It is known that old age, persons with chronic conditions including immunosuppression, diabetes, heart disease, chronic lung disease, kidney failure, dialysis and cancer are at higher risk for severe illness and or death from COVID-19 infection. That said, we have seen a few lucky ones in the  practice with several underlying conditions, SARS-CoV-2 PCR positive bilateral pneumonia, insist on going home. In these few instances the patients acted against medical advice, refusing  to return to the hospital to be admitted. Such dissent has been uncommon in my experience throughout the pandemic. Our algorithm is "...best to assume anyone with any of these conditions will likely do poorly, so monitor closely". Beyond the current generalizations it remains quite confounding in our encounter with patients to predict who with underlying condition(s) will do well. The algorithm is much less useful, from an ambulatory care doctor's perspective, than if one could tell who will do well.  And the art of solving for who in my primary care practice might do poorly after testing positive is not helped when an otherwise healthy 19 year old member ends up having ECMO to survive the infection. These all point to the fact that there's a lot more to COVID-19.  A recent published retrospective study of nearly 680 patients showed that the viral load (calculated by the Ct value from the initial nasopharyngeal swab test) at presentation is a reliable predictor of the risk for mechanical ventilator support and in-hospital death. The Ct (cycle threshold)  is a value ascribed by the assay to the number of viral replication cycles that correlates inversely with quantitative viral load. It is not routinely reported or released to clinicians. The researchers grouped patients in the study into 3 , low (Ct>30) , medium (Ct 25-30) and high (Ct <25) viral loads. 

35% of patients with a high viral load were more likely to die in-hospital. While 17.6%  of those with a medium viral load died in-hospital only 6.2% with a low viral load died in-hospital. The risk of intubation was also higher in patients with a high viral load (29.1%), compared with those with a medium (20.8%) or low viral load (14.9%). Patients with higher viral loads were more likely to develop myocardial infarction, congestive heart failure, and acute kidney injury requiring hemodialysis.

Using initial viral load assessment, providers may have an added tool to triage patients. Identifying, as early as the time of the initial COVID-19 PCR test results, those who are likely to need more intensive monitoring is one step ahead of this disease. In addition, identifying these group of patients early will  aid decisions in allocating scarce resources such as remdesivir treatment. Admittedly, this tool seems most suited and applicable to guiding in-hospital patient care, but that may change.

Furthermore, additional viral load studies may begin to answer other questions such as the probability that very high viral load may in of itself be equivalent to all the other risks combined. High enough to explain the unexpected disease severity in young persons without any comorbities.

https://academic.oup.com/cid/article/doi/10.1093/cid/ciaa851/5865363

As primary care providers we must partner with our patients to navigate the pandemic as best as we can, and safely guide to resume health maintenance and preventive care. COVID-19 virus hit the world like nothing we have ever experienced. As the virus ravaged the communities, patients shied away from hospitals and doctors offices for fear of contracting the virus. Many primary care providers followed closely at the heels of their patients filing out through the exit door. With patients, the behavior was quite profound even among those who had serious illness with whom one would have expected a greater willines to brave the lockdown in serach of care. For example, compared with the 10-week period from Jan. 5 to March 14, emergency room visits were down by 23% for heart attacks, 20% for stroke, and 10% for diabetic hyperglycemic crisis from March 15 to May 23. Elective procedure and routine screening plummeted and in some cases ceased entirely because people avoided hospitals and the doctors offices. 

As the curve flattens and restrictions ease we now can take stock and patients must resolve to live again now and even after COVID-19. There is no longer a doubt we are in this for the long haul, either in one continous swoop or in seasons. Doctors appointments missed, cancelled or deferred amount to missed screening and preventive procedures. Screening and preventive care programs are well researched tools designed to seek and identify diseases including diabetes, cardiovascular diseases, cancer etc among populations, ages and gender where the disease would occur most frequently - and where the best outcomes will be attained when we intervene at its very earliest stage. With no screening comes delayed diagnosis and treatment. Cancers and many afflictions are picked up when a patient experiences symptoms and quickly checks the symptoms by going to his or her doctor. Yet it is well known that delay in almost all cases means that we end up dealing with advanced stages of the disease. Naturally in the pandemic we find ourselves, we must place surviving the virus a first priority. After all done, surviving past the virus becomes equally as important. And we can set to work both goals carefully in a safe and effective manner. There will be consequences if we don't, least of which includes losing much of the gains in survival due to early detection, appropriate cycled treatment protocols. Some models suggest that due to the disruption and delay in seeking care in non COVID-19 problems, we will see increased death unrelated to the virus itself as early as in a year or two and certainly within the next 10 years. In a model referenced by Norman E. Sharpless in an editorial in Science, he said that "the effect of COVID-19 on cancer screening and treatment for breast and colorectal cancer (which together account for about one-sixth of all cancer deaths) over the next decade suggests almost 10,000 excess deaths from breast and colorectal cancer deaths; that is, a ∼1% increase in deaths from these tumor types during a period when we would expect to see almost 1,000,000 deaths from these two diseases types”. That number many argue is a drop in the bucket compared to the more than 125,000 deaths in the US alone in six months of the pandemic. But If that model be the case 10 years out, then COVID-19 would still be winning our battle with it. Now may be the time we begin to see to it that we win instead. We must resume screening and preventive care and not defer, delay or cease altogether in a safe and predicable way that prioritizes patient, staff and provider safety. We must navigate the circumstances we find ourselves somehow before we go too far out and get lost and too far down the road to return. We must resume and act now and possibly make up for lost time.

CREDITS: (GRAPH) V. ALTOUNIAN/SCIENCE; (DATA) NATIONAL CANCER INSTITUTE

References:

https://science.sciencemag.org/content/368/6497/1290

https://www.cdc.gov/mmwr/volumes/69/wr/mm6925e2.htm

Right in the middle of a pandemic by a virus that loves groups and close quarters  of people, there is an outbreak of protests in response to a broad daylight public display asphyxiation murder of George Floyd, a black man by the Minnesota white police. In response, the streets are flooded by a sea of outraged protesters . Epidemiologists predict health facilities have to brace up for the imminent uptick in transmission and cases of COVID-19 infection. The struggles and history of ethnic minorities and persons of color have always been told, but never has it been so downright draped on ones consciousness, especially for the generations that did not witness the civil rights movement past, the gaping wounds left behind by a long unrelenting history of disparity that is so evident in a society. The link has never begged to be made that always has  existed a not-so-novel a virus of disparities, of social  and economic inequities, pervasive injustices, inequalities in educational opportunities. These social ills leave in their wake a roadmap for the lethal effectiveness and pathogenesis of COVID-19, the real novel virus  that followed . A disease, a new enemy virus,  that seemed to have earmarked whom, where and how it would hit disproportionately the hardest, communities of color, knowing how those have been forced to  live, breathe, eat and the work in America , a nation that once boasted promise of greater lives for those who set foot on her shores.

The old virus, the true “preexisting conditions” happens to be the social inequalities, disparities, unequal educational opportunities and injustice, hurdles that seem not go away. These hurdles give birth in communities of color to :

1. Inescapable urban living as against suburban or rural living, in crowded cities with poor air quality, multi-dweller apartments , close quarters and overcrowded cross-generational household with parents, grandparents and grandchildren that promotes disease transmission, difficulty practicing household hygiene and social distancing. According to a national survey, 56% of residents of urban counties are non-White, compared to 32% non-White in suburban counties and 21% non-White in rural counties. This is largely because black families earn less than white families and the wage gap has grown relentlessly. While the nations poverty rate has trended down in recent years from the lows of more than a decade ago, poverty for blacks stand at 20.8% compared to 8.1% for non-Hispanic whites.

2. Jobs and high exposure duties , low level, mid level and frontline employment  that must remain attended, essential, even when there is a lockdown and other workers stay home. These include our bus drivers/conductor, nurses, hospital janitors , postal/mail delivery worker. It may be true that many were able to keep their jobs but at the increased risk of catching the virus and paying with their lives.

3. Poorly educated and skilled persons . They are the members of society who have been robbed of occupations, operations and work tools that otherwise make it possible to effectively telecommute, telework and remote work from home. 

4. High consumption and dependence on public amenities including public transportation that increase exposure to disease and contamination. People and families of color are more likely to use public transportation to commute to work , church and shopping than their white counterparts.

5. Food insecurity and inability to access healthy diet and nutritious food leading to obesity, diabetes and high cholesterol.

6. Poor access to health services. Even with improvements in health care coverage for all racial/ethnic groups after passage of the Affordable Care Act in 2010, the statistics show Blacks (15%) and Hispanics (27%) were still significantly more likely than Whites (9%) to be uninsured in 2018.The Economic Institute found that black workers are 60% more likely to be uninsured than their white counterparts.

Constant accompaniment of the highlighted socio-economic predicaments confronting the communities of color are hypertension, obesity, heart disease,  and diabetes, and remain the foundations and etiology of our medical confounding features, the so called co-morbid conditions in the black and brown communities. 
New Jersey for instance with its estimated population of nearly 8.9 million, white alone 72% and black people contributing 15%, reported more than 11,700 deaths of which a disproportionately higher percentage of 18.5 % was black followed by Hispanic or Latino. Whites comprised disproportionately smaller 53% of the deaths.The unemployment among blacks soared nearly 17% as a result of the pandemic. If not for these socio-economic, educational “preexisting ” inequities of over 200 years in America , there will not be the glaring disparities in COVID-19 transmission, morbidity and mortality in the communities of color vs white communities as seen in this pandemic. 

The post COVID-19 era must be prescribed differently for the brown and black communities. Mitigation must carry on and continue into the future post COVID-19 for those who will be left to carry on. Measures to get people of color out of poverty, improve education and skills acquisition, better housing must intensify and endure. Focus must be on social justice for all, opportunity, fairness and equity.The fight to control obesity, hypertension, heart disease, diabetes and kidney disease are ineffective without surgically addressing the preexisting inequities of the black and brown experience in America and the world at large. For their part providers , physicians and health officials cannot fully discharge their role without embracing fully the advocacy for change for this segment of our society, who bear the brunt of inequity, one that continually invites the greater burden of disease, morbidity and mortality.