How Close Are We to Really Understanding What is Going On?

If you feel really confused about what is going on with this pandemic, you are not alone. Many the real experts are perplexed, and the confusion is sometimes made worse by some of the “TV experts” who are called upon to enlighten us while they bask in their 15 minutes of fame.  As a physician who has had basic science training and decades of experience in the past practicing internal medicine, pulmonary disease and critical care medicine, I too feel that that our collective experience is much like that of the “blind leading the blind” while our elected leaders try to persuade us that we are on the right path.  If truth be told, we re still wandering in the wilderness right now.  Here are but a few examples of  the confusion that we are dealing with and a smattering of logic along with them that might shed some light on the hidden realities surrounding this pandemic.

First, let’s take at look at the whole question of masks and social distancing. The central issue here at the beginning was whether or not facial masks were needed when we were out and about. Initially we were told that masks were not necessary except for care givers, first-responders and others in very close proximity to people infected with the virus. We were told that it was more important for infected people to wear them than non-infected people. Discussions were had in the media by the many “experts” first telling us that masks were not needed because the droplets from a sneeze or a cough cough do not travel very far and that there was very little risk of aerosolization or airborne transmission of the virus. A greater risk seemed to be the dormancy of the virus on various surfaces so that surface contact posed a greater risk than inhalation of a droplet that was coughed or sneezed out by a sick person. Here logic would dictate that if you were in danger of being in close proximity to someone coughing or sneezing, say in an elevator or crowed subway car, an ordinary surgical mask and eye protection would provide some degree of protection and if not a surgical mask than any type of face covering. However, we were not initially told that, or at least it wasn’t emphasized. Nor were we told that airborne transmission or aerosolization could possibly occur even in situations unrelated to ventilator management as in a hospital setting. For situations like this really an N-95 type mask, or better, would be needed. I don’t believe these were deceptions on the part of our medical commentators,  but rather failing to think logically or perhaps a failing to question recommendations by the prevailing authorities of the moment.  Yes, it is very important for sick people to wear the mask to protect others, but it seems very likely that wearing a mask even if you are not infected yourself gives you some degree of protection when you are in an environment where airborne exposure to the virus may occur.

Second, let’s take a look at the testing issue. From an epidemiologic point of view it’s most important to understand how many of us have or have had the virus, how may of us are symptomatic and how many of us are asymptomatic. This can only be done by testing for the virus itself to see if there is active disease or colonization and by testing for antibodies to the virus to see if there has been exposure in the past. There are a number of different manufacturers for the these tests. Unfortunately the tests are in limited supply for a variety of reasons, and it is not yet clear that all the various types of testing kits have been independently validated by the FDA.  So we are left in a situation where it is hard for us to get the testing done (in spite of what we are being told by many of our leaders), and there are questions about the validity of the testing. Are the tests comparable? Yet it is vital for us to have this information because without it we really do not know the actual prevalence or mortality rate of this disease. 

Third, let’s take a look at the issue of medications and vaccines. If the Sars-CoV-19 which causes the disease known as Covid-19 is like the simple cold virus, to which it seems to be related, or similiar to the common influenza virus, the likelihood is that it can mutate on a regular basis. If so, it makes it likely that any vaccine we eventually make will be only partially effective, which is much like the case now with influenza virus. That is unless we can develop a vaccine directed against an immutable part of the virus (a part of the virus that does not mutate). This may be difficult or impossible to do as evidenced by the fact that we need to get a different flu vaccine every year. Hand in hand with the development of a vaccine we need to make anti-viral medications just as we do for bacteria infections.  So far we have no definitive treatment modalities in that regard. Off label use of hydroxychloroquine and azithromycin have received a lot of anecdotal support, but have not yet been fully vetted. Both are old, easy to obtain drugs with relatively few side effects which makes them attractive for use. Although the anecdotal reports and some early studies are interesting, there have been some recent studies that claim to show some detrimental effects in Covid-19 patients. There are also a handful of other antiviral agents that are now being looked at for effectiveness.  Anticytokine type drugs have also been tried in some cases of Covid-19 with some success. For example, drugs like Actemra interfere with the progression of the “cytokine storm” which can be triggered by infection with the Sars-CoV-19 virus. The so-called “cytokine storm” is almost like an autoimmune reaction that is triggered by the virus resulting in a severe inflammatory response which can be very damaging to the lungs and other organs of the body. The downside of some of these drugs may be that they weaken the immune response to such a degree that the body becomes even more susceptible to infection. 

Fourth, let’s take a look at the concepts of herd immunity and social distancing.  Here’s the paradox. Herd immunity would be the ideal, but how do we get there without sacrificing more lives and illness? Herd immunity occurs when so many people in a community become immune to the illness that it not longer spreads. This usually occurs when anywhere between 40% to 90% or more of the population has immunity. The more infectious the illness , then the greater the percentage required to achieve herd immunity.  The concept of “herd immunity” is sort of like restating the obvious because it is obvious that the more people who are immune , the less likely we see new infections.  So we can get herd immunity either by vaccination or by naturally acquired immunity. The latter requires that people be exposed to and acquire the illness either symptomatically or asymptomatically. This is obviously not without risk because it could result in an overwhelming portion of a population becoming sick in a short period of time resulting in catastrophic effect on the health care system. Yet countries like Sweden decided to take this approach relying on naturally occurring immunity with a marked degree of success. They did not close cafes, schools, gyms and other social gathering places. The asked their citizens to act responsibly and maintain social distancing, but they did not close things down.  How they were able to do so without a devastating effect on their health care system is unclear at this point, but perhaps it had to do with Sweden’s population density and the rate of infection. If the rate of infection is slowed by virtue of such things as population density and social distancing, then the virus spreads into the population more slowly and does not overwhelm the health care delivery system. Population density issues in cities like New York City make such an approach impossible as we have already seen. 

More thoughts about this pandemic to come in subsequent posts……..


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