Do Lockdowns Work for Covid-19?

Maybe the World Health Organization (WHO) is finally getting something right.

This week Dr. Nabarro of the World Health Organization stated that world leaders should “stop using lockdowns as your primary health control measure.” He went on to say that “the only time we believe a lockdown is justified is to buy you time to reorganize, regroup, rebalance your resources, protect your health care workers who are exhausted, but by and large, we’d rather not do it.” This is a sobering approach that comes into line with what many experts in this country and elsewhere have been espousing for months now. Yes, indeed, this coronavirus is one bad virus that got exported to us and the rest of the world from China, but sometimes the cure is worse than the disease. Again, this is not to say that Covid-19 cannot cause very serious illness and death particularly in the elderly and those with so called co-morbidities like pulmonary disease, heart disease, diabetes, obesity, immunocompromised states and other ailments. For these patients and their families the illness can be devastating. However, for the vast majority of people who get infected with this disease and get ill their symptoms are fortunately relatively mild.

Dr. Nabarro went on to point some of the negative consequences that lockdowns have caused across the world, including devastated tourism industries and increased hunger and poverty in parts of the world already suffering from these problems. In addition, in this country as well as in many others we are seeing increased rates of alcoholism, drug abuse, violence, depression, anxiety. Also, many people are delaying visits to see their doctors resulting in lost opportunities to practice preventive medicine. Our educational system is likewise being badly affected and along with that the health and welling being of our children. All this and the Stress related to the lockdowns may very well cause much more death in the long run than the lockdowns will save.

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So maybe it is time for some common sense to arrive on the scene to help make us whole again while our vaccines and therapeutics are being developed. Remember, these things are already here or on the way. We will eventually get through this. To quote Franklin Delano Roosevelt, “we have nothing to fear but fear itself.” That was in 1933 when the U.S. was going through an even more difficult period.

So what are some of the common sense things to do?

  • Use masks rationally. Take a look at my previous blog about mask use, To Mask or Not to Mask…That Is The Question. If you are out in the open air, at the beach, walking in the park or on a country road, riding a bike or doing anything else where you are not in close proximity to people, i.e., not likely to be within 6 feet or so of anyone, there is really no need to wear a mask. Doing so only instills a sense of fear or dread which is totally unnecessary. Unless you are using mask wearing as a political statement. If you are in a crowded elevator or conference room, then by all means use a mask. But remember that simple cloth masks do not really provide protection against airborne aerosolized virus. They may give you some protection against droplets but not airborne virus particles. Only N-95 masks or better stand a chance of capturing the virus particles if you are on the receiving end. If you are on the giving end, in other words, the person with the virus and you cough or sneeze into your face mask, droplets and tiny aerosolized virus particles will still be dispersed. Even the CDC, which has flip flopped back and forth about the use of masks, recently reported a study showing that 70% of the patients who came down with Covid-19 wore masks regularly. So this study really puts into question the utility of wearing face masks. Nonetheless, the practice of wearing a mask (really an N-95 mask or better) may provide some degree of prevention and perhaps emotional security as well if needed, but to wear a mask (cloth, surgical or N-95) in the great outdoors where you are not in close proximity to anyone, or in environments where social distancing and good ventilation can be easily maintained seems fruitless and perhaps a bit paranoid.
  • It goes without saying that frequent hand washing and use of hand sanitizers should continue, but this is true even if the virus that causes Covid-19 were to disappear.
  • Society has to open again. That means restaurants, gyms, businesses, social gatherings, schools and so forth all using social distancing as much as reasonably possible and masks when appropriate.
  • Protect the elderly and most vulnerable. That means people with underlying medical conditions that may tend to weaken the immune system. In such instances, these folks should be kept away from situations such as large gatherings where they may be more likely exposed unless precautions can be taken to limit their exposure.
  • Continue to exercise, take Zinc and Vitamin D which seem to have some antiviral activity.
  • In short time more diagnostic tests with greater reliability and shorter turnaround times will become more widely available. While this may not completely solve the problem of identifying people who are potential spreaders, it will go a long way in alerting us to who has the virus and may be communicable. So screening before attending large gatherings may become more common and alert us to potentially dangerous situations.
  • In short time we will also have vaccines and better medications. The calvary is on the way to save the day.
  • We have to open up the country again soon. If we don’t, we won’t have a country to open up, or we will have one that is desperate and on the verge of collapse. People have lost their jobs. Educating our children has become a major difficulty. Alcoholism, suicide, drug abuse are all on the rise. People are not following up with their routine doctor visits and diagnostic tests. Some businesses are at risk of failing or have already failed. As many have already said, if we use lockdown as a cure for this virus, then the cure may indeed be worse than the disease.

Some further comments about “lockdowns” and herd immunity.

Maybe Sweden did have the right idea. After months of being criticized by the “experts” for not locking down as vigorously as its other European neighbors and seeing an early spike in cases, it now seems to be doing a lot better than many other nations in Europe and elsewhere. This may be due to the fact that the Swedes as a nation are developing a greater degree of herd immunity more quickly than other countries simply because they did not lockdown to the same degree as other countries which does seem to make some sense. Herd immunity, immunity related to widespread vaccination, better therapeutics and perhaps weakening of the virus itself will hopefully bring an end to this pandemic. However, we should also keep in mind that for a variety of reasons we may be seeing more of these viruses as time goes on. Therefor, from a scientific point of view we need to do more research on therapeutics and rapid vaccine development so as to be better prepared for the next battle.

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
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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.