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The Okanagan Valley in British Columbia, Canada is typically best known for its wineries, fruit orchards, and beautiful Okanagan Lake. But this week it’s making headlines based on a misguided misinterpretation of how the Covid-19 vaccines work. Steve Miller, owner of Sun City Silver and Gold Exchange, in the Okanagan city of Kelowna, spoke to Global News earlier this week: “We would rather not be exposed to people who have been vaccinated and who could shed the virus…Shedding is real, it’s a problem now and it is going to be a bigger problem as more and more people line up for these experimental vaccines.” There is also a sign banning mask-wearing inside the store. According to the city’s risk manager, the store is operating without a business license, and is promoting orders against those stated by local and regional public health officials.

Where does this notion of viral shedding after vaccination stem from, and is there any validity to this? As detailed in Victoria Forster’s recent Forbes piece, not only can’t you contract Covid-19 infection from the Covid-19 vaccine, you also cannot spread or shed virus from receiving the vaccine. This goes for any of the currently available Covid-19 vaccines, including those made by Pfizer-BioNTech, Moderna, Johnson & Johnson, and AstraZeneca.

Historically, and in some instances currently, some vaccines were made with either a reduced amount of live virus, such as smallpox, chickenpox, or measles, mumps rubella (MMR) or a small amount of inactivated/killed virus, such as hepatitis A, flu, or polio. Other vaccines, such as hepatitis B, human papillomavirus (HPV), and shingles (herpes zoster) use a tiny piece of a protein or sugar fragment from the pathogen. Still others are what’s know as toxoids, and are much shorter acting, as they provide only a miniscule amount of a toxin from the germ. Toxoid vaccines include diphtheria and tetanus, which last only five to ten years and require regular booster shots.

Both mRNA vaccines (Pfizer-BioNTech and Moderna) as well as both adenovirus-vector DNA vaccines (Johnson & Johnson and AstraZeneca) provide protection by enabling the recipient’s cells to produce the now infamous spike protein of SARS-CoV-2, or Covid-19. None of these vaccines enable the recipient to internally manufacture a virus. None of them. As Dr. Forster explained, “It’s like four tires on the starting grid of a racetrack, you know that they are car parts, but there’s no way someone can drive them around without the rest of it.” Spike proteins alone do not make a virus. The virus is comprised of RNA at its core, nucleoproteins, and the critical viral envelope, which protects it when it’s floating around looking for a host cell to grab onto with those spikes. Picture the image below with just the red spikes. They would fall to the bottom, as if a toddler smashed a well-constructed Lego set after you’ve already thrown out the instruction book, and managed to throw out a random number of critical pieces.

Thankfully a toddler is not behind mRNA technology, which uniquely enables formation of a specific spike protein, not a whole virus. Forming spike proteins simply primes one’s own immune system to form antibodies to bind to spike proteins, preventing viral replication if the real deal coronavirus sneaks into the vaccinated individual’s respiratory tract. If the spike proteins get blocked with said antibodies, the virus can’t replicate, can’t make you sick, and will be less likely to spread to others. But getting vaccinated has absolutely nothing to do with viral shedding. There is no virus formed internally after receiving any Covid-19 vaccine. That said, as more and more people get vaccinated (as of today, over 1 billion individuals worldwide have received at least one dose of a Covid-19 vaccine), immunity to getting infected, sick, and contagious does not fully develop until two weeks after the second dose of a two-dose regimen, or two weeks after a single-dose vaccine. In the early weeks following an individual’s vaccination, they remain just as susceptible for infection and spread as un-vaccinated people. But they won’t shed virus from the vaccine.

In India, more than 332,000 Covid-19 infections were reported today, along with approximately 2,250 deaths. Both figures shattered previous daily records for the country. India has a nearly vertical coronavirus case growth curve. Similarly, the daily reported deaths curve’s slope is practically vertical. The official daily death toll is probably a significant underestimate. Moreover, soaring test positivity suggests the case count is also vastly underestimated.

Maharashtra, India’s second most populous and wealthiest (per capita) state, tops the list of most affected states in the country.

A fragile and fragmented healthcare system is buckling. Hospitals have been overwhelmed and have had to turn away scores of patients. There aren’t enough beds. There is an acute need for all kinds of medical supplies. Hospitals in the Mumbai and Delhi regions are running short on oxygen. In a video that has gone viral, a Mumbai physician, Dr. Trupti Gilada, describes the severity of the current crisis, and provides fellow citizens guidance on how to prevent contracting coronavirus as well as advice on what to do in case one falls ill.

Until this latest surge, the prevailing thought was that given India’s high population density it had done a remarkable job curbing the spread of Covid-19 and keeping the death rate comparatively low. But as Professor Madhu Pai, Research Chair of Epidemiology and Global Health at McGill University, explains, India has become a Covid-19 cautionary tale for the whole world. Government officials declared victory over Covid-19 too soon. In mid February Prime Minister Narendra Modi asserted that India’s “successful fight against Covid-19 is inspiring the entire world.” Authorities lifted most lockdown restrictions designed to stem the spread of the virus. Poor public health messaging ensued and people dropped their guard, many becoming non-compliant with masking and social distancing protocols. Large mass gatherings took place, including election rallies and religious festivals.

Also, despite having a considerable capacity for vaccine output – the Serum Institute of India is after all the world’s biggest vaccine maker – India ranks far behind China, as well as almost all European nations and the U.S. in terms of Covid-19 vaccine doses administered per 100 people.

Antibody tests taken several months ago indicated that in certain areas of India, such as Delhi, as many as 50% of the population had been exposed to the novel coronavirus. Yet, one of the world’s worst Covid-19 spikes on record is currently taking place in precisely those areas.

How much of a role the new Covid-19 variants play is uncertain. Specifically, questions have been raised around the B.1.617 variant, which was first detected in India in October 2020. The B.1.617 variant carries two mutations; E484Q and L452R. Both mutations may help the virus evade antibodies in the immune system, and as a result become partially resistant to one or more vaccines. This said, it’s highly unlikely the mutations would make vaccines completely ineffective.

Genome sequencing data suggests evidence of the “double mutant” B.1.617 in more than 60% of samples in Maharashtra. However, it’s still not determined the degree to which this new variant is driving the current surge. Scientists have also not ascertained this variant’s virulence, and whether it makes people more vulnerable to reinfection, more infectious, and more resistant to vaccines. There simply hasn’t been enough data sampling. In lieu of more evidence, the B.1.617 variant retains its “variant of interest” denotation rather than “variant of concern.”

Thus far the world’s reaction to the catastrophe unfolding in India has been muted. A number of Western countries have instituted travel bans, barring flights from India. But, besides offering words to express concern, Western leaders haven’t put forward constructive plans to help address the Indian crisis at hand. Surely, in short order much can be done to deal with India’s acute needs. For one thing, the U.S. could lift the embargo of raw material exports that supply India’s vaccine manufacturers. In addition, the U.S. is currently hoarding vaccines. For example, it has an inventory of at least 35 million doses of Astra Zeneca vaccine which it will likely never use. And, the U.S. and other countries could airlift personal protective equipment, oxygen, ventilators, Covid-19 treatments, and even trained personnel to various hot spots.

The Covid-19 emergency in India isn’t merely a humanitarian crisis of potentially monumental proportions. It also has negative repercussions for global economic growth, international reopening plans, and supply chains for a wide variety of products, including vaccines. India is the world’s 6th largest economy; the second largest emerging market, behind China. It is one of the world’s leading manufacturers of Covid-19 vaccines. Yet now, it cannot export vaccines to other nations in need. India’s desperate circumstances consequently have a snowball effect on vaccination efforts in other nations.

Worldwide, the Covid-19 pandemic is in a rapidly ascendant phase in a number of countries, including India. Clearly, the pandemic is far from over. Given the world’s interdependence, the motto, no one is safe until we are all safe, applies.

Are you one of the millions of Americans who used telehealth services – possibly for the first time – last year? Will you continue to do so post-pandemic? Many patients (and healthcare providers) discovered the benefits this type of appointment can bring when COVID kept us at home, and began using it for conditions and visit types unheard of in the past.

Doing so meant eliminating the stress and expense of traveling to a doctor’s office, reducing the chance of infection, time and fuel savings, adding patient convenience, improving access to doctors for those unable to drive (and reduced dependence on others for transport), and access to out-of-area providers.   

Telehealth vs. Telemedicine

The American Academy of Family Physicians defines telehealth as referring “broadly to electronic and telecommunications technologies and services used to provide care and services at a distance” and telemedicine as “the practice of medicine using technology to deliver care at a distance.” The distinction between the two is scope. “Telemedicine refers specifically to remote clinical services, while telehealth can refer to remote non-clinical services.”

Augusta, Georgia-based Rafael Salazar II provides patient rehabilitation services remotely and worked on the state’s telehealth guidelines last year. He says that this capability allows clinicians to deliver quality, high value care across a wider geographic area, noting, “The addition of virtual health services can decrease the cost of care in many ways, such as early detection, prevention, decreasing lengths of stay or courses of traditional in-person care.”

Expanding Services

SreyRam Kuy, a board-certified Houston, Texas-based surgeon, notes that while these services have existed for years, their use is expanding to new practice areas. “About a year ago, I’d never done a video appointment to see a surgical patient; aside from telephone calls, all were seen in the clinic.”

The belief in her field was that you needed to lay hands on a patient to determine if they were surgical candidates, or check to make sure the patient didn’t have a postoperative complication. “In the surgical community, we just didn’t routinely think we could do those things by video.”

COVID changed this mindset, she shares, with its imperative to provide services and reduce exposure to the virus. “As it turned out, our concerns about challenges of adopting telehealth were rapidly relieved. Yes, we can do a post op wound check by video. Yes, we can preoperatively examine a patient by video and assess them as candidates for surgery. And yes, we can protect our patients from risks of unnecessary travel during the COVID-19 pandemic.” This was particularly beneficial to Kuy’s older patient population, which accounted for about half of her telehealth appointments, she says. “The adoption of telehealth in our general surgery clinic has been phenomenally rapid.”

Mental health visits – called teletherapy when done virtually – are another increasingly popular form of telehealth, Roseann Capanna-Hodge, author of the Teletherapy Toolkit and a Ridgefield,  Connecticut-based educational psychologist, says. Her virtual visits have grown from 15% of her practice to 50%, she reports. “Compared to adults, kids can do as well or better in a virtual appointment,” Hodge comments.

Board-certified internal medicine doctor Alexandra Sowa of New York City created an at-home lab test to check for insulin resistance and metabolic health, pairing it with telehealth services for her largely tech-savvy Millennial patient base. Home-based diagnostics and devices support telehealth services by allowing patients to facilitate some of the testing on their own that was previously only available in doctors’ offices. “Several telehealth appointments will be ahead of, or following, some at-home diagnostics,” Sowa shares.

“Blood pressure checks, blood sugar checks, heart rate checks can all be easily done at home, and the information quickly sent to your physician for telehealth follow up,” Kuy says. 

Safety and Security

The common element of all of these disparate services is care in your home. That means your living space needs to be set up in a way that facilitates your service needs. “First, pick a room that’s quiet and secure,” Kuy suggests. “It needs to be quiet enough that you can hear your doctor easily, and your doctor can hear you. Second, the location needs to be secure, so that unauthorized people won’t be able to overhear your private healthcare information. It also needs to be secure so that if you are being examined as part of the visit, someone doesn’t walk in on you.” 

The surgeon suggests a room that can be locked from the inside. She also recommends having access to a phone and providing that number, along with your location, to the doctor in case of an emergency during your appointment. The phone can double as a backup means of communication if your technology fails during the visit, as can certainly happen.

“Privacy is very important for a telehealth or teletherapy appointment because without it, a patient won’t feel comfortable to speak truthfully,” Capanna-Hodge points out. “Creating a physical space that has privacy and audio and video capabilities for a telehealth or teletherapy appointment is ideal. You want to make sure that you won’t be interrupted or distracted, so you can make the most of your time with your provider, as well as respecting the time your provider has created for you.” 

She suggests setting boundaries for your household before an appointment, so that everyone knows when you can’t be disturbed. “Having a schedule on the door to let everyone know this is your time can go a long way in improving communication and reducing friction.” 

Efficiency and Comfort Planning

Within your selected area, you also want to have everything you need handy, Sowa suggests. “Ensure you have any relevant medical devices, medications, or required items in an accessible area.” Having these stored close to where you’ll be participating in these sessions will be essential for as many sessions as the clinician schedules with you. The internal medicine specialist also recommends having your insurance cards close at hand in case your physician’s office requests the information before or after the consultation.  

If you’re going to participate in a series of teletherapy sessions, Capanna-Hodge suggests adding to your feeling of safety by creating a supportive space for your visits. “Adding in sensory items can soothe nerves and make for better experiences,” the psychologist notes. “Creating a comfortable environment could be sitting in a big comfy chair, having a soft blanket or pillow, using a weighted blanket, diffusing essential oils, lavender or scented candles, or dimmed lights. Accessing one’s senses to reduce stress can support the subconscious to calm enough for one to have better mental control and thinking to do therapeutic work.”

“Design for telehealth from the home may be similar to the set-up for home offices, but should provide adequate support to access any health-monitoring equipment used by the patient,” recommends Susan Chung, vice president of research for the American Society of Interior Designers. For ongoing needs, she suggests, “Homeowners could consider having a wellness room that functions as a telehealth space, can be transformed for in-home care when needed, but used as a refuge area overall.”  

Technology Needs

“Both parties need to have a device with a screen (smartphone, tablet, or computer),” rehab specialist Salazar comments. “Make sure that they’re charged, plugged in, or that you have a power supply at the ready, as some devices deplete battery at a faster rate when they’re used for video conferencing.”

Ryan Herd, a Pompton Plains, New Jersey-based technology integrator who specializes in caregiving for seniors via smart home systems, works with both family members and patients in making telehealth work well. “Internet service provider quality and speed are paramount, followed by Wi-Fi in the loved ones’ home,” he advises. “Depending on how many Wi-Fi devices the person has, the size of their home, and where they would like to do the telehealth appointments, the client might need to update their ISP speed; I would suggest a package of 100 megabits per second or greater.” He also points to the age of a client’s router, noting, “We have seen routers that are 10 years old in clients’ homes. That is old technology that has issues connecting with the new smart devices used by telehealth.”

His older clients typically don’t want all of the bells and whistles available in a full-scale smart home or wellness space, he says. “As an industry, we need to do a better job of explaining the benefits of using technology to support or enhance their lifestyle, independence, and dignity.” In the wellness realm, the potential is tremendous.

Final Thoughts

“Telehealth is so much more than ‘Zoom calls’ with your doctor,” Salazar comments, “but is a tool to address whatever the condition is.” He predicts a hybrid healthcare model where in-person and remote services work seamlessly together. “Telehealth, and all that it encompasses, has the ability to radically transform the way healthcare is delivered.”

A man with his sleeves rolled up speaks into a headset while staring at a laptop.
Enlarge / In this 2011 photo, Dr. Michael A. Lee uses Dragon Medical voice-recognition software to enter his notes after seeing a patient.

Earlier today, Microsoft announced its plans to purchase Nuance for $56 per share—23 percent above Nuance’s closing price last Friday. The deal adds up to a $16 billion cash outlay and a total valuation for Nuance of about $19.7 billion, including that company’s assumed debt.

Who is Nuance?

In this 2006 photo, Rollie Berg—who has extremely limited use of his hands due to multiple sclerosis—uses Dragon NaturallySpeaking 8 to interact directly with his PC.
Enlarge / In this 2006 photo, Rollie Berg—who has extremely limited use of his hands due to multiple sclerosis—uses Dragon NaturallySpeaking 8 to interact directly with his PC.

Nuance is a well-known player in the field of natural language recognition. The company’s technology is the core of Apple’s Siri personal assistant. Nuance also sells well-known personal speech-recognition software Dragon NaturallySpeaking, which is invaluable to many people with a wide range of physical disabilities.

Dragon NaturallySpeaking, originally released in 1997, was one of the first commercially continuous dictation products—meaning software that did not require the user to pause briefly between words. In 2000, Dragon Systems was acquired by ScanSoft, which acquired Nuance Communications in 2005 and rebranded itself as Nuance.

Earlier versions of Dragon software used hidden Markov models to puzzle out the meaning of human speech, but this method had serious limitations compared to modern AI algorithms. In 2009, Stanford researcher Fei-Fei Li created ImageNet—a massive training data set that spawned a boom in deep-learning algorithms used for modern, core AI tech.

After Microsoft researchers Dong Yu and Frank Seide successfully applied deep-learning techniques to real-time automatic speech recognition in 2010, Dragon—now Nuance—applied the same techniques to its own speech-recognition software.

Fast forward to today, and according to both Microsoft and Nuance, medically targeted versions of Dragon are in use by 77 percent of hospitals, 75 percent of radiologists, and 55 percent of physicians in the United States.

Microsoft’s acquisition play

Microsoft and Nuance began a partnership in 2019 to deliver ambient clinical intelligence (ACI) technologies to health care providers. ACI technology is intended to reduce physician burnout and increase efficiency by offloading administrative tasks onto computers. (A 2017 study published in the Annals of Family Medicine documented physicians typically spending two hours of record-keeping for every single hour of actual patient care.)

Acquiring Nuance gives Microsoft direct access to the company’s entire health care customer list. It also gives Microsoft the opportunity to push Nuance technology—currently, mostly used in the US—to Microsoft’s own large international market. Nuance chief executive Mark Benjamin—who will continue to run Nuance as a Microsoft division after the acquisition—describes it as an opportunity to “superscale how we change an industry.”

The move doubles Microsoft’s total addressable market in the health care vertical to nearly $500 billion. It also marries what Microsoft CEO Satya Nadella describes as “the AI layer at the healthcare point of delivery” with Microsoft’s own massive cloud infrastructure, including Azure, Teams, and Dynamics 365.

The acquisition has been unanimously approved by the boards of directors of both Nuance and Microsoft and it is expected to close by the end of 2021.