or other group settings if they have a respiratory illness.

8. If you develop a respiratory illness, warn your healthcare providers that you wish to be seen, but tell them you wonder if you should and/ or their staff should be “masked” at the outset of the encounter, before entering their facility; that includes urgent care and emergency facilities- protect the healthcare professionals by “The Golden Rule”. We’re going to need them alive and working.

9. Focus on activities away from others- be more a homebody the next couple months.

10. Emphasize exposure avoidance, awaiting the possibility of anti-viral medication treatment possibilities and potential vaccine development.

11. I have been asked whether public venues, such as fitness clubs, should be screening arrivals for fever. It can’t hurt, but the COV-19 problem is all those walking among us shedding the virus for days or weeks before they become ill, if they become ill at all.

The government alone cannot achieve control in a country like ours. We need to take personal responsibility to keep level-heads, to be informed, and to adjust behaviors until we get through this. And, hope for an early, warm Spring.

Ed Rensimer, MD

 

 

CORONAVIRUS UPDATE 2: SEEKING EVALUATION FOR CORONAVIRUS (COVID-19) 2/12/2020

You’ve recently traveled to a place where coronavirus cases have been diagnosed. Now, you have developed fever, cough, shortness of breath, and/or diarrhea. From your reading, you know coronavirus is a consideration.

What do you do?

1. Call your local hospital Emergency Department and ask if their lab is equipped to send specimens for COVID-19 testing.

The point of this is your doctor’s office cannot collect and process specimens since there are complex rules for safely packaging and shipping such infectious samples, and they must go at least to the state health dept. lab, or interstate to the Centers for Disease Control in Atlanta, GA. Individual practices are not set up to do this until local labs are able to do the testing; at which point specimens need not be shipped.

2. Tell the ER staff you need evaluation for COVID-19 and ask what is their procedure for seeing you while minimizing risk of exposing others (their staff and other patients) to you.
a. Likely, they will tell you to call on your mobile phone when you arrive outside their facility, so they can meet you with a respiratory mask before you enter.
b. Such a procedure is necessary to not expose unaware medical staff or other patients to COVID-19. And, a facility not handling this with a rigorous, clear procedure might find itself shut-down by public health officials, should a COVID-19 case be diagnosed after-the-fact. Your doctor does not want this, nor does a hospital Emergency Department.

3. Until you are seen by a physician, separate yourself from others-
a. Do not go to public gatherings: shopping areas, schools, church, etc.
b. If you can procure an N-95 respiratory mask (medical supply stores, Home Depot, etc… Google it), do so.
c. Wash your hands frequently, but optimally have no physical contact with anyone.
d. Cough into your bent arm if you haven’t a kerchief.
e. Drive yourself- no passangers.

4. Alternatively, you can call your county or state health department to get directions on where best to go for evaluation and testing. Your primary care doctor will not be able to handle this situation at this time, as testing is not available through his/her routine laboratories.

Finally, realize that influenza is much more likely to account for such illness in the U.S., at least until about the end of April.

Edward R. Rensimer, MD

Director, International Medicine Center

Houston, TX

Copyright, E. Rensimer, MD, 2020, All Rights Reserved

CORONAVIRUS UPDATED 1: 2019 NOVEL CORONAVIRUS (COVID-19)
China Origin 1/30/2020
FACTS TO KNOW/ PERSPECTIVE

COVID-19 is an apparently “novel” respiratory virus that emerged in Wuhan, China and spread from animals (?bats) recently to cross-over to cause disease in humans for the first time. That is what makes it “novel”, and so more dangerous as there is no broad-based immunity in the human herd from infection in prior years (such as exists with influenza viruses from past vaccines and infections). As such, the conditions exist for rapid spread widely, across large populations. How deadly it might be is not clear as of yet and relates to the COVID-19’s “virulence”, or ability to cause destruction in tissues and to invoke an immune response, which can destroy tissue (see the “Spanish Flu” of 1918). As the virus passes through humans, it can mutate such that virulence and transmissibility can increase or decrease, strengthening or weakening the ability to cause serious disease or death. It is a slot-machine model on which way that goes. If everything lines up, you have a worldwide pandemic. This is why you are seeing urgent public health bulletins from the CDC, the main goal containment to minimize passage through human bodies and so the risk of mutation and evolution to a more ominous disease agent. The news media, on the other hand, hype everything for market share. Realize that paying attention to this is being responsible, without assuming a position of emotional distress or outright panic. Maintain rational balance as information develops to inform your actions.
The other relevant facts are that there has been a COVID-19 case with dramatic inflammatory lung infiltrates in a person who was exposed (and so presumed contagious), but with no symptoms of disease or illness. Additionally, it appears that COVID-19 has an incubation period (virus acquired but the victim not yet showing signs of illness) of several to 14 days. Both situations mean you could be exposed and at risk for illness and not know it.
So, what are reasonable conclusions at this time?

1. Travel: If planning travel to or through areas where there has been widespread COVID-19 illness, it would be prudent to delay such travel.

Public health and political officials often craft propaganda during outbreaks to stabilize social and economic volatility over the specter of widespread, communicable illness. So, you must weigh the information at hand as possibly the tip of the iceberg. Officials tend to bleed bad information out gradually, in small doses, to calm the populace. As such, you could find yourself on a trip and,

2. Your itinerary is totally disrupted because of barriers to transportation and public health prohibitions.
3. Large public gatherings are prohibited (quarantined), such as at tourist spots, restaurants, retail centers, etc.
4. Healthcare resources are overwhelmed (just as you become ill).
5. Airports are shut down or travel directed to chosen airports (out of your way).
6. Quarantines are imposed on travelers attempting to return to the U.S. until a 14-day incubation period has expired without evidence of illness.
7. You become ill and must engage a foreign healthcare system, with all that that implies. Be aware, most people who can afford travel to exotic places are probably over 50, usually over 60. The majority of deaths from COVID-19 have been in those over 65. Not a good set of facts.

What to do if you must go?
1. Take an N-95 respiratory mask.
2. Take hand cleansers (60%, or more, alcohol concentration); soap and water.
3. Avoid close contact with anyone with respiratory symptoms or fever (6 feet or more distance).
4. Avoid spending prolonged periods of time in closed, shared air-spaces with others, especially groups.
5. Take a thermometer and medication for fever, body aches, nausea/vomiting, and diarrhea; possibly a respiratory tract infection antibiotic for bacterial infection secondary to the preceding viral infection.
6. Review your health insurance and obtain a temporary supplement for international travel. Medicare does not cover overseas medical care. Hate to say it, but if you are over 50, consider a medical air-evacuation policy and policy for repatriation of remains (death).

Finally, if you return from a country with COVID-19 activity and develop a fever-associated or respiratory system illness (fever, cough, sore throat, and/or shortness of breath), seek prompt medical evaluation, but wear an N-95 respiratory mask (can obtain at a pharmacy or medical supply store) and warn your doctor, the urgent care center, or emergency department staff that there may be a concern for COVID-19 so they can take measures to protect themselves and their facility (from Public Health closure). Also, put yourself on quarantine from family, friends, and co-workers.

Edward R. Rensimer, MD

Director, International Medicine Center

Houston, TX

Copyright, E. Rensimer, MD, 2020

COVID-19 PANDEMIC/ AMERICA’s FUTURE

The dialogue is on-going. Do we keep everyone, except for designated critical societal functions, out of work until we can assure no one will catch the virus and maybe die, or do we, at some point during the outbreak, substantially re-populate the workforce and get America back to work? But, what if people die? Is the President then blameworthy because he chose a buck over a life? At least, that’s the crass way the media, which mostly revile President Trump, have framed the problem. He is forced to let the economy unravel or be a deliberate murderer… a callous, stone-cold-hearted businessman.

How about, in order to properly wordsmith the dilemma, we exercise some empathy? You know, put ourselves in that position of leadership and see the situation from there; feel what he feels. And, one step further, ask ourselves what we would decide to do and how we could live with it?

You keep the populace at home, binging on NETFLIX ad nauseam, doing crossword puzzles, and napping, until they can barely do it anymore. But, you stay the course. A month, two, maybe three. By that time, millions of small businesses (99% of the businesses in our country are “small”) have shuttered, never to open again. Mortgages have defaulted. Retirement savings lost. Careers side-tracked, on hold, maybe ruined. Families wondering where next week’s meals will come from. Homelessness rampant. The elderly left without support… with the broad, middle-class taxes gone (out of work), no revenues coming into the US Treasury to fund Social Security payments or Medicare. For that matter, no funds for the military budget. Oh, yeah, this is a national security situation, that our enemies are loving. And, maybe the U.S. is defaulting on its loans. Now, with so many out of work, no one has money to support (by spending) the remaining businesses. So, maybe Amazon, Google, Tesla, United Airlines and Hilton Hotels are facing default and collapse- and their thousands of workers out of jobs. Who comes to the rescue? The federal and state governments are in arrears with no money coming in.

You have societal breakdown. Then what? Social disorder. Anarchy.

Be clear the media and presidents political opponents are putting him on the spot to not be a murderer with their questions. Why? They don’t want all of this. But, they do want some of this. Just enough for a recession to kick him out of office- the only solutions for his 3 years of success and an unprecedented economic boom that would re-elect him, since all they have is a cognitively incapable candidate and a Marxist as contenders. Problem is, no one knows if you let this genie out of the bottle that it can be controlled or limited. Bill Maher, a well-known liberal TV host, mused just that in the past year. That what we need is a “good” recession. That was the only way to get the Left back in the White House. Of course, rich and entitled, he would never lose his house or retirement accounts in a downturn. So, getting the power back was worth some terrible suffering and disruption… of others’ lives.

Why is this relevant? Because it is what underlies the questions of media in the Rose Garden at the daily COVID-19 press conferences with President Trump’s Pandemic Task Force. Can he guarantee no one will die if he sends folks back to work a bit early? It is a set-up.

Does anyone realize that if he sends people back to work too late, all the above can happen, and fast? What if he sends them back to work and some people die? The answer is, either way he goes, people die. The key is it cannot be put on him. Decisions must be made and people will die. Is this any different than wartime? We decide the country’s future is at risk, we conscript young people, and we train them to fight and die. Then we ship them off, knowing a good percent will not come back. If you are not comfortable with this you cannot lead, or be in a position where your decisions can impact a person’s longevity or even result in pre-mature death- like a physician. We physicians get all of this. It is not easy. It is not for the disinclined. It hurts. But, it cannot incapacitate you and you must be able to live with it. There will be losses. There can be no losses. Your job is to get the best outcome in a bad circumstance; minimize losses. And, live to fight another day.

Current political leadership has a responsibility to every single American and to the reality of America – e pluribus unum. From many, one. Each of our ultimate responsibility is to something bigger than ourselves, to our way of life, which is America.

So, what are the steps?

1. A substantial interval of total societal pandemic suppression by self-imposed quarantine– only those at work who do life and societal essential services- probably a month.

2. Continue all those at home for a month or longer who can carry on at home without loss- such as students on home study.

3. Absolute quarantine of all COVID-19 high-risk for death groups- over 65 yrs-old and those with medical problems.

4. Somewhere around 4-6 weeks into suppression behavior, send low-risk for serious disease people back to work,
a. Those industries most vital to economic resurrection
b. Areas of the country not currently epidemic “hot spots” for disease activity
c. Continue mitigation behaviors across the society- masks, handwashing, social distancing.

5. Accept the premise of herd immunity as a goal- that we hope to let the virus infect those unlikely to die or to end up in hospital. We want infection to immunize the general low-risk population (ultimately the students, too) so that there is much less risk of resurgent epidemic waves of disease as we restart our society. Use the SARS-CoV-2 virus as the vaccine.

This approach should “flatten the curve” to match numbers new of illness cases to available medical resources (physicians, nurses, hospital beds, ICU beds, ventilators, medications), so we avoid horrible rationing decisions and we break the 50-foot tsunami pandemic wave down to five 10-foot waves.
It is critical, though, that there is a consensus that we will have rational expectations- that some of us will die, in the name of an American way of life for the generations of our children and grandchildren that will be our legacy. No different than what many Americans before us did on beaches and battlefields, not even having kids or grandkids. Let’s join with our president and his Administration leadership to tell them we are with them to rebuild the American Dream, not to point fingers, to blame- – let’s put politics on hold. We’re better than that. We’re Americans.
Now, how do we get this rhetorical language and content to the President of the United States?

Edward R. Rensimer, MD

Infectious Diseases

COVID-19 Pandemic: Natural Solution

HERD IMMUNITY: Natural Solution for COVID-19 Pandemic

This past week the COVID-19 Response Team at the Imperial College London, published a critical report, “Impact of Non-Pharmaceutical Interventions (NPIs) to Reduce COVID-19 Mortality and Healthcare Demand.”, they ran computer simulations to project the effectiveness of NPIs (social distancing, isolation, quarantine, and lock-down of public venues and workplaces) in diminishing and containing COVID-19 in the short-term as well as into the months ahead when, for practical reasons, such interventions would need to be relaxed or stopped.

Suppression: The goal is cessation of new disease, stopping it.

Mitigation: The goal is blunting the exponential trajectory of new cases such that the straight-up curve is bent horizontally, ultimately downward toward no new cases. Mitigation is controlled occurrence of new cases to try to match case volume to healthcare resources, such as general hospital and ICU beds and staffing to achieve optimal survival numbers. The goal is management of the epidemic to spread it out over time, but not immediately ending it.

Both approaches have their problems. All out suppression may kill the epidemic, but also the “economic and societal patient” with the cure. If it continues for more than a couple weeks, the damage to people’s lives may be devastating and irreversible , for at least a long foreseeable future. COVID-19 causes literal death in probably 1% of cases (this figure subject to change with broader virus testing). However, the loss of a business, a home, retirement savings, a career path, and so on, is a virtual or figurative death. Furthermore, such disruption or even destruction of our American societal model is a national security matter. If a substantial segment of the tax base (the middle-class) is out of work and now financial entitlement dependent, there is no revenue coming into the treasury to support the military, Social Security, Medicare… you get it.

Looking over these data, I have reached a conclusion. A number of facts support it as the solution to this pandemic, which I will detail further on. The solution is a new goal- deliberate herd immunity. This goal embraces suppression and mitigation strategies in a hybrid model, and uses NPIs in a timed way to preserve the foundations of our economy and society while managing the ongoing contagion.

In a word, the concept of deliberate herd immunity is to use SARS-CoV-2 virus as the vaccine. Use the virus against itself. Our problem (as is, by definition, the case with pandemics) is this is a “novel” virus- one to which the human race had not been previously exposed. So, there is no immunity worldwide to it. Once we get through this initial epidemic, it will no longer be “novel”. Most will have survived (about 99%, by current figures), and, though there will likely be future uprisings of SARS-CoV-2 again, those events should be more like seasonal influenza outbreaks.

So, the premise is simple, but somewhat counter-intuitive. What I am suggesting is that, in a deliberately constructed plan, we run toward SARS-CoV-2. Embrace it so that it passages through the majority of our low-risk population while they are at school, at work, conducting their lives. Once a majority of the society is immunized (the “herd”), the virus has very few places to go and so the risk of the virus to the high-risk minority is less. If 70% of 238 million Americans are infected (Germany recently estimated that number for its country), a 1% mortality rate translates into 1.65- 2.2 million deaths; 1.65 million directly from the virus, the rest from non-COVID-19 collateral damage deaths.

But, if you can immunize with the virus the 84% of the population under 65 yrs-old, then the remainder is 52 million people; 1% of that group infected is 520,000 deaths (compared to 1.65-2.2 million). DHI would be effective.

And, the answer is in front of us. Let nature take its course. Run toward the virus in a planned and tightly controlled way.

Mitigation can never completely protect those at high-risk from severe disease or death, but many of those would likely have succumbed anyway. You are trading off that reality for a preserved social and economic order. It sounds cold, but an apt analogy is war. We have conscripted young men to send off to battle, accepting that many will never return. This is done when the country is at stake. This is no different. This is war.

The Plan

1. Complete Suppression (early in epidemic to decrease chance of healthcare system overload)
– 2 weeks across the society (the incubation period of the virus)
– 4 weeks for those who can sustain it economically

2. Mitigation
– 3-5 months
– Return to school/universities in 2-4 weeks
– Return to work in 2-4 weeks (unless able to substantially work at home)
– Public venues (restaurants, small business, entertainment) open in 2 weeks

3. High-Risk Group Carve Out (65 yrs and older, serious pre-existing medical conditions, and immune-deficient individuals)
– Strict suppression NPI until epidemic gone.
– Organized supportive services to elderly (≥65 yrs old) by family, social services organizations, churches, etc.
– Telemedicine virtual visits with treating physicians
– Pharmacies providing extended prescriptions of maintenance medicines and home delivery service
– Only the elderly with critical jobs, such as healthcare professionals should be exempt.

4. Shut-down of mass transit for the foreseeable future (until a clear change in the new case curve downward), accounting for the risk of social crowding and picking up the virus from contaminated surfaces.

5. Healthcare System Suppression: currently measures to control the virus in even major urban medical center hospitals are cosmetic and inadequate. Taking the temperature on arrival of staff and visitors for entry is worthless. Most people coming to a hospital are feeling well, or likely would not go there. All infections cause fever 1-4 times per 24 hours, each in a short period of time. So, a spot temperature reading has no value as a screen for entry. Yet, both hospitals and immigration officials at airports are doing this; suggesting fundamental ignorance of infections or a deliberate “window-dressing” attempt that something is being done. The government needs to impose strict directives on hospitals as follow,
a. No visitation
b. All hospital professional and support staff screened for SARS-CoV-2 every 2 weeks as a condition for work-fitness (not currently being done);
c. Strict mitigation procedures by all hospital professional staff and support workers, not just those attending infected patients in isolation rooms. Masks, handwashing, social distancing. (not currently being done)
Understand this, the healthcare system, its workers and facilities, is the epicenter for the spread of SARS-CoV-2. These workers currently come to their shifts, physically handle the sickest in our society, and then go home to their families. In the hospitals I have been in recently, the staff are going about their duties with no change in behavior anywhere close to what the general population is doing. It is as though they think there is a special exemption from SARS-CoV-2 once you enter a medical building. I suspect they rely on hospital leadership to adequately supervise infection control measures. The government needs to focus its most intense efforts on providing personal protection equipment and mitigation rules of conduct across the profession, inpatient and outpatient. The healthcare system should be the role model for the broader society. It is where the rubber meets the road in a pandemic.

6. Pregnancy: For now, there is no definitive information on SARS-CoV-2 and a fetus. Until more science is developed, it would be better to practice contraception until the pandemic is behind us.

7. Post-Illness Isolation: 2-4 weeks, with 2 negative tests to assure virus is gone.

Conclusion

This proposal puts a suppression hard brake on contagion, then the mitigation phase carves-out the high-risk groups as a special circumstance, then returns the majority of active, productive people to their lives to pass the virus through the population to self-vaccinate with the virus. If herd immunity becomes widespread and endures, new cases and deaths will decline, probably over 3-6 months. Counting on a vaccine is unreasonable.

Be clear, the deliberate herd immunity premise has risks and unknowns. It is not certain that SARS-CoV-2 infection generates enduring immunity. However, the original SARS virus appeared to have provided immunity for at least 2 years in immune-competent individuals, and it is reasonable to assume it is analogous to COVID-19. Mortality rates below 65 yrs-old appear to be 0.2-1.3%, down to 10yrs-old, below which there have been no deaths after a worldwide total of 375,000 diagnosed cases. And those numbers will come down once we have testing to enumerate all those with modest or no symptoms who have not yet been measured. The death rate in those under 65 yrs-old might approach the 0.1% rate of seasonal flu- a reasonable trade-off for not destroying our country’s economy. Asking the American people, most especially the elderly, to put their lives at risk to save the country is no different than the sacrifice we ask of our young military in wartime, except that those at the most risk from COVID-19 have lived the majority of their lives and are focused on their legacies- their families coming up behind them. And their risk is likely about 1% for death, probably far less than that of a 20 year-old serviceman going to another type of war. I think there would be unanimous concensus by the American people, especially the elderly, that this is the right thing, the way to go.

If enduring herd immunity does not result from the experiment, what have we lost? But, we may have gained our lives and the future of our country.

This approach is a rational process of using the power of information to manage the pandemic, but also to the long-term critical foundations and interests of the country, and so of each of us.

Edward R. Rensimer, MD
Infectious Diseases
Director, International Medicine Center
Houston, TX

Coronavirus Walk-In Testing Center

‎‍Walk-In Coronavirus (SARS-CoV-2) Testing

International Medicine Center

9230 Katy Freeway, Suite 400

Houston, TX 77055

We are suspending COVID-19 screening tests until we clarify whether Harris County Health Department has regulations over where and how such testing can be performed. We regret any inconvenience to you and if we can re-open our site we will post that ASAP.

Edward Rensimer, MD
Director
International Medicine Center

Our facility is offering expedited, walk-in (no physician visit needed) testing for SARS-CoV-2. We prefer to do this with a brief appointment so that we can manage workflow in our facility as well as to minimize exposure of all involved to each other. The aim is minimal or no waiting time here.

Procedure,
1. Call our office to request testing and to set-up an appointment.
a. To receive an appointment time, you must email us our short form request for a testing appointment “Coronavirus-19 (SARS-CoV-2) Walk-In Testing Intake Form” (see attached)

Coronavirus-19 Walk-In Testing Intake Form Order Sheet

Send to: imc@traveldoc.com

2. On arrival at our building, call us again so we can instruct you on when to enter our office, at which time you will,
a. Be asked to clean your hands.
b. Fill out a brief form (If not already done online and forwarded).
Our staff will meet you at our side entrance (not the main waiting room glass door; knock on arrival), where the specimen will be taken and you can then go.

3. When results are back, we will call you (expect 3-5 day turnaround); consider self-quarantine while results are pending.

4. If physician consultation is desired, notify us so we can set up a formal appointment.

5. Charges: Administration/Case Eval: $150
Lab Test: $51.31 (the lab will bill you; we cannot guarantee this test will be covered by your insurer).

6. If you have a positive test,
a. Immediately self-quarantine.
b. Inform all those with whom you have had ongoing close contact (household contacts, co-workers, schoolmates, etc) of your test result and advise them to be tested ASAP.
c. Contact your personal physician for further direction.
d. Both the lab and we will report your result to the U.S. Centers for Disease Control and Prevention.

Edward R. Rensimer, MD
Director
International Medicine Center