Tag: Coronavirus

Covid-19: Are We Rounding the Curve?

It has been months now since we were attacked by the SARS-CoV-2 virus that one way or the other was brought to us from China. So let’s review a little bit of history before we figure out if we are indeed rounding the curve of this dreaded illness as it pertains to the U.S.

Rounding the Curve

Since the coronavirus was first officially acknowledged by Chinese officials on December 31, 2019 many, many questions remain unanswered about the origins of this virus that may never be answered. Such questions as to when it actually started in China and how it started in China are not likely to be answered by China even though they may have the answers. The disease probably began several weeks before December 31, 2019 in China, but was not acknowledged by the Chinese authorities. An article in the South China Morning Post, said that Chinese authorities had identified a case as early as early as November 17 of 2019 – weeks before they actually announced the emergence of this new virus.

The first confirmed case in the US was on January 20, 2020 in Washington state. Eleven days later on January 31, 2020, President Trump suspended entry of foreign nationals who had traveled to or resided in mainland China within the past 14 days in spite of many people labeling him as a xenophobe. Exceptions were made for returning U.S. citizens, immigrants lawfully in the United States, and immediate relatives of U.S. citizens. That move saved thousands of lives.

On March 11, 2020, President Trump issued a suspension of foreign nationals traveling to the U.S. from a majority of Europe.  He then extended this suspension to the United Kingdom and Ireland a few days later. That move again likely saved thousands of lives. Nonetheless in spite of these early precautions to prevent the virus from coming to the U.S., which parenthetically again caused the President to be falsely labelled as a xenophobe, the virus spread like wildfire. To date in many European countries the spread of the Sars-CoV-2 has been even more severe and catastrophic than it has been here in the U.S.

It is unclear why the virus spread so rapidly in this country and so many others in spite of precautions such as limiting international travel from countries with high rates of infection. There may be several reason for the disparities:

  • The virus was apparently carried by people traveling from Wuhan, China. So a lot of the dispersion of the virus initially depended on where these people were going whether it be the U.S., Europe or elsewhere.
  • The demographics of the countries receiving these travelers from China varied greatly. Some of these countries have an greater elderly population more susceptible to infection.
  • Some countries and also some locales within these countries have a greater population density and cultural characteristics which makes it easier for the virus to spread.
  • Some of these travelers coming from China and elsewhere may have been so called “super spreaders” of the virus.
  • The virus itself may have several strains some of which may be more lethal and contagious than others.

The bottom line in terms of infectivity and spread is that the situation was unpredictable and remains unpredictable. Keep in mind that data concerning the prevalence and death rate of the virus in this country and elsewhere is in a constant state of flux for a number of reasons including the following:

  • The fundamental data is often unreliable. For example, there have been many instances wherein deaths have been mislabeled as Covid when they are not conclusively due to Covid alone.
  • The testing may have been unreliable, inconclusive or inaccurate. It is now getting better.
  • Treatment protocols are evolving and were different in different parts of the country. As we learned more about the virus and how to treat it, survival and recovery have been drastically improved and treatment protocols have become more uniform.

So what is happening now? The U.S. currently with death rate of 13.7 per million as of October 28, 2020 is doing a lot better than many other countries across the world. Bear in mind that the reporting of cases and deaths is often inaccurate or misrepresented. Take a look at this recent article in the New York Post that tries to put some of this reporting in perspective. The CDC estimated that about 177,000 Americans died during the 2017-2018 flu season, from either the flu itself or by complications of pneumonia. That’s not to far off from the total death toll to date for the Covid -19 though this should not be taken to minimize the severity of Covid-19. Furthermore, two recent peer-reviewed studies also showed a sharp drop in mortality among hospitalized COVID-19 patients in the U.S. The drop was seen in all groups, including older patients and those with underlying conditions, suggesting that physicians in the U.S. are getting better at treating this disease.

Where do we go from here? First, consider that case numbers may be increasing, but death rate is definitely going down. There may be flare ups of the virus in various regions for many different reasons, and the fact that case numbers are increasing is also due in large part to increased testing. That’s only logical. The more you test, the more cases you find. Moreover, in a somewhat paradoxical way having more cases may not be as terrible it sounds. The more people who have the had the virus, particularly if they are not very ill or not ill at all as most people who have had the virus seem to be, then the greater the degree of “herd immunity.” With all due respect to Dr. Fauci who seems to have played down the concept of herd immunity, many epidemiologists would disagree with him in that regard. Bear in mind that we actually get herd immunity in two ways: by natural infection and by vaccination when it is available. The vaccines have yet to be proven though in all likelihood they will be very helpful in arresting this pandemic. Nonetheless, the herd immunity will likely be due to a combination of both of these factors not just vaccination alone. Second, consider that we have made great strides in treating this disease. We know a lot more about how to treat the cytokine storm which can be a devastating sequela of this infection leading to respiratory failure, other organ failure and death. We have learned more about when and how to ventilate patients better when needed. We have a variety of therapeutics, more are on the way, and we have several vaccines about to be launched. That is not to say that we will not see more cases and more deaths particularly among those who are more vulnerable, but to answer that question as to whether we are “rounding the curve” I believe we are, and the data seems to substantiate that.

So what’s next? We stay the course and continue to move forward by:

  • Maintaining social distancing and wearing masks when appropriate. I don’t think that should mean absolutely no socializing. Socializing is important for many reasons including mental health, but take reasonable precautions. Try to socialize in open areas with good ventilation and wear a mask when you can’t maintain social distancing until the virus is under better control. Take a look at some of my earlier Blogs about the proper use of masks for more information about the role of masks. It makes little sense to wear a mask when you are out in the open away from people such as walking on a beach, a country road or a park. I think doing so just promotes a sense of paranoia when we are already fearful.
  • Opening up our businesses and schools wherever possible. If we lock down the country for long, unreasonable periods of time we will no longer have a country, and we will not be able to address all the other medical, social, and business issues that we need to address as a country.
  • Continue our therapeutic research. We must develop new medicines and vaccines not just for Sar-CoV -2 virus but also for others that my be coming down the pike. This virus may be just the beginning, but a stream of therapeutics will have to be developed just like we did for bacterial infections decades ago. We know how to do this. It’s just a matter of focusing our research attention on this.

Most importantly we have to remember that we will see twists and turns with this disease. There will be flare ups that we will have to deal with, but that doesn’t mean we’re losing the battle. It just means that we have to keep on fighting until we get complete control which we will eventually and the sooner the better.

So to answer the question “are we rounding the curve” ? I think we, are but there will be more twists and turns before we see the straightaway.

Rounding the Curve

The Devil Is In The Details

Covid-19: Florida v. New York

The Nursing Home Issue

According to the New York Times as of 7/23/2020 there were 414,405 cases of Covid-19 reported in New York State and 32,270 deaths.*  According to the Florida Board of Health there have been a total of 389,868 coronavirus cases and 5,632 deaths.  Though the populations of New York and Florida are similar (Florida has about 2 million more residents) and the number of overall cases reported by each state thus far are similar, there is close to a 6 fold difference in mortality.  Hopefully Florida will not catch up to New York in regard to the death toll, but why we have this difference is not yet completely clear.  It may never be completely understood, but there are some logical reasons as to why Florida has had so many fewer deaths than New York so far in spite of the fact that Florida has the larger population and a greater percentage of elderly patients.  One likely reason for this is that Governor Desantis took a more aggressive approach in protecting this vulnerable, elderly population.  For example, unlike in New York elderly Covid-19 patients were not sent into nursing homes where they could easily infect other residents and staff.  In early March, Governor DeSantis put out a strong preventive message to his elder population, advising them to stay at home in order to avoid potential exposure.  He made sure that nursing home personnel had the protective personal equipment (PPE) that they needed to help prevent acquisition and spread of the virus.  He deployed the National Guard to help institute testing in the state’s nursing homes where older COVID-19 patients were not sent.   These actions and others helped to give Florida a much better survival rate for patients in long term care facilities compared to New York.  On the other hand in New York, Governor Cuomo had patients with Covid -19 go back to nursing homes that were not prepared to care for them.  In spite of the fact that there were other alternatives such as the hospital set up at the Javits Center, the Hospital Ship Comfort that was sent to New York Harbor by President Trump and the Samaritan’s Purse field hospital that was set up in Central Park.  There was inadequate protective personal equipment (PPE) for the staff in these nursing home facilities in New York and inadequate isolation procedures which led to promulgation of the virus and increased death tolls among staff and patients.  In late April, the New York State Health department finally clarified that nursing homes should not take any new residents if they are unable to meet their needs.  In May Governor Cuomo finally reversed his directive, and tried to shift the blame for the nursing home fiasco on to President Trump though President Trump had no role in determining Governor Cuomo’s  response to the pandemic on a statewide basis.  Governor Cuomo also said that nursing homes could have refused to comply, but he did not specify how they could do so without incurring any penalties.

Some Other Reasons Why New York Infections Skyrocketed

Another probable reason as to why New York became an epicenter of this virus is that early on in the pandemic, New York’s Governor Cuomo and the New York City’s Mayor de Blasio, tended to downplay the significance of the virus telling people to continue their normal activities including socializing.  This lead New York City with its great population density to become an epicentre of the pandemic in the U.S. in such a rapid fashion that New York’s hospital system was overwhelmed. Their response as political leaders was marked by missed warning signs and health care policies that many health-care workers say put residents at greater risk and led to unnecessary deaths.  For example, in the first few days of March, Governor Andrew Cuomo and Mayor Bill de Blasio assured New Yorkers things were under control. On March 2, Mayor de Blasio tweeted that people should “go see a movie”. Only after the disease was running rampant in the New York City’s low-income neighborhoods later in March did Governor Cuomo and Mayor de Blasio mobilize public and private hospitals to create more beds and intensive-care units.

Some Good News

The good news is that the death rate from the virus seems to be decreasing nationwide even though the incidence of infection may be surging in some areas like Florida and Texas right now.  The reasons for this decrease in death rate are again not completely clear, but some of this may be due to the fact that we have learned how to better manage this infection.  We know more about the sequelae of the infection and how to treat them. We have better contact tracing and management.  We have some therapeutic modalities that seem to be helpful.  Whatever the means, driving down Covid-19 deaths is becoming a major breakthrough.  If treatments for Covid 19 eventually result in a mortality rate of only 0.1% similar to influenza than the Covid-19 would no longer be a major health problem even though it might persist in the population for  long time to come.

More Testing Means More Numbers But Accuracy and Interpretation of Data Are Key

It should also be remembered that it may also be possible that the virus itself is changing and mutating to a less virulent and less infectious form.  As far as the incidence of new cases is concerned some of these numbers have to be interpreted in light of the fact that more and more people are being tested.  Moreover, as we get further and further away from this pandemic as time goes on, we may find that there have been irregularities in the data reporting and problems with the various screening tests that have been brought to market in terms of their reliability and accuracy.  For example, the number of false positives and false negatives will need to be better scrutinized especially since there are a number of companies marketing tests that may not have been fully validated.  So the total numbers of patients who have been exposed to coronavirus may be greater or lesser than what we now appreciate.  Mortality issues will also need to be reevaluated. Many patients who have been cited as having died from coronavirus may actually have died from other illnesses, but they were listed as Covid-19 deaths because they were found to be positive for the virus when they were tested in the hospital.  It’s well know that many patients who have the virus are asymptomatic or relatively asymptomatic so having a positive test in someone who ultimately died of something unrelated to Covid-19, but reported as a Covid-19 death, would obviously skew the data regarding total Covid-19 deaths.

Importance of “Herd Immunity” Cannot Be Overemphasized

Given the increased numbers of individuals who have been exposed to and presumably have antibodies against the virus should lead to greater “herd immunity”  as time goes on.  Overall, even though we are seeing some peaks of infection nationwide, the pandemic seems to be decreasing. “Flattening the curve” does not necessarily mean eliminating the virus all at once. What is really means is that the incidence of infection is flattening so that we are not overwhelmed by large number of cases. Things should only get better as time goes on and we get vaccines along with better therapeutics in the months to come.  Also, as time goes on “herd immunity” will become greater and greater.  Ultimately the virus that causes Covid-19 virus should, if not disappear completely, become much more manageable much like our conventional influenza virus.  We may need annual vaccines like we do for influenza, and we may need to rely on different antiviral agents to treat sick patients.  However, Covid-19 will likely become much much more manageable as time goes on similar to influenza.  There is also the possibility that this coronavirus (Sars-Cov-2) will mutate to a less infectious and aggressive form as these viruses sometimes do although the alternative is also possible.

*This was data collated by the New York Times from several sources.

The Devil is in the Details

    “This Too Shall Pass”

    This phrase has a long history dating back to biblical times in one form or the other.  Though the origin of this saying cannot be pinned down, it seems particularly pertinent to what we are experiencing as a nation today.  It is a reminder that regardless of our troubles today with coronavirus and the overwhelming impact it often has on our daily lives,  it will indeed ultimately pass.  We have been damaged physically, emotionally, socially and economically.  Thousands of lives have been lost,  but we and the rest of the world will get over this sooner or later.  Hopefully, we will all be smarter and stronger having gone through this so that we are better prepared for the next pandemic which is sure to come at some point.

    So now one wonders what is next with outbreaks of the virus occurring in different parts of the country when it just began to look like we might have had things under control.  Keep in mind that this should not have been unexpected.  The virus is here to stay until one of two things happens.  First, the virus may mutate itself out of existence meaning that it changes in such a way that it becomes less capable of attaching to and invading human cells.  However, there is a caveat to this first scenario since the virus could also mutate in such a fashion as to make itself more likely to attach to a human cell and replicate.  The second thing that could happens, which we should hope for, is that so-called “herd immunity” develops.  This occurs when a large portion of the population either asquires the illness, survives and produces antibodies to the virus; or, a vaccine is given which also creates immunity.  When immunity develops in either fashion, the virus is less likely to enter a host to replicate, cause illness and spread to other susceptible people.  Those who were either sick and have recovered and those who have had the vaccine can no longer harbor the virus and thereby prevent it from replicating and invading the remaining susceptible individuals.  In those who have been vaccinated and developed antibodies, the virus is not longer able to attach to the host cell and enter it to cause damage to the cell and replicate itself.  In those who have acquired the immunity by having had the illness, antibodies likewise develop which prevent attachment of the virus to the susceptible cell so the virus once again cannot replicate and spread.  Either way, the chain of transmission is thereby blocked and the incidence of viral infection decreases in a population.  However, there is a caveat here also in terms of those who have naturally acquired immunity through infection; namely, that some individuals who have had the illness and recovered may theoretically become carriers of the virus.  Not enough is yet known about this virus to make any comments about a carrier state.  Remember that our objective here is “flatten the curve.”  That does not mean that we have eliminated the virus.  What is means is that we have reached a point where the rate of new cases occurring has slowed and reached a plateau making it much easier to control the pandemic.  Hopefully at some point the virus will have disappeared, but that may never completely occur.  Instead, what we may see is a situation similar to the influenza virus where we have to deal with a new strain or strains every year.  In the meantime while we await the development of vaccines and antiviral medications, we try to identify and isolate infected people as quickly as we can, maintain social distancing in a reasonable way in order to minimize exposure, and we try to resume our lives as close to normal as possible.

    How And When Will The Pandemic End?clear-glass-with-red-sand-grainer-39396

    We do not know yet how and when the pandemic will end, but it will will end.  This does not mean that the virus itself  will completely disappear though it may.  Instead, we may see this coronavirus  or other similar coronaviruses popping up periodically in different places for years to come. 

     

    Lessons To Be Learned

    This Sars CoV -2 coronavirus is “novel.” Its combination of easy transmissibility and its wide range of symptoms makes it somewhat unique, but there are lessons that can be learned from previous pandemics like the Spanish Flu of 1918. This pandemic lasted over two years and came in three waves that killed 50 million and 100 million people.  Exactly why the virus became extinguished remains unclear. There were no vaccines for it and no effective treatments.  It has been estimated that over a period of two years 500 million people worldwide were infected and somewhere between 50 and 100 million people may have died.  Several theories for its disappearance have been postulated, but it seems likely that this was due to a combination of factors.  One of these might have been that the virus mutated to a less pathogenic form which often happens with viruses.  Social distancing once it was used more aggressively likely decreased the rate of transmission.  Also, as time went on more and more people got exposed to the virus and became immune leading to so called “herd immunity.”  When enough people in a population are immune either through naturally occurring infection or immunization, the likelihood of transmitting the virus to the remaining others in the population who are not immune decreases dramatically.  This is where we are hopefully heading now.  

    What happens next and how soon this pandemic ends depends on a combination of factors in addition to the development of herd immunity.  This includes the natural history of the virus itself, in other words, will the virus mutate to a less aggressive form; how effective the vaccines are; how good we get at discovering new antiviral medications; and how good we get at treating the inflammatory effects of the viral infection such as the so called “cytokine storm.”

    Through all of this turmoil just remember that “this too shall pass.”

    white and black moon with black skies and body of water photography during night time
    Photo by GEORGE DESIPRIS on Pexels.com

    A Tale of Two Illnesses

    We in the U.S. are currently battling two major illnesses that may change the social fabric, customs and morality of our country for years to come if not forever.  Both are very different but certainly intertwined.  Together they will test our strength as a nation.

    The first of these is Covid-19. While as a whole the country seems to be doing better handling this pandemic, we are by no means out of danger.  More illness and death is yet to come.  However, keep in mind that as time goes on and more and more people are exposed to the virus more herd immunity will occur, and that is really what we need in order to overcome the threat of pandemic. We achieve that “herd immunity” in two ways (see The Dilemma of Immunity).  One way is by immunization.  The second way is through naturally occuring infection.  This means that as more and more people are exposed to the virus naturally in the environment and recover, then fewer and fewer people are left susceptible to the virus.  The corollary to this concept is that people who have had the disease and recovered would be unlikely to spread the disease to the remaining others who might still be susceptible.  Hence there will be less communicability as time goes on.  This may seem obvious, but it is an important concept and probably as important as immunization if not more so.  However, there are some caveats to be considered here.  For example, we are assuming with good reason that having had the infection confirms immunity. While this is likely it has not yet been completely validated at this point. Neither has it been validated that the immunity will be lifelong..  Another issue which remains open yet is whether the virus will mutate to such a degree that prior immunity will no longer be effective as often happens with the influenza virus for which new vaccines are required on a yearly basis.  Of course the alternative is also possible; namely,  that the virus will mutate and become in and of itself less infectious as time goes on.  We will likely have a vaccine (or vaccines) for Covid-19 early next year and newer antiviral medications will likely be developed in the months ahead as well.  Also, very importantly,  other medications to treat the lethal inflammatory sequelae of the virus will soon be developed thanks to our robust pharmaceutical industry.  All of this should save lives. However, other new viruses and infectious agents will also likely come to our shores in time to come, and we will need to be better prepared for this future possibility.  Please see my previous blog about what we have learned from this pandemic (seeWhat Have We Learned From Covid-19).  In the meantime our experience with Covid-19 has had dramatic effects on how we live our lives and conduct our business.  There is no more hand shaking. Social gatherings are limited.  People walk around in fear of getting a dreaded illness, which by the way, has a mortality rate far lower that initially projected.  People are wearing face masks in situations where there is no rational reason to do so (see Pandemic). Uncertainty about our economic future and security is causing fear and panic in the population leading to unreasonable doubts about our survival as a nation.  We will survive the Covid-19 pandemic and other infectious disease threats that may follow. Not only will we survive these threats, but will will do well once we learn how to cope with them.

    The greater threat to our health, both individually and as a nation, is the emergence of various anarchist groups threatening to overthrow our government and the rule of law without which no society can survive.  The widespread violence and destruction that we are now seeing and the inability of local governments, particularly those in left wing democratic cities, to control this is a greater risk to the health and wellbeing of the nation as a whole compared to any viral pandemic. We can face pandemics together as one nation and do what is necessary to overcome them if we put petty politics aside and use good judgement.  Instead, what we see happening is our politicians using this pandemic as a political tool to destroy the opposition putting power before country.  Beyond this we see some of our elected leaders, principally socialist democrats, on a state and local basis permitting, condoning and even encouraging rioting and destruction.  There is absolutely no doubt that we have social problems that need to be urgently addressed, but destroying the country is not the healthy way to do so.  The wanton destruction of private property, the desecration of  monuments, the attacks on law abiding citizens does nothing but create more fear and hostility at a time when what we need is unity.  The health of the nation and its citizens depends on it.  To destroy our government and our institutions, as the leftists and particularly the anarchists want to do, is like seeing a sick patient in the hospital who has an excellent chance of recovery and saying he has to be euthanized because he is not worth saving.

    What Have We Learned From Covid-19

    Hopefully we are drawing to a close of the Covid-19 pandemic or at least getting it under better control although the recent rioting the country has experienced may be leading to a new wave of infections far worse than the resurgence that was previously predicted. Nonetheless, the pandemic seems to have slowed down a bit for now so now may be the time to reflect on the state of the pandemic and some lessons that we may have learned.

    First, it is clear that we were by no means well enough prepared for an event such as this. We had had warnings that something like this might happen, but we failed to recognize the warning signs. SARS, MERS and the H1N1 viruses were the warning signs that a worse virus was likely to occur at some point in the future, and it did so in the form of SARS-CoV-2.

    The orginal  SARS (severe acute respiratory syndrome) broke out in 2002. SARS first affected people in southern China, but it eventually spread to 29 countries. It apparently started in animals, but then spread to humans. There were at least 8,000 cases world wide, and it killed about 800 people giving it a death rate of about 10%. The SARS virus is very similar to the current  SARS-CoV-2 virus which causes the illness that we now call Covid-19, but by 2003 there were only 8 laboratory confirmed SARS cases in the US. H1N1, otherwise known as the swine flu, is a different type of virus more closely related to the influenza virus. Between 2009 and 2010 it caused 60.8 million infections in the US and 12,469 deaths. Another coronavirus (MERS-Cov virus) first reported in Saudi Arabia in 2012 also caused a severe respiratory illness known as the Middle Eastern Respiratory Syndrome with (MERS). Only two people in the US have been know to come down with this virus and both survived. 

    The U.S. should take Covid-19 as a warning and start preparing for the next pandemic as soon as possible. There are many reasons why this is likely to occur. Spontaneous mutations of the Sars-CoV-2 virus and introduction of new viruses from the wild into human populations are just a couple of reasons why this might happen. Given the interconnectivity of people traveling throughout the world, the spread of a new contagious virus in a pandemic fashion is very likely to occur. Shi Zhengli, a Chinese virologist, has warned that we are now dealing with the “tip of the iceberg” when it comes to impending viral epidemics.

    This should tell us that we need to expand work on antiviral agents that will have as broad a spectrum as possible in terms of antiviral coverage especially since vaccines take a long time to develop and are not effective once the virus has taken hold in a patient. Think of vaccines  as preventive treatments, but treatments that may need to be changed frequently since the vaccines are often very type specific. We also need to develop better pharmacologic agents that will block entry of the virus into the cell so that it does not have a chance to propagate within the cell,  and treatments that interfere with the replication of the virus if it indeed manages to enter the cell.  Furthermore, we need to work on developing treatments for effects that the virus has on the body if it manages to enter the cells and replicate. This is what triggers intense inflammatory reactions such as the “cytokine storm” and “the multisystem inflammatory syndrome.”  So from a patient management point of view we need to work on three things: better antiviral agents with a broad spectrum of coverage; the ability to adapt manufacturing processes for vaccines quickly because the virus will change and new ones will appear; better regimens for treatment of the effects of the virus once it enters the body. Of course all of the above has to be achieved in such a way that we are never dependent on a foreign country, much less a potential adversary, to supply us with the medicines, vaccines or anything else needed for us to treat another pandemic. 

    We learned that social distancing, as controversial as it may be,  likely had great impact on the mitigating the spread of Covid-19, and it is a practice that in all likelihood should be implemented again quickly as soon as the next pandemic arises.  The current pandemic showed us that certain areas of the country were more impacted than others for a variety of reasons that we are still being investigated. 

    Very importantly this pandemic was also a lesson in logistics that should not be forgotten, and it goes hand in hand with the evidence that not all parts of the country were similarly affected by this virus. There has to be mobility in terms of the delivery of healthcare in any crisis situation we may face in the future so that we can deliver medical personnel, equipment and medications where they are needed. This includes the ability to to get mobile hospitals up and running anywhere in the country they may be needed. We demonstrated some of that capability when the Javits Center in New York was converted into a hospital, the hospital ship Comfort arrived in New York and Samaritan’s Purse set up camp in Central Park to help out with the hospital bed shortage. However, for reasons that are as yet puzzling and distressful, none of these facilities was used effectively in terms of terms of relieving the overwhelming burden of the those city hospitals that were inundated with Covid-19 patients.  For future medical catastrophes, which are sure to come, we need to be able get mobile hospitals up and running quickly wherever they may be needed. 

     

     

     

    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 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

    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

    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.