2019 Novel Coronavirus (CoVID-19): Part XIV
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:
September 3, 2020 update Part 14
Paul Herscu ND, MPH
This is the fourteenth piece of writing on the current epidemic. Please read , , , , , , , , , , , , and Part 13 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.
One element at a time: Induction, or where should they focus
Back during the SARS epidemic, and then the Ebolavirus epidemic, I spoke a great deal on the topic of public health modeling. Specifically, and you can hear this on tapes of the day, I mentioned that, medically speaking, we are in the new era of germs. Every few months or years there will be a new germ discovered that is lethal to human or animals or crops. And that basically, as a species, we need to develop a better way to think about germs. Instead of thinking of germs as deadly and how they need to be eradicated, a better way may be to learn to adapt towards them and encourage the bug to adapt to become less virulent. But the bottom line is that we will discover more germs, the science is there for that capacity. And if we are not thinking of it in the right way, we are going to go insane worrying about all the germs constantly surrounding us. Enough said here for now.
One of the main points I made is that everyone, every single person, from about middle school onward, is able to greatly understand the underlying issues if you can present them with the science of epidemiology, of public health. More or less, everyone arrives at the same position then, and can make informed decisions. The problem is that these basic public health concepts are not taught to most of us. Many of you have attended lectures where I have presented the basics in a few hours talk. What I want to do here, now, is review that material, one important piece at a time. Yes, they apply to this particular epidemic, but if you understand the basic concept it will help you into the future and with any potential epidemic. Let’s start.
One of the short topics we can start with is that of Induction and Latency. But first let me set a scene. You send your child to school and after a few days the parents in the class get a call that a student in the class went home with a fever and sore throat. What do we do? How long do we worry until we know what that child has?
Broadly speaking the concept of Induction defines that period of time between when you are exposed to the bug to the time that a diagnosis is made. In other words, let’s say that in this instance with SARS-CoV-2, the bug that causes COVID-19, you are exposed to the virus. The question is how long does it take to find out that you have the virus yourself. This is a vitally important number to all of us, since it allows us to get a sense of whether we are safe or not. If I just went to the grocery store, how long will it take me to find out if I caught the virus or not? That, in public health terms is called the Induction period. And typically, with COVID-19, we have settled on a range of days, around 6 days until you become symptomatic (more or less), and then after that, a certain number of days for the testing to be done, and a certain number of days for the results to be returned. Induction period. After that period, as the diagram below suggests, the disease progresses for a period of time, and then it ends, making that the duration of the illness. Let’s leave out the types of tests and how often and when for another time.
Be aware that this is a sort of simplified version of the topic, but enough to arrive at the main points. Right away, it becomes obvious where the problems might lie, and where the money and public health measures regarding this point should go:
1. Develop tests that can be administered soon after exposure, before symptoms arise.
2. Speed up the results of the tests so that we know who has the illness and who does not.
In both instances, we would be shortening the Induction period (i.e., time to diagnosis).
This has not gone as well as it could have! Some of the reasons are purely technical/biological. For example, and this is just one example, the virus that causes COVID-19 is very, very similar to other viruses, like the one that causes the ‘common cold’. Which means that many times, a simple test is not possible, because we would be picking up the wrong coronavirus, picking up the ‘cold’ one as well, and not just the one causing this current pandemic. In other words, we are trying to develop a test that both picks up this coronavirus AND at the same time excludes other coronaviruses, of which there are many. This makes it slightly more difficult, but not impossible.
The science is known as to how to arrive at the right tests. The USA has enough commercial interests, labs, trained people, and a head start on the topic, since the virus is similar to SARS and we have been working on SARS already. Just as importantly, in the USA, the government has the right to take over testing and production of different facilities, during public health emergencies. To be sure, I was involved in one such site, when during the Ebolavirus, the government took over the facility to produce vaccines. This can, and does occur. But no matter what the reason, there was a sort of confusion in this country, in terms of poor coordination of our assets. The government stepped away from taking over the lead in development. As a consequence, the pathway that primarily was settled on, after months, was that commercial and university labs would take the lead, using government funding. Then the government waited for the solutions and further developed, bought and distributed the solutions. Broadly speaking that is how it settled. Right or wrong is a different matter, and I am not really addressing that, but more so addressing what happened. There are two consequences of this decision. The first, which is a very bad one, is that we wasted months working this out. The second, which is actually very positive is that as an effect of this strategy, there are many labs developing numerous strategies on how to address number 1 and 2 above. They are working on both how to shorten the Induction period and how to speedily test/and identify true cases. The ideal, which I described years ago is still the same, saliva test with the results in minutes. I think we are getting close to that now. Hopefully, this will be within our reach in the very near future.
I hope this makes sense thus far.
Politics sort of messes this simple concept up. As hard as it may seem, step away from the politics, and appreciate where we are now. If this were to occur, if you could shorten the Induction period and at the same time have a very rapid, easy to administer good-enough test, then the country could restart with full confidence. I actually think we are closer than we think here. We just need to keep the pressure where it should be, and the proper funding, to get to the finish line.
If there were going to be a proper discussion on blame, then it should be specific and accurate, and belongs, regarding this topic, on only one variable. Should the government have led the process or should the government have funded the right private/university places/people to get the job done. This is really the main question upon which to have an argument and there are plusses and minuses on both sides. Every country dealt with this differently. Some countries had the government lead and in some of those the success was fantastic, really fantastic and almost unbelievable, and in some it was horrible, I mean really horrible. But if you know where the issue really was, then you can then follow it up by finding out what went wrong there. Where was there inefficiency and mistake. But please have a proper conversation about it.
Personally, if I were going to make a comment on this part, I would say that it ‘sort of’ settled on the strategy after months rather than clearly articulating that this would be the plan and going for it full force. It seems as though we settled here rather than decided to be here. And this cost us precious time and sadly, many lives.
(As an example of having proper conversation that looks at mistakes, we can take the pathway that Sweden is taking in this epidemic. The government is still very much sticking to their plan, and they state their reasons. BUT, THAT SAID, they then go forward and state that they made mistakes in implementation of that strategy, and here is the mistake, and here is how they would do it differently. Their strategy might be right or wrong, but they are clearly articulating what it is and where they made errors so that they can fix them. This is what I mean by having a candid look at where we are and how we got here.)
OK. If you are with me thus far, I want to add a bit of complexity to the modeling, just for more completeness. Let’s talk about Latency.
Here, Induction period is shortened from the exposure to the germ up until the person is going to become sick. In other words, illness is about the start. Latent period is from that point up until the person become symptomatic. Up until becoming symptomatic they are subclinical/preclinical/(and let’s include asymptomatic folks here, even though this is not correct, just for simplicity sake.) This was offered by , in1981, for a variety of reasons, but especially to highlight that during the latent period, there are different elements that could slow or speed up the progression of the symptoms and other elements that might make the symptoms more or less serious. I get this. And in fact, I believe this to be the case. I believe that there are things you can do that would modify the disease. But until we are allowed to publicly describe those elements again, then for all practical purposes, the Latent period is included for now within the Induction period. So please do not email me that I forgot this.
Some Final Thoughts
And if you are still with me on the topic of Induction periods, I would like to make some final comments on the topic:
1. Multiple Induction periods. One obvious point to bring up is that for any one individual, there may be several different exposures, over a period of time, and therefore the Induction period is different for the different elements. This is a bigger topic for chronic disease but here matters as well. The classic example is the Induction period for a heart attack or for cancer. The genetics Induction period would be from birth. The smoking Induction period might be since 25 years old. The poor diet choices might be since college. The exercise choice or lack thereof might be since 30 years of age. We see that the Induction period is different for different exposures. And there are many of them. This is also true in epidemics, but thought I would mention it here, to say that this is playing out in the researchers that are trying to understand what controls the Induction period in different folks, the symptoms they develop, and in general, the course of their disease.
2. The models they use are too simple. I believe the conceptual models the government and researchers are using are actually too simple and in that simplicity are putting us at risk. First, let me give you an example. It has been shown that driving on the wrong side of the road, against oncoming traffic, is detrimental to your health. You get into car accidents. In other words, you could start the stopwatch from the time you cross the median line and start to drive unto oncoming traffic until you are in an accident and call that the Induction period, of say 1 second on a busy road, or 1 minute on a less busy road. And that would be the Induction period. And everyone would be sort of happy knowing that. You build barricades, or more bright lines, or put bumpers in the median to prevent the change in lane. But if you ask yourself, why did the fellow cross the road, you might get to alcohol ingestion, for example. He drank alcohol, and then crossed the road and then was in an accident. You see my point. If you start at the alcohol timeframe and get all the way to the accident, you get a longer Induction period. Which is then actionable in a different way, as in don’t drink and drive, and tickets or jail if you drink and drive, or checking blood alcohol levels. Or developing rules like if I drink this much, I must not drive for 2 hours, or 4 hours, etc. By taking a broader look at the incident you are able to go backwards in time, and be able to identify common elements that clearly start the cascade that leads to crossing the lane and the accident. A longer Induction period. But one with new ways to stop this from occurring.
Personally, I believe this is the case now with this virus. I believe that there are things one could do for proper bodily functioning that might help. But I can’t say these now because I was asked not to. And also, because none of these things were properly tested because of cost and because the public funds are not being sent in that direction. None of it is difficult to test. It is actually easy. It just isn’t getting tested. Or to put this more plainly. I think that before a person is exposed to the virus, they are already not functioning properly. Then when they get exposed to the virus, their prior state makes it more likely that they get a more severe state rather than a less severe state of the illness. Even getting away from the idea that once exposed and before you develop symptoms, during Latent period, there may be things that you can do that change the outcome of the symptoms, leaving that out, just describing the original pre-exposed state, there are variables that may be actionable. Until the FTC allows us to discuss potential variables so that they are known to the scientific community and then may be tested properly, this just becomes a mute moot point. We need a solution here. People are dying!
3. The long (bad) arm of disease prevention. I know I said this in January, AND February AND March, and nevertheless here we are, and there is no way to go backwards, there is another thing I said before, and I have to reiterate it now, as my time is shrinking on this. Decades from now, we will find that there is an uptick in the percent of people with osteopenia and osteoporosis, and heart disease, and depression. And there will be many reasons that will be rightfully attributed to. HOWEVER, I believe one such reason, is the panic that this epidemic has caused has led to the lockdown, that has led to less activity, less outdoor time, less sunshine, and all of this will lead to these increases in lifestyle-preventable diseases. This is my way to plead with you, one more time to make sure that you get some exercise, get fresh air, especially get some sun on your face or body. This is just for proper bodily functioning.
4. The long arm of disease. One of the most common and important observations I made, as well as almost everyone else, is that the vast majority of people that develop COVID-19 do not experience it as a true acute situation but rather as part of their chronic picture. Which means, to me, since January, that unlike common respiratory tract infections, which usually last for a bit and leave, this one will leave many people chronically ill. The thing is that many people will not actually see those symptoms for years or decades later. I think 20 years a from now we are going to see an increased percent of heart failure and COPD and other lung problems, and when we look more closely, will be able to say that it is because that person caught this virus now. In other words, for those, the Induction period for COPD would have started now. And just as I highlighted above, these are, by and large, I believe, often avoidable. We need the FTC and FDA or enter into dialogue of how it is that we might be able to discuss some of these elements so that they may be properly tested and discarded if proven ineffective or generalized to the larger population if effective. Sadly, that is not the case now.
Until then, I think this is the most important part of the discussions around Induction period. And while these variables are important when discussing COVID-19, they are the same points that are true for every epidemic.
Until we know more, I think trying to stay generally healthy is useful, in terms of proper normal functioning. Towards that, regular exercise, get some sunshine, Vitamins D, C, E, Essential Fatty Acids, Resveratrol, and Zinc.
In the next Update, let’s discuss potentially effective treatments.
Paul Herscu ND, MPH