Tracking COVID-19's toll on Florida: Doing better, but not good enough

Last July, Florida reported a record daily number of COVID-19 cases for any state and Tampa was among the nation’s 10 fastest-growing hot spots for the virus. Since then, cases of COVID-19 in our region and state have slowly come down, yet Florida’s total reported cases remain third-highest nationwide, according to Statista, a global business data collection platform.
 
What are we learning about this disease?

To answer this question, the Hillsborough County Medical Association (HCMA) recently sponsored its third Town Hall to update our community on COVID-19 and attempted to shed light upon the tsunami of COVID-19 reports since meeting three months ago.

Moderated by HCMA President-Elect Dr. Joel Silverfield, the panel included Hillsborough County Medical Director Dr. Douglas Holt, two infectious disease specialists from USF, Dr. John Sinnott and Dr. Kami Kim, and Dean of the Morsani College of Medicine Dr. Charles Lockwood.

Here are five takeaways from that discussion.

COVID-19: A virus with long-term effects
 
About one-half of COVID-19 cases are asymptomatic and 80% of symptomatic cases have a mild response. Most of those with a severe response recover in a few weeks or tragically succumb to the disease. But a third group is emerging with symptoms that may persist for months or even longer.

Many of these “long-haulers” have underlying medical conditions and symptoms. Dr. Kim, Director of the USF Health Department of Internal Medicine’s Division of Infectious Diseases, noted “it’s pretty common to see chronic fatigue and lingering respiratory problems as well as exercise fatigue and neuropsychiatric symptoms.”
 
“We’re at a critical tipping point,” says Dr. Douglas Holt. “And, while I’m optimistic for now, I’m also very concerned about the weeks ahead, especially Thanksgiving when families will be the most mobile, coming together from all over.”
Among the earliest reported non-respiratory COVID-19 complications is microvascular thrombosis, which can cause heart attacks and stroke. COVID-19-related heart diseases can also be caused by an inflammation known as myocarditis.

Dr. Sinnott, USF Health’s Chairman of the Department of Internal Medicine, noted a growing list of chronic ailments linked to COVID-19, citing a recent report from the Journal of the American Medical Association revealing that 10-15% of individuals suffer some effects for up to 90 days.

Limiting exposure to COVID-19: The 3 “V’s”

Absent a vaccine, the CDC has from the beginning emphasized the 3 “C’s”-- avoiding crowds, closed spaces, and close contacts to prevent exposure to the virus.
 
With Florida’s Stage III reopening on September 25, allowing 100% capacity in restaurants, Dr. Holt introduced the 3 “V’s” -- venue, ventilation, and vocalization -- as increasingly relevant factors affecting viral spread within closed spaces.
How best to manage these factors “will depend on the details,” according to Dr. Kim, and, in particular, with time spent and upon the degree of mask-wearing, critical predictors of outcome.

Answering a specific question on automobile travel, Dr. Kim, reflected that COVID-19 exposure may take several days before symptoms to develop and suggested that long car rides would likely be risky if one of the riders had been exposed to the virus.
 
COVID-19 in Hillsborough County: A steady plateau

Dr. Holt described the COVID-19 caseload in Hillsborough County as having “come down a mountain” (since peaking in mid-July) but now holding at a plateau since late August. He noted that “September was a big month for us with the opening of schools, Labor Day, and the Executive Order for the bars' opening,” adding “and now when you look at the numbers, we’re holding at a pretty high prairie.”

These numbers represent close to 150 new cases per day in Hillsborough County or about 10 per 100,000 in our population. Dr. Holt states: “We’re not yet where we need to be and still have plenty of kindling being burned right now.”

He would like to see that number tenfold lower closer to 1 case per day for every 100,000 people, the metric many experts use as indicative of viral suppression. “We’re at a critical tipping point,” he said. “And, while I’m optimistic for now, I’m also very concerned about the weeks ahead, especially Thanksgiving when families will be the most mobile, coming together from all over.”
 
Dr. Lockwood noted that for a variety of reasons Hillsborough County started out with a lower average age of infection than in the state as a whole -- from a high of about 42 years, then dropping to an average age of about 34 years -- representing a predominantly younger, lower-risk population.

“We’re certainly in much better shape than we were three months ago and the demographics have changed and with that a tremendous reduction in the number of hospitalizations down to about 5 per day in the past two weeks,” Dr. Lockwood said.

Considering our older population, Hillsborough County “should have had a very high case fatality rate” noting that the county’s actual rate of 1.6% is much lower than, for example, New York state’s average case fatality rate of 8.5%. When the pandemic hit this area, “we were prepared and also had learned from the New York experience,” he indicated, adding that early use of remdesivir, steroids, and convalescent plasma all contributed to the region’s success in combating the virus.

Reflecting that “there’s a lot we don’t know about this disease,” Dr. Lockwood suspects we nonetheless “may reach partial herd immunity earlier than we think” due to growing awareness of a second line of defense perhaps just as vital as antibodies: memory T cells. These are white blood cells that fight infection by attacking other cells that have been infiltrated by the virus.

Current studies, he notes “report up to 50% of patients with COVID-19 are asymptomatic, perhaps in part due to T cell immunity.” And with so many patients in nursing homes surviving this disease, Dr. Lockwood speculated: “We may find out in retrospect that this helps account for why Florida has not had a big rebound in COVID-19 infections.”

Dr. Kim added that USF has received FDA approval for “compassionate use” of remdesivir and has been participating in a variety of national clinical trials while also participating in other experimental trials involving potential therapeutic drugs such as the monoclonal antibody drug Regeneron.

Air travel and a novel experiment at Tampa International Airport

With Florida increasingly more open and mobile, passengers at Tampa International Airport now have the option of being tested at the airport, a new pilot project involving TIA, Hillsborough’s Health Department, and BayCare Health System. Originally intended for international travelers, the project initially offered the PCR test ($125) with results in 48 hours and then added the slightly less accurate antigen test ($57) with results in minutes. Both are available to all departing and returning passengers who are within three days of travel.

As details are still being worked out, Dr. Holt advises allowing extra time if you are considering testing. “For returning travelers about to visit families, I think it’s a great service,” he added, “allowing them to get tested right there and carry on their way without interruption.”
 
The panel discussed the relative safety of airline air filtration systems known as “HEPA” (high-efficiency particulate air) that remove 99% of bacteria, fungi, and virus clumps. And while it doesn’t protect against being sneezed on by a sick passenger, Dr. Holt reassuringly noted the airplane itself “is a very safe environment. It’s getting to and off the plane -- that’s where the risks are.”
 
When will we have a vaccine? A return to normalcy?

The panel reflected consensus about not rushing the vaccine development process. Dr. Sinnott stressed, “we need to do exhaustive testing” around safety and effectiveness. “The vaccine story” he believes “will be played out more like a novel than a short story,” adding that “there’s going to be a push back by the American public on vaccines.

Yet, Dr. Silverfield, the panel’s moderator, noted, “over 300,000 generous souls have volunteered to be part of these vaccine trials.” In the United States, the first wave of clinical phase III trials of RNA-based vaccines are currently being led by two U.S. manufacturers, Moderna and Pfizer, along with the British-Swedish firm AstraZeneca and Johnson & Johnson that have recombinant adenovirus-based vaccines (both recently paused because of unexplained illnesses in subjects) with whom the U.S. has partnered.

The FDA has declared a vaccine must protect at least 50% of people to be declared effective. The panel noted that forecasting when the country will have an effective vaccine and some significant degree of herd immunity remain difficult to predict.

“I’m optimistic,” said Dr. Lockwood. “If we can start rolling out the vaccine in January to March, then somewhere between April and July the world might actually look familiar to us.”

All agreed that much depends upon a fatigue-laden public’s ability to keep practicing proven mitigations from masks to distancing. And, now, of course, getting the seasonal flu shot.

Dr. Bruce Shephard is a retired Tampa Obstetrician-Gynecologist and Affiliate Associate Professor, Department of Obstetrics and Gynecology, USF, Morsani College of Medicine.

To learn more about global data on COVID-19, visit Statista.


The moderator and panelists

Read more articles by Dr. Bruce Shephard.

Dr. Bruce D. Shephard, a retired Obstetrician-Gynecologist and Affiliate Associate Professor, Department of Obstetrics and Gynecology, USF Morsani College of Medicine, is best known locally for delivering more than 7,350 babies. He now occasionally teaches and always practices good health, dabbles in writing, and raises monarch butterflies. He and his wife, Coleen, live in Tampa.
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