2019 Novel Coronavirus (2019-nCoV (first named); COVID-2019
(later named disease); SARS-CoV-2 (final name of the virus causing COVID-2019),
COVID-2019 Pandemic:
DON’T PANIC, be concerned, but don’t
panic. It just makes everything worse.
March
18, 2020 update Part 10
Paul
Herscu ND, MPH
Herscu
Laboratory
This is the tenth piece of writing on the current epidemic. Please read Part 1, Part 2, Part 3, Part 4, Part 5, Part 6, Part 7, Part 8, and Part 9 for context and also, please read my other writing on this site for a larger context on the overall topic of public health and epidemics.
Person/Place
and Time
When I teach on this topic of epidemics, I focus on
the very important variables of Person/Place and Time. For example, if I mentioned
west Africa 2014, you would say Ebola virus, and if I said early 1980s, San
Francisco younger gay men, you would say AIDS crisis. In other words, when
dealing with epidemics, we have to contextualize our comments, plans, and
processes to the moment (the exact time we find ourselves in) place (are we talking
about a city, a state a region, or the country?) and people you are talking
about (and with COVID-19, thus far, the main variable has been old age, though,
as I mentioned you will start to hear more about younger people soon).
Place and Time
As I mentioned originally, this whole epidemic could
have been over before it started with proper local testing. Sadly, that time
has passed. And where we are now is, for the most part, with local outbreaks
throughout the country. But because of the extent and seeding that has
occurred, I believe we will soon move from local to regional outbreaks as a way
to think of it, and if we still do not work together properly, we’ll then have a
national epidemic. More on this below. The main point is: what sounded like
good public health procedures and recommendations before, will not necessarily
work now. As of this writing, we have in the US 7,339 confirmed cases, and 116
deaths. I am guessing that the number is actually closer to 30,000 cases at
this point (meaning that 340 million do not yet have this illness). Proper
action now can still stop a galloping epidemic with most people not even
knowing anyone that has fallen seriously ill, but soon this possibility may pass.
Clarifying
Language: Local versus General, Quarantine, Lockdown, Shelter in Place, etc.
Depending on where you live, you might be hearing
different things from the federal, state, and/or local government, let alone
different countries. While not discussed, there is a good reason for this. In
many ways, even though we are dealing with the same virus, the local realities may
vary, requiring different solutions. Back to the person, place, and time
concept: initially, if you have a highly localized outbreak, containment zones
may do the trick. But really, truly, only if you test everyone in the zone will
you achieve a quick reduction and end. A good example of containment zones was
New Rochelle, NY. This was one of the first ones in the country, and probably
sounded intense, at the time, to you. Simply, it meant that all large gatherings,
large institutions, and any place that has many people present had to close. The
National Guards came in to clean the area and provide assistance. I know people
were thinking that it was sort of like East Berlin during the Cold War, but it
was much less militaristic. Small gatherings still took place, many stores remained
open, and most importantly, people were allowed to come in and out of the area,
people could go out for walks, exercise, etc. To the government that made sense
at the time. A local focal area. However, that was not enough, and by then, there
were many local, focal areas, all over the state. This meant that this process
of local containment with local rules might not be enough, and state rules came
into place. In one way or another this progression is mirrored throughout the
country which ultimately led to national guidelines and restrictions. And all
of these are changing in response to the mounting numbers and information
gleaned from modeling of the epidemic. Sadly, and frustratingly, the guidelines
and restrictions are occurring in response to the reality on the ground, not to
the predictions that were made months ago. In other words, we are 8 weeks
behind where we should be. And in an epidemic that doubles every few days, this
has worked against us.
Shelter
in Place
Briefly, we went from very little done, to only
worrying about and isolating those with fever and cough, to worrying about and
isolating those that the confirmed cases were exposed to, to worrying about large
groups of 1000 or more, to groups of 500 or more to groups of 250 or more, to
50 and now down to 10 people groups. And in many places, the advice is shelter
in place, but what does this mean? In most places, this will mean no
unnecessary travel, no unnecessary gathering, no large crowds at stores, and hotels,
restaurants, casinos etc., too close. What is still open are medical facilities
unless there is a local problem there (though many physicians have shifted to
telemedicine), pharmacies, emergency providers such as police, ambulance, fire
departments, as well as all the workers who keeps a city working such as gas
station attendants, food delivery people, supermarket staff, pharmacies, etc. Anything
you need to stay fed and medically cared for, stays open. The things we need to
live are staying open. The things that make like fun and interesting are
closing or being postponed.
Quarantine
Quarantine is what we do when we think we have been
exposed. We do this for a period of time to see if we do get sick, and at this
time, since we believe the vast majority of people will develop symptoms within
a 2 week period of time, that is the length of the quarantine period.
Case
Isolation/Self Isolation
Case Isolation/Self Isolation is what we do when we
know we are ill and want to limit other people getting sick. Here we stay at
home or the hospital trying to keep away from the community. The good news is
that this limits spread to the community. But there is a real cost to this. This
being real life, it means we stay indoors with our family, and it makes it more
likely that our family become sick from being around us. Rarely are we
isolating completely by ourselves, without our family or support people somehow
interacting. This trade-off of getting more people you are intimate with sick
but limiting strangers exposure can explain why the nursing
homes/hospitals/cruise ships/jail are such focuses of transmission.
Social
distancing as a tool
You may recall I highlighted the concept that this
coronavirus is transmitted through contact, which means you have to pass it by
one of three ways: touching someone, touching a surface they touched, or coming
in contact with droplets which can occur within about a yard. At this time, for
good measure the suggestion is to keep 2 yards between people. But the concept
that this is a contact form of transmission seems to be holding, which is good.
Mitigation?
Suppression? Where we are now? What is
expected?
The
good, the bad, and the ugly.
As I mentioned, we seem to be in a reactive mode instead of a full-on proactive mode. We have accurate models, informed
by what we know has transpired in other countries that are ahead of us by a
couple of months. And from the models what you might hear can be scary, but I
want to contextualize this for us. When you get just little pieces of
information spread out over time, it is easy to miss the larger reality.
At this time, if you still go by the official known
numbers, we have a transmission rate of about 2.4, so incidence is doubling
every 4-7 days or so. The official mortality rate is still hovering at about 3.4%.
However, if you look at completed cases as of today, in other words those that
are finished with the illness by getting over it or passing away, the mortality
rate as of today is much higher. At this moment there are 222 closed cases,
with 106 recovered and 116 passing away, a mortality rate is 52%. This is
almost exactly where China began with mortality rate of nearly 50% which finally
dropped down to the low number described. Italy also had an original 50%
mortality rate though theirs is still high. Iran ran through the epidemic and a
month into it mortality rates were still 50% before starting to drop. We know
this, and knew this several months ago, but had not prepared well for it in any
way conceivable. We have a disturbing reality if the numbers continue as they
are. We are looking at the same course as China, Iran, and Italy. What we are
doing is the same sort of ratcheting up process these other countries did,
though a bit late, which means, unfortunately, we will have to pay some price. Without
any changes to the reality on the ground, the peak of the epidemic curve will
take place in 6-8 weeks.
Modelers have predicted the following as of now. Which
I still categorically do not believe will happen. Somewhere around 100 million
people will catch the virus this year, and somewhere around 2-3 million will
die in the USA. They also modeled mitigation, which is what we are now doing,
versus suppression which we are heading toward. By mitigation we mean we are
not trying to get rid of the epidemic as much as control it, sort of letting it
build slower over a period of time, rather than a sudden spike that would
overwhelm intensive care facilities. By mitigation, we include all the social
isolation strategies we are doing now. In this way, the good news is that, you
sort of slowly, slowly build immunity through the population. People still get
it, but not at a pace that overwhelms intensive care locations. Perhaps 3
million do not die, but with this strategy, the model is that many, many people
still perish. Which I refuse to believe this will be allowed to occur.
Suppression is a bit more intense. Here the goal is
to end the epidemic. Not just control it, but end it. The strategy here is to
shut down almost all interpersonal
contact. Close everything down, as we see in Italy now, and what China did. If
this were to be the strategy the good news is that you could end the wave
pretty quickly. This is what we saw in China. The main problem though is that
most people are not exposed to the virus, and if you did not eliminate it
completely, then it is likely that the people who were not exposed to this
before would restart the epidemic. This is exactly where we are right now in
China. They are past peak, the first wave is over, and they are opening up many
places that were closed. If everything holds, then we know that suppression is
a good, medium-term solution. If it does not hold, then we know that this
strategy is mainly used to buy time. I think that if nothing changes in the
science, we will be heading to a complete suppression mode very soon. This is
the reason why we see border closings now.
Why
I reject this model. What is missing from it?
I have several main problems with the models being
reported, on science, and from the naturopathic physician perspective.
Modelers use a set of parameters that they are aware
of and from past experiences, but the science is ever-changing and what we
learn allows us to adapt. For example, all models assume the germ does not
change, when in fact, germs evolve constantly in nature. This should be
factored in, or highlighted as it may well impact transmission, morbidity, and
mortality.
Modelers assume unchanging treatments. But in fact,
this is not the case. For example, here I specifically believe that there is a
method to triage those more seriously ill patients and offer preferential
treatments, as in testing the relative deficiency of C1INH, discussed in prior
updates. Most importantly, I believe any number of currently approved drugs can
be repurposed and can work to greatly modify the mortality rate. There are two
ways this can work. Firstly, taking patients off some of the drugs such as ACE-inhibitors
which I hypothesized two months ago, and indeed are now thought to be a risk
factor for worse outcome for those who fall ill. And secondly, finding pharmacological
agents that work well enough to either keep people from developing a dire form
of this disease or treat well enough those who are severely ill. I think these
drugs will be identified and tested in the very near future. For example, I have high hopes on a combination of Chloroquine,
Nelfinavir, (or other HIV drug), Rapamycin, and Dasatinib, as well as
other agents I mentioned previously. And when that
occurs, the panic will end, almost overnight, as we continue to hone in on
better and better treatments. A third assumption is that those treating the
very gravely ill are not developing strategies on the ground to modify the
mortality rate. This also does not reflect reality. For example, just recently
it was found that turning the patient on their abdomen seems to help in their
oxygenation, which is the main issue here. To making modeling more accurate, we
need to account for the fluid and evolving nature of both the virus, the
treatments being tried and ideas health care providers are developing.
The assumption is also that vaccines will enter the
treatment world in 18 months, but in fact this is not true. The higher the
mortality rate the more expedited regulatory authorities will allow the program
to roll out in a more expeditious fashion.
The assumption is that there are no new innovations
to transmission blockage, but again, we spoke about copper as one solution
amongst many.
The assumptions are that there is no real
seasonality in the virus. I believe this to be false. I think summer will
diminish the overall transmission rate. And if we get the timing right this
time around, when the virus is at a smaller footprint, we can do more as a
society to prevent it properly. See below.
There is the assumption that testing remains slow
and episodic. This is going to be false very soon. Testing will become much
faster, much easier, and more widespread, very soon. Here I still mean that the
best way to end this wave of the epidemic, at this time, is to test everyone,
and isolate those that are unwell. SPECIFICALLY, create barriers between those
that are most at risk of contracting severe forms of this disease and those
that may infect them. It should be said that this by itself will limit
mortality rate. Let the immunity build throughout the population before
exposing the vulnerable. And if you do not want to test everyone, then roll it
out quickly in testing health care workers, then testing the highest risk
groups for a bad outcome, the those around them.
Naturopathic Medicine
From the
naturopathic physician perspective, this model has faults. It focuses primarily
on the virus and on the age of patients. However, from my perspective, we have
to factor in the heterogeneous nature of peoples’ immune system and ask the
question: can we impact the immune system? In fact, I would argue that my entire
profession is built on the back of that proposition. We are taught primarily
that aside from impacting public health measures, and trying to kill specific
pathogens, we focus on modifying the immune system of the patients. This is not
factored in at all by the conventional public health leadership, which I believe
is a grave mistake. By not including this comment, we leave people to basically
wait to see what others may develop for solutions. But if we say that we want
to do this, to help the patient develop an appropriate and resilient immune
response to the virus, then it opens a treasure chest of interventions. I
highlighted this in 2 separate updates, one on supplements and one on
homeopathic remedies. We do not know if these supplements will modify the
COVID19 virus presentation. But we do know that these, in clinical trials, have
shown the capacity to impact viral presentation. It behooves those with money
and access, to conduct clinical trials to see if such approaches work with this
specific virus. I believe that some or all of these will show at least a degree
of benefit when tested. Until then, these are all available at your local store
from a variety of companies. Under compassionate use, it seems like there is
little to lose here and we should heed the lifestyle and supplement
recommendations shared earlier.
One way or another this wave will end. It only
matters how impactful this virus is to us. And I still say this is not a
medical question, but a political public health question. Let’s make the right
decision now. At this time, while the epidemic is at this stage, a great deal
of funding should go on widespread use of rapid, repeated testing of everyone.
Soon, this may be too late for this strategy and then the main strategy will be
to test all the most at risk groups, and the people around them. Some of you
can impact public policy. Push for this strategy.
In
health to you and your loved ones,
Paul
Herscu ND, MPH
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