Welcome to Thunderdome

These posts usually have to do with health issues that may affect all of us and are not really politically oriented, and to preface the following comments neither is this post politically oriented per se.  However, the concept of defunding or disbanding the police departments of American cities will inevitably have effects on the physical and mental health of our country and its citizens.

Let’s take a look at what this really means and more importantly let’s take a look at what may be the real motive behind this. “Defund the Police” is the new war cry of the liberal left or more specifically the anarchist groups like ANTIFA and others, but take a moment and think about this “social change” from their perspective.  These groups are not just stupid rabble rousers. Far from that they are compulsively driven, calculating and manipulative.  These leftist groups know that their communities will need policing.  It is inevitable.  After all, who is going to protect them when one of their own begins to steal, rape or murder? What these groups really want is to police their own neighbors with their own enforcers and their own court systems all controlled by their own oligarchy of  “leaders” who will likely drive their power through intimidation and fear. They do not want any interference from a centralized government whatsoever unless they ultimately become the centralized government. What they want is a tribalized society with the loudest and strongest amongst them becoming the leaders who will meet out justice as they see fit. Welcome to the World of Mad Max and Thunderdome where might makes right and the weak are left unprotected. Europe’s “no go zones,” in which militant Muslims have total control of some areas where even the police fear to venture, may have been the models for this concept.  As much as this type of a take over may appear to be unlikely it has already happened in some of the large cities of Europe.  Even Angela Merkel, Chancellor of  Germany has acknowledged these changes.

In essence these anarchists in our own country want their own countries within the U.S. Once they’ve grown sufficiently strong enough through intimidation and fear they will want to establish their own form of government which will not be a democracy but rather an oligarchy controlled by people with absolute power.  In the meantime they want the financial support of the federal government of the U.S. without any responsibility to the federal government. It’s a little like paying for the bullet that kills you.

As I said before, these posts usually have to do with medical issues, but in the broader context, this idea of “defunding” or eliminating the police departments around the country will have obviously have effects on our physical  and mental health. Imagine a world where you have no choice and no control as an individual…where your every thought and decision about mandated by a mob. How could this possibly be healthy?

Pandemic

More on masks….and the Confusion Surrounding Their Use

So much has already been written and discussed about the appropriate use of masks during this pandemic, but it still remains a confusing topic especially for those who are not front line care givers, first responders or in high risk occupations.  For those of us who are, the need to wear all the appropriate personal protective equipment (PPE) including the N-95 face masks and the like is quite clear.  The risk of exposure for such individuals is great, and therefore so is the the need for protection.  However, for those who are not on the frontline wearing a mask may simply be an expression of  an unreasonable fear or perhaps confusion about what should be done to protect oneself and others in a low risk environment.  A lot of this fear and confusion may be perpetuated by governmental authorities who feel that they need to control in every aspect what we do as individuals because ordinary people are not really capable of making sound judgements regarding their own care.  Dr. Fauci says he wears a mask because he wants to protect himself as well as others and also because he wants to make a mask a “symbol” for people to see that it’s “the kind of thing you should be doing.” However, do we really need a symbol in place of real information about what we should be doing and why so we can make our own sensible judgements?  Or, is the promotion of this “symbol” just something to help enforce compliance with a lot of rules and regulations that at this point in the pandemic are of questionable value?  Countless times I have seen people riding alone in cars with face masks on, riding bicycles on country roads or walking along deserted streets with face masks on.  Just recently I saw a woman leave her suburban house to walk down her driveway to her mailbox with mask and gloves on to pick up her mail with no one within a hundred feet of her.  I don’t think the use of a mask in situations such as these reflects symbolism or appropriate protectiveness to any degree.  Instead, I think this type of behavior reflects a paranoia engendered by the media and to some extent by governmental bodies which are confused, but none the less determined, to control our activities by telling us what we need to do even though there may be little or no proof that what they are telling us is indeed correct.  So having said all of this let’s take another realistic look at how and when masks might be used in the daily lives of ordinary people and not those of first responders, front line care givers or workers in high risk occupations.  To do so let’s also take a realistic look at how this virus spreads realizing that there is still a lot that needs to be learned. 

First, the virus can indeed spread between people interacting in close proximity.  For example, speaking, coughing, or sneezing can spread the virus from an infected individual to an uninfected individual.  However, the key words here are “close proximity.”  Usually that means within 6 to 9 feet of each other.  In light of this evidence, CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (for example, grocery stores, pharmacies, subways, buses, public buildings, etc. ) especially in areas where there is significant evidence of disease spread.  However, keep in mind that simple cloth masks will only help prevent large droplet transmission and not small airborne viral particle transmission.  So simple cloth masks may help somewhat in certain circumstances where close proximity is an unavoidable issue because large droplets will be retained by the cloth mask.  However, small airborne viral particles will not be retained by a cloth mask, nor will a cloth mask filter out such particles and prevent them from being inhaled by someone else.  So for the person with the virus who is coughing the cloth mask will help stop the droplets containing the virus from settling on another person, but it will not stop the tiny airborne viral particles themselves from being dispersed to others.  For the person who is not infected and wearing a cloth mask, the cloth mask will only help prevent the large droplets from reaching that individual but not the tiny airborne viral particles themselves. To help prevent airborne viral particle transmission which would be necessary in situations of close contact, an N-95 mask or better would be needed. Therefor, it makes very little sense to wear a mask of any kind when you are out and about away from people like when going for a walk or bike ride on country road, driving in your car alone, walking along a beach, etc.

 

More on Other Modes of Transmission

The coronavirus can live for hours to days on surfaces like countertops and doorknobs, but how long it survives depends on a number of factors like the texture of the surface, heat and humidity.  There is also evidence for fecal oral transmission.  A lot still has to be learned about how long this virus can survive outside the body, but as of now it seems that you are much more likely to catch it directly from another person than from surfaces.

Finally a Word About Mutation of the Virus

 

Viruses can mutate and that can cause a problem in terms of vaccines and treatments. However, mutation is not always a bad thing. Sometimes mutations can lead to a weakening of the virus so that it eventually dies out. The Sars C0V -2 virus seems to have a slower mutation rate than the influenza virus so that may be a good thing for vaccine development.  

The World Health Organization

WHO and the Covid-19 Pandemic

What did the leader of the World Health Organization know and when did he know it?

First, let’s look at some background information about the World Health Organization and it current director general Tedros Adhanom Ghebreyesus.

What is the mission of the World Health Organization (WHO)?  According to its charter it is supposed to “aim for the attainment by all peoples of the highest standard of health.”  It’s object is “to improve peoples’ lives and reduce the burden of disease,” and it is supposed to be the “coordinating authority on international health.” However, regarding the coronavirus pandemic it has failed miserably in its stated objectives. Much of the responsibility for this failure can be laid at the feet of its current Director General, Tedros Adhanom Ghebreyesus.  He is not a physician though he has a master’s degree in immunology and PhD in community health from colleges in Great Britain. He is Ethiopian and served as minister of health in Ethiopia from 2005-2012 and then minister of foreign affairs for Ethiopia from 2012-2016 following which he became Director General of the World Health Organization in 2017. It should be noted that Tedros Adhanom Ghebreyesus, who apparently according to Ethiopian tradition prefers to be addressed as “Tedros,” won the election for Director General of the World Health Organization largely because of the support of China which may explain why the WHO has seemingly become a tool of China in regard to the current coronavirus pandemic. It should be noted that the U.S., Canada and the UK supported British physician, Dr. David Nabarro for this position. The U.S. has been by far the largest financial supporter of the WHO for decades.

Tedros’ tenure as Director General of the WHO and before that as health minister for Ethiopia has not been without controversy.  The most recent of which has been his handling of the coronavirus pandemic (see below). While minister of health in Ethiopia he was accused by some of his country men of covering up Cholera epidemics. The organization “Human Rights Watch” also criticized Tedros during his campaign for the Who Director General position accusing him of being a proponent of an authoritarian regime in Ethiopia that persecuted its political opponents (Tedros). At one time he appointed Zimbabwe dictator Roger Mugabe as a goodwill ambassador for WHO. His appointment of a Russian to head WHO’s tuberculosis program was also regarded as controversial because of Russia’s poor history of tuberculosis management. Putting aside some of the controversial issues regarding his tenures as health minister and foreign affairs minister for Ethiopia, let’s focus in on how his actions concerning the coronavirus led to a worldwide pandemic.

How WHO’s Actions Promulgated  the Coronavirus Pandemic.

To do so Let’s look at the timeline beginning when the virus first arose in China.

  • Various reports suggest that the first case arose in Wuhan, China in early December or perhaps as early as November
  • December 30, 2019 an ophthalmologist at Wuhan Central Hospital alerted other physicians about the emergence of a SARS like illness. He was subsequently detained by police. Reports indicate that China also took measures to prevent information about the human to human transmission of the disease from being disseminated by people in its medical and scientific communities.
  • In late December 2019 the Wuhan Health Commission reported 27 cases of viral pneumonia.
  • On December 31 the Taiwan government contacted WHO and expressed its concern that that there was human to human transmission of this virus. WHO ignored this report in deference to China because Taiwan is not an official member of the WHO and China does not acknowledge Taiwan’s independence. 
  • January 1, 2020 Wuhan official close the Hunan wet market in an apparent attempt to blame the wet market as the source of the infection as opposed to the virology lab in Wuhan. We now know that it is much more likely that the virus somehow escaped from the Wuhan Institute of Virology either accidentally (or intentionally if  you suspect that China has some ulterior motives).
  • Beginning in January  2020 China begins a campaign to acquired more medical supplies in anticipation of the pandemic occurring.
  • By January 14 the WHO is still reporting that investigations by the Chinese found no clear evidence of human to human transmission. This is the official position that the Chinese maintained until January 21 in spite of protests to the contrary by some of its own physicians and scientists. However, internal documents obtained by Associated Press indicate that Chinese officials knew a pandemic was occurring much earlier (AP) .
  • The Chinese New Year was on January 25th. Many Chinese returned to Wuhan in January to celebrate the holiday after which they returned back to various parts of the world where they were living and working carrying the virus back with them to be disseminated throughout the world.
  • Jan 23 China puts Wuhan in lockdown. Chinese nationals can apparently leave Wuhan for other parts of the world, but are prohibited from flying to other parts of China in an obvious attempt to prevent the spread of the virus within China.
  • Jan 21 First Case Confirmed in the US.

At no point through all of this did the World Health organization under Tedros leadership raise any warning signs about the coming pandemic. Instead, it took the World Health Organization until March 11, 202 to declare the pandemic (WHO).

 

 

 

 

 

 

 

The Dilemma of Immunity

While we await the development of  vaccines for SARS-CoV-2 virus here are a few things to consider. First, will this virus be very much like the influenza virus meaning will it have a yearly variation or mutation requiring a new vaccine every year ?  The answer to this is very likely “yes” since in many respects this virus is like the influenza virus.

Second, how effective will the vaccine be? There are likely to be several different variations of this vaccine produced in the U.S. and elsewhere. It is very likely that we will not know for quite some time which will be most effective.

Third, there is the whole question of herd immunity. Most epidemiologists would agree that anywhere between 40-60% of a given population has to be immune either by prior exposure and subsequent immunity (so-called “naturally acquired immunity”) or immunity acquired through immunization. Since this virus is highly contagious, it is likely that the percentage of immune individuals in a society would have to be on the higher side in order to prevent or limit the likelihood of epidemic spread. Remember that in order for the virus to survive it needs to propagate. It does so by infecting the cells of a susceptible individual, replicating in those cells, spreading to other cells in that individual, and then moving on to infect other individuals in a community as the infected individual sheds viral particles one way or the other.

The fourth point to consider is the following, and herein the lies the dilemma. If we acknowledge that we need 40% to 60% of the population as a minimum to be be immune either by vaccination or naturally acquired infection in order to stop the spread of the virus, then by limiting naturally acquired infection by social distancing we may actually be increasing the susceptibility of our population as a whole to the virus as time goes on especially if the vaccines which we are banking on fail to provide the degree of protection that we anticipate. If these things happen, then we may actually end up prolonging the pandemic rather than shortening it. Remember the Spanish Flu epidemic of 1918-1919 occurred in two waves and only stopped when enough people world wide had acquired the infection and developed immunity. There was no vaccine at that time. Presumably as this happened the virus had fewer hosts to invade and within which to replicate.  As replication decreased there was less virus being shed into the environment so fewer and fewer people came into contact with the virus gradually allowing for its extinction and thereby putting an end to the Spanish Flu pandemic.  Either something of that kind happened or there was a spontaneous mutation of the virus which made it less lethal and infectious. 

This is not say we should not be working vigorously on vaccines for SARS CoV-2. We should definitely be doing so, but keep in mind that naturally acquired immunity may really be what saves us in the long run. This is essentially the route that Sweden has taken in allowing herd immunity to take place in an albeit partially controlled manner. They did not go into a draconian lockdown, but encouraged social distancing to minimize rate of exposure so as not to overwhelm their health care system all at one time. It seems to be working for them although some would disagree with their approach and results. Only time will tell whether their approach really did work for them and whether it is applicable to other countries around the world. Each country and population may be different.  There may not be a “one size fits” all approach that will ultimately work for the entire world. In the meantime work on a vaccine, or vaccines continues, as does the work to find therapeutics both to prevent viral replication and to treat the destructive  inflammatory processes caused by the infection itself. 

Pandemic

Capital Hill and the Politics of the Pandemic

Where Do We Go from Here?

Yesterday we heard from our scientific leaders and our leaders in Congress about plans for handling the Covid-19 pandemic, but it still seems that we are just feeling our way as we go along. To a large extent that may be all that we can do.  However, are we really emphasizing what we should be emphasizing ? There are some basic facts that we do know about this pandemic even though there is a lot that we do not know. For example, we know that this coronavirus is more communicable that the influenza virus and potentially more deadly. Based on the history of prior flu pandemics we know that this pandemic is likely to last one and half to two years assuming that there are no major mutations of the virus. Also, based on past history we know that the pandemic will not be over until somewhere between 60-70% of the population is immune either because of vaccination or naturally occurring infection. We know that a vaccine will take a least a year to develop, but it is also likely that it will take much longer to really find out if the vaccine is effective. In addition, it is likely that there will be different vaccines by different developers, and it will take some time before we know which is best. One other thing we really don’t know yet about this pandemic is whether infection or vaccination will confer long term immunity, and this makes it even more imperative that medications be developed to treat the active infection and its sequelae such as the so -called “cytokine storm” and the new Covid -19 related “Pediatric Multi-System Inflammatory Syndrome.”

So where do we go from here? Instead of spending trillions of dollars on fiscal stimulus packages, concentrate on TESTING. The sooner we have the ability to provide universal testing both for the presence of the virus and for antibody titers to detect prior infection, the sooner we define who is at risk and who has presumably had the infection and is likely to be immune. We have come a long way in terms of testing both for antibody and actual virus, but the sooner we have universal testing the sooner we can get everyone back to work and resume a more normal societal pattern. Identify those who have the virus and are presumably carriers. Isolate them as best we can until they are clear of the virus. That should slow transmission. Identify those who have had the virus and are presumably immune. Allow them to go back to work and maintain mitigation practices. Allow those who test negative to also go back to work while they likewise continue mitigation practices. If we do this, we can slow progression of the pandemic until we have better anti-viral treatments and vaccines. We can get people back to work,  and we can begin to resume more normal lives. If we don’t do this, we hasten the onset of economic catastrophe and the collapse of our way of life. 

The importance of getting the country back on its feet as quickly as possible cannot be overestimated. That means letting people go back to work, resume normal activity as much as possible and socialize. Testing is the the way to do this while we develop vaccines and treatments. If we don’t do this soon, will have no economy, no stability, no future and no country. We have the resources to ramp up testing and that is definitely what we should be doing at this point. Testing should become so easy that we can go to the drug store or our local doctor and get the test for both the antibody and the virus any time we want. Instead of spending trillions on subsidies and loans, let’s spend a large portion of that money on the testing we need. We have definitely increased the testing over the past few weeks, but we can do much more.  Testing needs to become so easy that any one at any time can get it done. We have the testing technology down. We just need to mass produce the tests. It can be done. Let’s spend the money needed to do that instead of pouring all the money into subsidies and bailouts. Once we do that, we will have gone a long way toward solving the problem of who can go back to work and who can enter society.  Identify those who are risk, especially the elderly and those with predisposing conditions, and isolate them when needed to protect them. Identify those who have had the illness and are potentially immune so they can go back to work. Identify those who are carriers and sequester them until the carrier state is resolved. While we are doing all of this, we continue to work on vaccines and improve them. We continue to work on antiviral medications and the medications needed to treat the various conditions associated with this infection. Spend our money on doing these things, and we will come out winners in the long run with much less of a national debt.  If we delay the testing and identification, the pandemic will last longer than it should while our economy and country continue to suffer.

 

 

Pandemic

Wherein Lies the Truth ?

As we follow the course of this pandemic the real truth about several issues remains elusive. In large part this is because so relatively little is know about this “novel coronavirus.”  However, in addition there appear to be elements of misinformation given to us by  our scientific leaders either because of their own lack of judgement, inability to understand what was really going on, failure to use sound common sense in dealing with this pandemic, unwillingness to read the signs emanating from China, or perhaps (hopefully not) underlying ulterior motives leading them toward decisions that may not be in the best interests of all.

“You shall know the truth and the truth shall make you free” (John 8:32), but at this point in time what is the the truth about this virus and how it is really being managed? So far it seems that we are being led by scientific experts who are sometimes flying by the seat of their pants, sometimes lying to us for one reason or the other, or sometimes doing both while they try to persuade us that they know what is going on and what is best for us. Many of our political leaders do not seem to be much better than their scientific counterparts when it comes to leading this fight against the virus as evidenced by the disjointed and confusing approach that many are taking. Likewise our “TV doctors”  often contribute to the confusion by latching on to the “latest scientific study” as a breakthrough development and “gamechanger” when in reality these studies are often poorly done, misinterpreted or just not providing the answers we need. Let’s take a look at some specific examples from around the country that really highlight the confusion we are living with day to day as we deal with this pandemic.

 

Here are three areas where the truth is hard to find

First, to paraphrase Hamlet  “to mask, or not to mask, that is the question.”  Initially, we were told that we did not need to wear masks unless we were health care providers taking care of sick patients and that really only N-95 masks would be helpful. Furthermore, we were told that wearing masks would actually be worse than not wearing masks because we would end up touching our faces which was more likely to cause us to acquire the virus. Then we were told that the n-95 masks had to be reserved for the health care workers who would more likely need them than the ordinary citizen. Now we are by told that that any cloth mask would work (really to prevent transmission to others) and that we should use them when we go places where social distancing cannot be maintained. Yet the general public is so confused that people are wearing them when they are driving alone in their cars, and walking or jogging on empty streets. The problem here is that none of this is really based on hard science. It would make sense that wearing a cloth mask would help prevent droplet transmissions from you to another individual with whom you might come into contract. However, if you walk into a room where someone with Covid-19 has just had a sneezing fit a cloth mask is not likely to provide you with much protection from breathing in suspended airborne virus particles in that enclosed space.  The problem here once again is that we really don’t have enough accurate information about the characteristics of this virus in terms of  inhalational and surface transmission. So an N-95 mask would be the best to protect you from breathing in infected air. A cloth mask would probably not provide much protection to you except for some droplet protection if you are near someone coughing or sneezing.  It might provide some protection to someone else if you are the sick one coughing or sneezing by reducing droplet transmission from you. So what do we do? We do the best we can under the circumstances. Use an N-95 in confined spaces like food shopping or pharmacy  if you got it. Otherwise use a cloth mask or some other mask, but when you are in open spaces it does not seem to be necessary to use any mask.

Second, next consider the question about where this virus arose. Casting aside the Chinese assertion that the virus was made in the U.S. and brought to China by some U.S. soldiers,  we were first told by the authorities in this country and elsewhere that the virus originated in a “wet market” in the city of Wuhan in China where bats were sold, and that the bats were presumably the carriers of the virus and if not the bats than the pangolins that were also sold at the market. Then were were told that the virus did not originate in the wet market but that it was being studied in the Wuhan Institute of Virology and that a worker there accidently acquired it and passed it on to others. An obvious suspicion has been raised by some politicians and people in the media that this virus may have been genetically modified in the Wuhan Virology Laboratory to make it more infectious and virulent. This hypothesis has been denigrated by most scientists who say that this could not be done.  They insist that this a natural evolution of this virus. Yet, there are a few scientists who say that this is indeed possible, and that it was in fact done. Not being a geneticist or virologist myself I really cannot weigh in on this except to say that it would seem logical that something of this kind could in fact be done by manipulating the RNA of the virus. Could CRISPR technology or some other technology possibly be used to alter the nucleic acid sequence of an RNA virus? If so, perhaps this coronavirus was indeed modified in the laboratory to become more lethal and infectious. One has to ask the question why this virus, which presumably originated in bats living in caves in the Yunnan province of China many miles to the southwest of Wuhan, suddenly became a horrible pathogen in Wuhan when the there was no preceding epidemic amongst people living in the Yunnan Province in close proximity to the bat caves. This casts some doubt on the idea that this was a “spontaneous evolution” that occurred in this coronavirus because it would be logical to have seen evidence of a widespread infection in the Yunnan province where the bat caves are located before the infection spread in Wuhan City in Hubei Province. This was simply not the case. So we are left again wondering whether this virus was modified or somehow engineered in the lab at Wuhan.

Third, what is the real story behind hydroxychloroquine and azithromycin? At the beginning of this pandemic there were a flurry of reports about the effectiveness of this combination of drugs in treating Covid-19. Now the enthusiasm seems to have waned because of reports of some toxicity and lack of effectiveness when the data was looked at more closely. The chief complaint regarding the latter centered around the lack of large well controlled, randomized clinical trials. None the less it is hard to discount the large number of anecdotal reports and studies, which as flawed as they may be, purport to show the effectiveness of these drugs in patients with Covid-19. It is likely that the final word on treatment is not yet in as far as these drugs may be concerned. Remdesivir has now stolen the spotlight, yet it is generally acknowledged that this drug is not a “blockbuster” in the fight against SARS-CoV-2. Many other drugs are being evaluated about which we hear relatively little, but in the meantime Gilead Sciences will make a fortune. It also makes one wonder whether anyone on the task force has connections to and an interest in Gilead.

 

More to come….

Pandemic

So How Do We Develop A Plan Of Treatment?

Before we get into potential treatment modalities, let’s all realize that there are some unique features and as yet unknown characteristics about this virus that make projections about it’s future course difficult to make. For example, we know that this virus can be deadly in some cases, but a relatively mild illness in others. In fact, it is turning out that the vast majority of individuals who acquire this virus are asymptomatic or only mildly ill.  So why is it that some people have a severe life threatening illness  whereas others are mildly ill or not ill at all?  Sure, people who have “predisposing conditions” like diabetes, heart disease, pulmonary disease, advanced age or debilitation are for one reason or other more likely to be at greater risk.  However, the same is true for any illness, so why is that we are also occasionally seeing young previously healthy individuals succumbing to this Coronavirus? Some of this has to do with the fact that we are not all built the same way. Some of us have a different immune response to an infection. In others words, some of us respond to this infection, or any infection for that matter, differently than others. You might have heard the term “cytokine storm” used in describing the overwhelming inflammatory response that this viral infection triggers in some people leading to severe pneumonia, respiratory failure, renal failure, blood clots and a whole host of other deadly reactions. This does not happen to everyone who has Covid-19. In fact, it happens to a relatively small percentage, but it is not a unique situation occurring only in patients who have Covid-19. This type of thing happens in other infections as well. There are differing immune factors in any given individual that determine what the response will be to that infection.  This is obvious, but it bears discussing because the media sometimes seems to create an aura of  panic and mystery around this virus that may not warranted. From a medical point of view  it is important to realize that an individual’s inflammatory response to the virus may be what really needs to be treated particularly in severely ill patients.  Another issue to consider regarding this virus and how to deal with it is the fact that it, like other viruses such as the influenza virus, may mutate periodically making it necessary to change vaccines periodically.

There needs to be a four pronged approach

The first prong has to do with developing medications that impair the ability of the virus to either replicate itself in the cell or penetrate the cell.  One such medication is remdesivir. This drug produced by Gilead has received a lot of attention recently. It seems to shorten the time to recovery by a few days (by about 31%) and lower mortality a bit, but it is really not a “game changer”. In fact, a recent Chinese study showed no real improvement in a remdesivir treated group of patients.  This drug presumably works by interfering with viral replication. Hydroxychloroquine and azithromycin have received a lot of attention in the past. A number of studies around the world early on in the pandemic reported a remarkable improvement in patients treated with the combination. However, more recent studies have been less supportive of its use and have pointed out some potential side effects. Although azithromycin is an antibiotic designed to be used against bacteria and not viruses, it has been shown to have some antiviral activity though it’s mechanism of action against viruses is not clear.  Interestingly, hydroxychloroquine’s effectiveness against coronavirus, if any, may not be so much related to antiviral properties per se, but rather it’s anti inflammatory effects as an immune modulator.  Some antiviral medications used to treat HIV may also have some effect on the coronavirus, but these drugs are in trial at this point. Tamiflu, an antiviral medication used to treat influenza, has not been shown to be of much help. There are a number of other anti-viral medications that are currently being investigated that either impair the ability of the virus to replicate or prevent it from attaching itself to the cell so that it can’t enter the cell and begin replicating.  Immune globulin therapy, an old modality in dealing with infections, may also turn out to be very helpful in preventing the virus from penetrating the cells and initiating the infection. With this technique the immune globulins of people who have experience the disease are harvested from their blood, purified and injected into individuals acutely ill with Covid-19. These antibidies attach to the virus and prevent it from entering into the recipient’s cells giving the recipient time to mount his or her own antibody response.

The second prong has to do with developing medications to treat the “Cytokine Storm”.  Once the virus enters the cell and begins to replicate it can, in some instances, trigger an overwhelming immune response known as a “cytokine storm” which is likely responsible for a large proportion of the the deaths associated with this virus. This “storm” causes a sort of autoimmune response that can result in irreparable damage to the lungs, kidneys, heart and other organ systems. Drugs like Acetemra which is an immune modulating drug have been used with some success in the “cytokine storm” phase of Covid-19. The down side of drugs like Acetemra is that they can also weaken the the body’s ability to fight off an infection. An older anti-inflammatory drug, colchicine, is also being studied to see if it has any effect against “cytokine storm.”

The third prong has to do with the development of vaccines that are effective against this virus. However, if this virus is anything like the influenza virus which in many respects it resembles, then we can expect mutations in the coronavirus which will limit the effectiveness of a vaccine.  Mutations in the influenza virus are why we need to get a new vaccine every year and that’s also one of the reasons why the influenza vaccine may be effective in only about 45% of the population depending on whose statistics are reviewed and how accurate the surveillance is.  We can expect the same with the same with the Sars-Cov-2 virus.  None the less, vaccine development will be crucial in limiting the spread of the illness. A number of companies are now working on developing a vaccine depending on which components of the virus are used in the process.

The fourth prong has to do with the evolution of so called “herd immunity.”  Herd immunity occurs when so many people in a community become immune to a contagious disease that it stops spreading. Statistics vary regarding this,  but herd immunity may go into effect when as little as  40 percent of the people in a population become immune to the disease either due to prior infection or through vaccination.  However, some authorities feel that 80 to 95 percent of the population must be immune to the disease to stop its spread. The difficulty in achieving herd immunity naturally; i.e., without vaccination, is the risk it poses in causing severe illness and death in a large number of people. In the case of Covid-19 herd immunity will occur slowly over time as more people either acquire the disease or develop immunity through vaccination. How long this will take is unclear, but having adequate and accurate testing for the virus and for the antibodies against the virus will go a long way in helping us to identify who may be immune and who may be at risk so we can take precautions to isolate those who are are risk and those who are carriers of the virus. By doing so we may be more easily able to open up society again and speed up return to normal.

Pandemic

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……..

 

Pandemic

How to Open Up the Economy from a Medical Perspective and What Happens if We Don’t

 

First, let’s realize what will happen to this country and its citizens if we don’t open up the economy. We are literally only a few months from the collapse of our society if we don’t get the economy going again. People are being laid off in staggering numbers. Basic necessities are in short supply. Stores of all kinds are closing. The housing industry is grinding to a halt. The stock market is imploding. Plus, we have a powerful adversary in China which is a fact that we have to acknowledge and somehow deal with. To paraphrase Joe Biden in a contradictory fashion, “China wants to eat our lunch.”

So, we really have no choice but to get the economy going as fast and as safely as we can.

How do we do this? It’s a matter of absolute necessity, but we have to do it so as to minimize the risk to the health and lives of our citizens. Here are some steps to consider:

  1. Test everyone in the country for presence of the virus. There are several companies making test kits now with Abbot Labs being the most well known. One of their test kits can give results about the presence or absence of the virus in minutes, but we don’t need speed we need accuracy.
  2. Check everyone for the presence of antibodies to the virus. While we do not as yet know if antibodies confer life long immunity, the likelihood is good that the presence of antibodies will confer at least some immunity for a least a season. Remember that it is likely that this virus will return on a recurrent, if not seasonal, basis much like the flu.
  3. Get our pharmaceutical industry to work full speed on antiviral agents as the priority. This will likely be more important than a vaccine. We know that influenza vaccine are not completely effective. In fact, some studies show that the so called “flu vaccine” is only effective at most 60% of the time. That is likely to be true for any coronavirus vaccine we come up with in the near future. Limited studies and anecdotal reports on the use of hydroxycholoroquine and azithromycin are encouraging. We should continue to study these drugs as we go forward using them, but they may not be the complete solution so we need to vigorously study other antiviral agents. We can do this. We have the science and the means if we make it a priority. Treat this as a real war like we did in WWII when we transformed out manufacturing industry in a matter as months.
  4. Retool our industries to make all the masks, PPE and ventilators we need now and possibly in the future. Never let us become dependent on any other country for any of the things we need. This country is blessed with all the natural resources we could ever need. As nation never let corporate greed supercede our needs as country. Never put profit before country. This is partially what got us into trouble now.
  5. As we test everyone for the presence of the virus and the antibodies, we have a better idea as to who is non-communicable and perhaps resistant to infection. Get these folks back to work as soon as possible, but retest them periodically until the pandemic is over and we have the antiviral medications we need to combat this virus and other which may yet come.
  6. Lastly, we live in an international community. There is no doubt about that, but that does not mean we have to follow the herd. It does not mean that we have to subjugate out rights and privileges for other nations. In fact, we should be wary of countries like China whose declared goal is to replace the US as the premier economic and military force in the world. We cannot let that happen, and we as US citizens have to realize this threat before it is too late. This pandemic should be a wake up call for all of us.