Fall and winter pandemic surge is here

Cooks Corner Health Department will offer free COVID-19 testing Nov. 9 and 30.

(Editor’s note: As of Monday afternoon, the Virginia Department of Public Health reported 145 confirmed COVID-19 cases in Middlesex County, with nine Middlesex patient COVID-19-related hospitalizations and 11 deaths involving Middlesex residents. The Virginia Department of Public Health cautions that because of limited testing, the actual number of cases in Middlesex County is likely much higher.)

by Richard Williams – 

COVID-19 new cases across the United States continue to increase rapidly; the seven-day moving average is about 75,000, and more than 40 states are reporting higher case rates. We have had more than 8.6 million cases in the United States, and we have more than 225,000 deaths. In Europe, cases continue to increase rapidly across the continent.

In Virginia, we are still doing pretty well. The  seven-day moving average of cases by date reported was 1,033 on Oct. 25. The  seven-day average percent positivity of tests is currently 5.0%. Community transmission extent in the central and near southwest regions are substantial (high). Community transmission extent is moderate in the eastern, far southwest, northwest and northern regions. The moving  seven-day average of people hospitalized for COVID-19 is 999 on Oct. 25. We have good hospital and ICU capability across the state.

In the Three Rivers Health District, which includes Middlesex County, we experienced less new cases than we have had in a couple of months. We had 102 cases reported last week across our jurisdictions. According to the CDC K-12 School Metrics, Lancaster, Mathews, and Westmoreland counties are at highest risk from a case incidence perspective. Our remaining jurisdictions are at higher risk. Our 14 day percent PCR positivity ranges from 1.26 (Richmond County) to 5.41 (Northumberland County). We continue to have outbreaks, which are indicators of enhanced viral spread. The main source of community transmission continues to be individual exposures during private, unregulated events.

Halloween guidance

Maintaining a sense of normalcy when possible is imperative during this pandemic. This is especially important to children; celebrating holidays and special occasions helps with this. When celebrating Halloween, remember any activity that places people in close proximity to each other increases the risk of an exposure significant enough for viral transmission to occur. Wearing a mask, practicing social distancing, limiting the time spent in close proximity to others, and proper hand washing reduces the risk of transmission. The VDH developed guidance stratifying the following activities to lowest, moderate, or highest risk categories:

Lowest risk:

• Carving or decorating pumpkins with members of your household and displaying them.
• Carving or decorating pumpkins outside, at a safe distance, with neighbors or friends.
• Decorating your house, apartment, or living space.
• Doing a Halloween scavenger hunt where children are given lists of Halloween-themed things to look for while they walk outdoors from house to house admiring Halloween decorations at a distance.
• Having a virtual Halloween costume contest.
• Having a Halloween movie night with people you live with.
• Having a scavenger hunt-style trick-or-treat search with your household members in or around your home rather than going house to house.

Moderate risk:

• Participating in trick-or-treating with distancing strategies in place (e.g. treat-givers provide individually wrapped goodie bags lined up for families to grab and go while continuing to social distance (such as at the end of a driveway or at the edge of a yard).
• If you are preparing goodie bags, wash your hands with soap and water for at least 20 seconds before and after preparing the bags.
• Stopping only at houses where individuals are wearing masks, and it is easy to maintain six feet of distance between the host and other trick-or-treaters.
• Attending a small, outside event such as trunk-or-treat, where social distancing can be maintained and everyone is wearing a mask.
• Visit pumpkin patches or orchards, where wearing masks is encouraged and enforced, and people are able to maintain at least six feet of physical distance.

Highest risk:

• Trick-or-treating to a large number of houses or visiting multiple neighborhoods, where participants go door to door.
• Trick-or-treating at houses where individuals are not wearing a mask, and where six feet of physical distance is not maintained between individuals.
• Attending parties or events that may become crowded and social distancing is difficult to maintain.
• Going on hayrides or tractor rides with people who are not in your household.
• Going to indoor haunted houses where people may be crowded together and screaming.

Trick or treating, our most traditional Halloween activity, deserves special mention. The VDH guidance states: 

“Trick-or-treating involves increased risk for transmitting COVID-19, due to the potential for close proximity to many people and the difficulty for children trick-or-treaters to follow mask use and social distancing recommendations. If you do choose to trick-or-treat, it is important to protect yourself using the following recommendations:

1. If you have COVID-19 symptoms, have tested positive for COVID-19 in the past 10 days, or have been in contact with someone with COVID in the past 14 days, follow VDH guidance to stay home and away from others. If you are self-isolating or self-quarantining, do not participate in trick-or-treating this year, and look for other virtual options to celebrate.
2. Be sure to maintain at least six feet of distance between yourself and others who do not live in your household at all times.
3. Wash your hands before going trick-or-treating or handing out candy. Hand sanitizer should be used while trick-or-treating or handing out candy when soap and water aren’t available.
4. Wear a cloth mask. Halloween masks may not fit snugly against the face and may not cover more than the nose and mouth. Halloween masks with gaps and holes do not protect against inhaling respiratory droplets from other people. Cloth masks should be worn under costume masks to keep a close fit more than your nose and mouth. Ensure that any cloth mask worn under a costume mask does not inhibit the ability to breathe easily.
5. If you hand out candy, consider setting up an area outside, like a folding table or chairs, to set out candy. Space out the placement of treats so that multiple people do not have to reach into the same bowl or find contactless ways to deliver treats, like a candy chute that is more than six feet long. For trunk-or-treating, create distance between cars by parking in every other space.”

 Testing

Virginia has received a large shipment of Abbott BinaxNOW card tests. The federal government purchased 150 million of these rapid antigen test cards, aimed primarily at nursing home use. They are primarily useful in clinical settings to identify positive COVID-19 cases and in vulnerable facilities such as nursing homes. The VDH health districts may receive some of these rapid tests for local use. We are discussing plans for using these testing resources if we obtain them.

Our testing team in the Three Rivers Health District is actively conducting testing events across our jurisdictions. Upcoming events include:

• Thursday, Nov. 5 — Rappahannock Bon Secours Hospital, Dream Fields, 10 a.m.-1 p.m., 1385 Irvington Road, Weems.
• Monday, Nov. 9 — Middlesex County Health Department, 10 a.m.-2 p.m., (by appointment only), 2780 General Puller Highway, Cooks Corner.
• Monday, Nov. 16 — Gloucester Library, 10 a.m.-2 p.m., (by appointment only), 6920 Main St., Gloucester.
• Monday, Nov. 30 — Middlesex County Health Department, 2-6 p.m., (by appointment only), 2780 General Puller Highway, Cooks Corner.

To make an appointment for testing, please call 804-815-4191 Monday through Friday between the hours of 9 a.m.-4 p.m. We are offering 150-250 tests per event, there is no charge for the testing, and all events are open to the public. Our more than all test positivity rate for these community events is currently about 1.9%.

Get your flu vaccine

It is more important than ever to get our flu vaccine, to reduce flu case rates, ease the burden on our health care system, and help lessen confusion with COVID-19 cases, which may look just like flu. It is possible to have flu and COVID-19 at the same time; getting your flu vaccine lessens your risk of becoming infected with flu virus, and may lessen the severity of flu disease if you do get sick. We are starting to receive reports of flu in our communities.

Trials back on track

Johnson and Johnson, Moderna, Pfizer and AstraZeneca all have vaccines in phase three trials in the U.S. The AstraZeneca and Johnson and Johnson trials were both paused in the United States, and they have resumed. Novavax, a Maryland based company, has a vaccine in phase three clinical trials in South Africa and the UK, and still plans to launch in the U.S. later this month. The company could deliver 100 million doses by early next year if the vaccine is successful. The VDH, working internally and with stakeholders, has developed a very comprehensive draft COVID-19 Vaccination Plan that is being refined continuously.

The FDA approved Remdesivir as a treatment for COVID-19 for ages 12 and older, based on three randomized trials that demonstrated efficacy with improving clinical status and shortening the course of illness. Two recent studies also indicated improvement in mortality rates in COVID-19 patients since the beginning of the pandemic, reflecting better supportive care and treatment for the severely ill.

The CDC revised its close contact guidance last week. CDC guidance now defines a high risk (or close contact) exposure as being within six feet of an infected person for a cumulative total of 15 minutes or more than a 24-hour period starting from two days before illness onset (or, for asymptomatic patients, two days prior to test specimen collection) until the time the patient is isolated.

We are still on a steep learning curve concerning the SARS CoV-2 virus. Whether or not the virus transmits and causes infection depends on the intensity and duration of the exposure. We always knew there was nothing definitive about the 6 foot/15 minute continuous exposure rule. The virus has been able to more than come that limitation and transmit, at least in one documented circumstance. The dose of virus does not have to be delivered all at one time; cumulative doses are effective for transmission. From a risk management perspective, this will not change our recommendations to maintain social distancing, masking, staying out of crowds, and practicing good sanitation and hygiene. The six-foot distance is based on the behavior of droplets in air, and that guidance remains valid at present. Six feet of social distancing with masks should provide a good level of protection (unless future evidence demonstrates differently). The main change will be in contact tracing, and in potential exposures in the workplace and in educational settings. We will now all have to think about and guard against cumulative exposures within six feet of a COVID-19 positive individual.

Last week questions came up several times concerning HVAC systems and COVID-19 transmission. I am aware of no new evidence documenting COVID-19 transmission through HVAC systems. There is evidence, however, that very small particles can carry the virus and stay airborne for long periods. Theoretically, these small, airborne particles can be circulated through HVAC systems. This information further supports the principle of masking while indoors in congregate settings.

Pandemic containment

Our Three Rivers case investigation and contact-tracing capability remains excellent. To date we have hired 11 case investigators, 10 contact tracers, and one team supervisor. It is clear that we are entering a period of increased viral transmission across the country, commensurate with increasing indoor congregate activity and a worldwide northern hemisphere fall/winter COVID-19 pandemic surge. We have been able to detect outbreaks early thus far and will work to contain them quickly.

K-12 school status

Most school systems are making plans to bring students back into the schools and begin in-person operations, guided by current community transmission extent. More children are being diagnosed with COVID-19 in the United States, 44,000 detected in the last week. It is important to remember that most cases of COVID-19 among children are asymptomatic or minimally symptomatic, children rarely suffer severe complications from COVID-19 infection, and long-term health effects among children remain unknown.

We continue to experience COVID-19 cases among school faculty, staff and students in multiple Three Rivers Health District jurisdictions. All of these have been community acquired, and we have still seen only one case of viral transmission that actually occurred in the school setting. We have recommended isolation and quarantine for some individuals working in our schools and for some classes experiencing extensive exposures, but we have not yet had a COVID-19 outbreak in any of our schools. Thus far, our schools have been able to pay diligent attention to and maintain social distancing, masking, and hygiene. This, in combination with early detection, case investigation and contact tracing appear to be working together to protect our educators and students. The VDH launched a K-12 COVID-19 outbreak dashboard last week, which can be viewed at the following link: https://www.vdh.virginia.gov/coronavirus/outbreaks-in-school-settings/.

Our objective remains to prevent cases from occurring in schools, contain any COVID-19 cases that do occur, minimize outbreaks and prevent further community spread. There is absolutely no question that the lower the level of community transmission, the safer we all will be, the better our economy will be, and the safer it will be to send our children in person to school. We must work together to decrease virus transmission as much as possible.

Businesses continue to comply

The General Assembly passed HB5093 on Oct. 21, which provides an alternative to misdemeanor prosecution for violation of an executive order. This bill “Provides that a violation of an executive order declared by the governor as the director of Emergency Management shall be punishable either as a civil penalty of not more than $500 or as a Class 1 misdemeanor. Under current law, the only penalty for such a violation is a Class 1 misdemeanor. The bill also mandates that a violation of an executive order that is punishable as a civil penalty shall be charged by summons and may be executed by a law-enforcement officer when such violation is observed by the officer. The proceeds of any such civil penalty that is imposed shall be paid and collected only in lawful money of the United States and paid into the state treasury to the credit of the Literary Fund. This bill has an expiration date of June 30, 2023, and is identical to SB 5117.”

We continue to investigate concerns and complaints and enforce executive order compliance to the best of our ability across the district, sometimes in collaboration with the Department of Agriculture and Consumer Services and the Department of Labor and Industry. We have had outbreaks in many business settings, and in other congregate settings, which are reflected in our more than all case numbers. We have not yet had an outbreak in an educational setting. Most of these outbreaks are indicators of enhanced community spread, but have not in and of themselves served as major sources of widespread community transmission. Most of our transmissions continue to occur between friends and family members, and in private venues that are unregulated by any authority.

Best defense

Our best defense remains prevention of disease by social distance, masking, staying out of crowds, hygiene and sanitation.

To repeat our most important message, this virus repeatedly demonstrates its ability to transmit briskly if given the opportunity. We all hope for an effective vaccine, and we all hope for better medications to treat this virus. Our best defense remains to prevent virus exposure and disease through social distance, masking, avoiding crowds, washing our hands, and practicing good sanitation methods. Our secondary line of defense is containment activity with extensive testing, case investigation and contact tracing, intended to control spread of active infections that we are unable to prevent.

If you are sick at all, even if your symptoms do not feel like COVID-19, stay at home, consult your health care provider, and do not hesitate to seek testing. The virus can masquerade as many other diseases, and can fool us all. Again, difficulty breathing remains a sign of possible serious disease; if this develops, please seek help very quickly.

(Richard Williams is the director of Three Rivers Health District of the Virginia Department of Health. The district includes Middlesex County. Williams’ email address is richard.williams@vdh.virginia.gov.)