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Covid Blog- Herd Immunity Orange County

By editor
April 19, 2021

A farmhand was helping the farmer with his herd of cows. The farmer asks, "How many cows are in my herd?"

“49,” says the farmhand.
"Ok then; round them up!"
"Ok,fine! You have 50," says the farmhand.
 
Now that I have you trying to figure this out, I will do something totally out of character for me. 
 
I will make a prediction. About Covid. 
 
This is risky because all the predictions about Covid by experts, epidemiologists, the CDC, WHO, and even the Geico Lizard have proven wrong.
 
For example: 
-It wasn't like the flu. 
-It didn't end in warm weather. 
-It didn't burn itself out after a year. 
-It didn't only kill frail seniors and diabetics.
-And the vaccine was not at all a piece of cake.

 
So here is the senior cynical doctor’s prophecy:

We will reach herd immunity this year. In 2021.
 
As a matter of fact, I see it by Halloween. Maybe even Labor Day.
 
When I say herd immunity, I mean enough people will become immune to Covid, rendering its spread unlikely. As a result, the entire community will be protected, even those who are not themselves immune.
 
A disclaimer, I am not the only forecaster to make this projection. But I do firmly believe it.
 
In January, as I was couch bound recovering from Covid, I spent time with my iPad aimlessly surfing. I started doing the math, and as the data is now more solid, the facts speak for themselves.
 
It seems the government experts are trying hard to downplay this scenario. It makes sense-they don't want us complacent. Ripping our masks off. Filling up restaurants. Just in case we NEVER reach herd immunity. 
 
Remember, these are the same people that said antibodies will not protect us.
And no test of cure is needed.
And only get tested if you have symptoms.
And that we need to close our schools,,.no I mean open the schools,,.no close...no....you get the idea. 
 
Now I have an alternate theory. 
First, I would like to pay homage to Monty Python and the genius of John Cleese. If you haven't seen it, please You Tube the “Pythons Ann Elk” skit on the theory on Brontosauruses.
 
Here is my theory  
AHEMMMM!
 
My theory--which belongs to me--is as follows...
 
This is how it goes--
 
The next thing I will type is my theory...
 
Ready???
 
My Theory by Dr Gregg DeNicola will begin now...
AHEMMMM!
 
We will reach herd immunity via natural antibodies against Covid, with additional antibody protection from vaccine programs.
 
That is my theory, which is mine, and belongs to me, and I own it. 
 
For any viral disease, immunity is afforded by antibodies. 
There are only two ways to get these gems in your system. You can make your own, however that would require you to actually contract Covid.
 
The antibodies are also obtained via a vaccine. 
Which are better? I refer you to hours of research on the WWW where you will find no clear answer. 
 
"Natural" antibodies appear to keep you Covid free 99% of the time you have them. 
Vaccine antibodies also appear to be working at a 99% clip. 
 
So, as your bartender says---"Pick your poison."
 
Although if you have had Covid, odds are you are protected- we just do not know how long the protection lasts. We've seen it last a month. We have seen it last 11 months. 

With the vaccine the CDC is hoping for a year efficacy but we don't have the data to support that. A yearly booster is likely.
 
So let’s do some math to validate my theory.
 
To achieve Covid herd immunity as defined earlier, the numbers vary from 50-80% by epidemiologists. Because of potency, penetrance, geographic spread, and different strains, each virus has a different percent.
 
Measles needs 90% herd immunity. Polio only 80%. 
 
Remember herd immunity does not eradicate the virus from the face of the earth. That has only happened once in history. The wonderful Dr. Edward Jenner and his Smallpox vaccine destroyed the Smallpox virus, with the last known case reported in 1977.
 
Since we do not know the exact percentage for Covid yet, let’s pick a reasonable 75%. 
 
In 2020 the US population was 331 million. Let’s say the 2021 US population will be 333 million.
 
That includes infants and children, who notoriously do not have antibodies, so this will require a higher number of adults to have antibodies.
 
333 million Americans, times 75%, means we need 250 million of us with antibodies at one time to achieve the Holy Grail of herd immunity.   
 
On April 1, we had 56 million Americans vaccinated.  
 
The CDC reports in the US, we average 3.1 million new vaccines a day (not the second shot). So by May 1, we should be at 150 million Americans vaccinated. 
 
Now let’s say for various reasons, we do not hit 150 million until July 4th. We also have to count the number of post-Covid patients with antibodies.
 
Sloan Kettering did a study on "seroprevalence" to estimate that in March we had up to 120 million Americans immune due to post-Covid antibodies. 
 
December 2020 had over 20 million documented Covid cases in the US. We are averaging 70,000 new cases a day currently. That means between April 1 and May 1 alone we will have around an additional two million Americans antibody protected. (Yes, nearly all Covid cases make antibodies.)
 
The wild card here is that these numbers are only for swab POSITIVE cases. Experts estimate that there are at least three additional cases never tested or reported for every swab positive patient.
 
You get it. The Mrs. has symptoms, gets PCR tested positive. The Mr. also has symptoms and says “no need for testing, I know I have it. I’ll just hunker down until I feel better.” Then their 2 kids with fevers refuse that "brain biopsy" swab. Four cases but only one positive swab.
 
The "untested" immune help offset the fact that of the 150 million vaccinated Americans we will get to by the summer will include a fair number of people who ALREADY have antibodies from a prior Covid infection.
 
So the math says of the 150 million people that will soon be vaccinated, perhaps only 66% had no antibodies. 
 
That makes 100 million protected from getting the vaccine.
 
NOW add the 120 million people the experts say are protected from natural antibodies post-Covid 
 
Add 30 million people who are protected but don't know it because they haven't (or won’t) be tested.
 
VOILA! 250 million protected Americans, the number for herd immunity. 
 
This doesn't even count continuing at three million vaccines a day, and the 70,000 new cases that are still occurring across the country getting natural antibodies.  I postulate herd immunity by Halloween is not only possible, but probable.
 
An example is the DeNicola Thanksgiving dinner in 2020. There were nine at the table. All tested PCR and antibody negative days before.  All nine were negative.
 
Today, just four months later, six of the nine have had Covid and have antibodies. Six of the nine also have had the vaccine. All nine are currently protected, either by natural or vaccine antibodies. This is happening all over the country.
 
The more people that contract Covid, the more protection we achieve.
The more people that get the vaccine, the more protection we achieve. 
 
Want to hear a joke about immunity?
Never mind, you've already “herd it.”
 
What herd immunity should mean is no more masks. Eating at a restaurant that has tables three feet apart. Salad bars back. Stadiums and concert halls full again.
 
We will know there is herd immunity when the 14 day rolling average of new cases and deaths take a sharp drop to below what a typical flu season has.
 
Yet, I suspect public health experts will still want masks and distancing practiced long after herd immunity has kicked in. Immunity is invisible, and our paranoia over any possible Covid spread will make returning to normalcy difficult. 
 
Yet my math says that we are far closer to herd immunity than the public health officials want to acknowledge. 
 
Yes, new mutations and strains may not respect the vaccines or antibodies.
Yes, some vaccines may wear off in three months without our knowledge.
Yes, natural antibodies may disappear in two months, leaving the post-Covid patient unprotected.
 
Yet despite those concerns, there will still be a steady flow of both natural antibodies and vaccines offsetting them. 
 
And we will reach herd immunity by Halloween.
 
That is my theory. Which is mine and belongs to me.
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group, PDQ Urgent Care & More, PDQ Telehealth


Covid Blog 2021 Physicals Orange County

By editor
March 16, 2021

With apologies to Gilbert and Sullivan, this is for all you Pirates of Penzance fans who have had to deal with the pandemic over the last year.
 
Pirates of Pandemic Patter
(to be sung at a rapid tempo)
 
After all the quarantine it’s time to move around, even dance
Ask Gilbert and Sullivan; sing along to Pirates of Penzance
 
You are the very model of a novel coronavirus
You ruin health, economy, and holidays are quite the fuss
 
Sneaky how you incubate, 2 weeks ‘til you rear your ugly head
Some folks don’t even know they’re sick while others can’t get out of bed
 
You mimic every symptom out there, what a tangled web you weave
So many “experts,” self-appointed, hard to know whom to believe
 
CDC just cracks us up, thinks it knows exactly when you’ll leave
You come and go without reservation, offering no reprieve
 
 
Time to take a break from the patter
Let’s talk important next steps that really do matter.
 
Whether you’ve had COVID or not, you’ll need a checkup in 2021.
 
It will be different than any physical you’ve ever had before.
 
In fact, at Caduceus there are three categories of checkups for 2021. As we introduce HUEY, DEWEY and LOUIE, see to which one you relate.  Call us quacks if you like, however Caduceus may be the only medical group with COVID specific checkups for 2021!!!
 
 
HUEY-
 
HUEY has not had COVID.  He mostly stayed home, wasn’t able to exercise, packed on the COVID 19 pounds, may have consumed more than his usual amount of cheeseburgers and does recall daily happy hour.  Diabetes runs in his family however he’s sure he’s fine.  HUEY schedules his annual checkup which includes:

  • Lab work to check on diabetes, high cholesterol, fatty liver and more
  • If female, mammogram and Pap, depending on date of last test
  • COVID antibody testing.  Huey may have been an asymptomatic case and already have protection.  Or Huey many have gotten the vaccine(s) and have antibodies

If over 50, HUEY meets criteria for:

  • Colon cancer screening
  • PSA if male
  • Bone density testing
  • Shingles vaccine

If over 65, HUEY meets criteria for pneumonia vaccine.
 
HUEY is still nervous to go out in public, so the good news is HUEY DOESN’T HAVE TO COME INTO THE OFFICE.  We can start the 2021 checkup from the comfort of your home or office.
 

  • Curbside lab draws
  • Video Visits to review the tests
  • We’ll go from there – some things will require an office visit as we haven’t figured out how to biopsy a mole, pierce an ear, or do a Pap remotely.

 
 
Can’t resist the urge to rhyme
Let’s indulge the patter one more time
 
Virus analogy is a dragon, with a very long tail
Ignore bedrest and do too much, the symptoms come back without fail
 
Docs try and try, I don’t know why, as we all know there is no cure
Despite Hydroxychloroquine and Ivermectin, you endure
 
Z-Pak, zinc, lots of vitamins, then Decadron and Tylenol
Trying any and everything, like throwing pasta at the wall
 
Has convalescent plasma become the ultimate gift to give?
Will sharing antibodies be the thing that helps others to live?
 
Prone position, oxygen, Remdesivir flowing through the vein
As soon as something starts to work it transforms into a new strain
 
 
DEWEY-
 
DEWEY did have COVID last year, not a bad case.  DEWEY took a Z-Pak, some cough medicine, and had an inhaler, just in case.  He feels pretty lucky to have been out of commission only a short time.  He’s pretty sure he’s back to 100%.
 
In addition to EVERYTHING COVERED in HUEY’s physical, DEWEY’s checkup will include some additional post COVID labs.  Studies show that even people with asymptomatic or mild cases may have post-COVID Syndrome, affecting their organs.  Labs may include:
         

  • Tests double checking your heart, lung, kidney, and liver function
  • Additional labs looking for post-COVID inflammation
  • Antibody testing monthly

 
 
OK, it’s time
A little more rhyme…
 
IgM and IgG – antibodies are talk of the town
Everybody wants a bunch, to last and last and never go down
 
Pandemic rocked our world so hard and now the aftershocks we feel
Enter Moderna, Pfizer, J& J – is vaccine the real deal?
 
You are the very model of a novel coronavirus
You ruin health, economy, and holidays are quite the fuss
 
Learning more each day; using science and common sense best we can
Let’s hope virus this mutates out, and leaves as fast as it began!
 
 
LOUIE has survived the monster virus, had a severe case, may or may not have been to the hospital and may or may not be feeling back to 100%.  LOUIE may still be experiencing fatigue, occasionally still needs inhalers, sometimes can’t sleep, and his head feels a little foggy.  Oh, and LOUIE’s gut is still bothersome.  LOUIE is not alone.  We are shocked at the number of patients who still have lingering post Covid symptoms.  Post-Acute Sequelae of Sars-CoV-2 infection (PASC) is a thing.  Worldwide, reported incidence ranges from 10-30%.  LOUIE has won the war, however the battleground may have sustained some damage and needs time to repair.  LOUIE’s annual checkup will include everything that HUEY’s and DEWEY’s did, and can also start from the comfort of home or office. We may run a few additional tests or labs to specifically check on LOUIE’s heart, lungs, kidneys and brain depending on the severity of LOUIE’s post Covid symptoms.  Tests may include:
 

  • EKG
  • Echocardiogram
  • Pulmonary Function Studies
  • Pulmonary Rehab
  • Antibody testing monthly
     
    So, for 2021, are you HUEY, DEWEY or LOUIE?
     
    We recommend antibody testing regularly for everyone and will offer monthly antibody options for all categories.
     
    We’ve instructed staff not to giggle if they receive a call asking to schedule a HUEY/DEWEY/LOUIE physical!

    Gregg DeNicola MD CMO, Caduceus Medical Group, PDQ Urgent Care & More, & PDQ Telehealth
    Mary DeNicola DNP PDQ Operations Officer 

 

 

 

 

 


CMO Covid Orange County Blog- Shares his story

By editor
January 26, 2021

It was 3 PM on my second day in the hospital--Christmas Eve- and was due to have a half hour IV infusion of Remdesivir for my Covid pneumonia. 

I looked up at the IV bottle.

It was a dark glass container, looking identical to an upside down Kahlua bottle. More bothersome - there were three heads coming off the bottle, each looking like a Satanic face.

Scared, I assumed I was dreaming. But squeezing myself, I knew I was totally awake. I closed my eyes, and looked up again at the bottle being hung. Same vile image. I noted one of the faces looked identical to the character "Anonymous.”

As a physician I knew I was hallucinating.  I knew hypoxia or high flow oxygen, of which I was having both, can cause hallucinations.

Yet it was as surreal as it comes, physician or not.

I decided to not look up until the infusion was done, and not ask my nurse about the unorthodox IV she hung.

The next day on Christmas, at 3 PM it was time for my second dose. The nurse came in to hang the IV bag. It took all I could do to look up as she hung it. It was a small clear vinyl bag, used for all IV meds. I was relieved the devilish Kahlua bottle was nowhere in sight.

I summoned the courage to ask my nurse, “was yesterday’s dose put in a different bottle?” “No,” she said, “it was the exact same small clear IV bag.”

I asked her if I had been napping when she hung the first dose. “No,” she said, “you were wide awake; why?”

I decided if I ever wanted to get released, I’d best keep my hallucinations to myself. “Just wondering,” I answered.

This falls into the category of "you know you are sick when.”

I can boil my experience into three unexpected memories. That bottle was obviously number one.

The second was my activities during my nine day stay. I had brought some books to read, planned on watching classic movies, brought a shaver and toothbrush, and some shampoo if I had a shower in my room.

Ok, I had never been hospitalized before. What did I know?

I spent eight days laying on my right side-flat, which produced the best oxygen readings.  Flat on my right side, 24/7.
 
Realize all of my adult life, I was a multi-tasker. Running a busy practice.... Running a business.... Working as a Medical Director.... Husband and raising three boys into men.... Cooking and wine tasting.... And recently I took up gardening and boating, weaving those into the hours I had in a week. The idea of lying down in my bed for even 30 minutes during the day would be my biggest nightmare.

Yet here I was, lying flat for 200 consecutive hours. This wasn't a bad dream;  it was torture.

There were a few exceptions. I could sit up to eat. But that dropped my oxygen so it had to be done quickly. One day physical therapy visited and stood me up. To achieve that, they had to crank my high flow oxygen even higher. I had one quick sponge bath. No shower, no shaving, no reading, no TV, and no visitors. My only view was of the nurse’s call button on the rail next to my face.

I knew that position was the only way my oxygen number would stay in the 90’s, allowing the nurses to try to wean the high flow oxygen from the 100% they started me on to the 30% goal-- when they could convert me from high flow to regular low flow.  They had mentioned if they couldn't wean me in two weeks, I may be transferred to a "higher level of care". I knew what that meant-- the ICU for possible intubation.

To keep from going crazy, I tried to think of as many bad doctor jokes as I could ...you know, like-

“I’m sorry,” said the doctor to his patient. “You have Covid.  We must quarantine you, and you’ll only be fed sliced cheese and bologna.”

“Will that cure me?” the patient asked.

“Well, no,” the doctor replied, “but it’s the only food that will fit under the door.”

OR

“Doctor, there’s a patient in room one who says he’s invisible.”

“Well, tell him I can’t see him right now.”

OR

How did the doctor cure the invisible man?

He took him to the ICU.

That took up about half hour before I realized I’d rather be hallucinating than thinking up bad jokes.

By day eight, they finally managed to wean me from high flow to low flow, but I was still confined to lying flat on the right side position. On day nine, they tried to sit me up. My numbers held in the 90’s. Not only could I read, eat, and watch TV from a sitting up position, but also they said they were sending me home. There were too many people in the ER as sick as I was the week earlier with no beds available. My Italian guilt took over as I realized I was glad there were enough sick people to force them to kick me out of my prison.
 
That leads to the third unexpected experience being home.

I imagined sitting on the couch watching Netflix, catching up on my medical reading, chatting on the phone with friends and family, and being back to normal in a week or so.

You can stop grinning now.

I was still on 24/7 oxygen, so my nurse/wife Mary was in charge of the slow steady wean. I am still on oxygen now, so I learned this will be a long-term project.

I was given exercises to help build up my strength. Problem is they drop my oxygen numbers plus they exhaust me. I need to use an incentive spirometer every 10-15 minutes to expand my lungs.

So I found recovering from Covid pneumonia is a lot of work. I should have believed my doctors who warned me to measure my recovery month to month, not week to week.

Yet as I recover, I find myself wanting to resume previous activities. When I was first came home, I told my staff I was retiring from blogging. Yet three weeks later, I know I want to go back to some sense of normalcy.

Believe me, writing this blog today is much more therapeutic for me than you.

One of our patients in Laguna Beach is the glass blower from the Sawdust Festival. 

He isn't going to believe the special commission I have for him this summer.

I just need to empty out a bottle of Kahlua.
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group, PDQ Urgent Care and More, PDQ Telehealth 
 
P.S.  It is an understatement to say I am overwhelmed by the hundreds of cards, emails, and calls from our amazing patients and skilled staff wishing me healing. I tried answering everyone personally, then realized it was an impossible goal.

Reading these well wishes was stronger healing than the Remdesivir. I am truly humbled. Reading them made me realize I have had a career blessed by the heavens and the very best patients in the universe. Believe me the love goes both ways.
 
Remember to get tested with ANY symptoms and stay home as much as possible. I have been asked where I contracted Covid and I am sure it was from some asymptomatic person I came in contact with at work. I was still seeing patients in the office four days a week and masks are only 80-95% effective. It was a matter of time that a Covid particle sneaked around the masks we were wearing.

In retrospect, I should have stayed home doing video visits only when the numbers exploded after Thanksgiving. Do not repeat my mistake.

Caduceus will not be receiving the vaccine soon, so make best efforts to get vaccinated where you can. If you have had Covid, we advise a monthly antibody test through 2021.

We are now researching what a 2021 check up should entail and will be publishing that in a future blog.