January 27 2020 update Part 1
Paul Herscu ND, MPH
In writing about epidemics over the past 3 decades, my first goal has been to create information scaffolding for readers so that you have sound context to receive and understand the bombardment of information about any epidemic. If you want a broad and deep understanding of the concept of epidemics, which I strongly suggest,
First Things First. The Immune System with Relation to the 2019 Novel Coronavirus (2019-nCoV)
In understanding a patient’s reaction to the 2019 Novel Coronavirus (2019-nCoV), it helps to think of the challenges it presents as twofold. First there is the damage that the virus causes by itself upon the body. Secondly, and perhaps more importantly, there is the damage, which may be lethal, which is caused inadvertently by one’s own immune system responding to the virus.
This is a very important point to highlight. Though the virus is particularly virulent at this moment, not everyone dies. It is thankfully, only a very small fraction of those exposed who perish. There is an additional small fraction that become quite ill, and the rest become ill in a usual flu manner. And for some people, the damage that the immune system causes upon the individual, is perhaps worse than the insult caused by the bug itself.
There are different professions that have focused, since their inception, on supporting the immune system, and helping patients develop an appropriate immune response. Naturopathic physicians form one such profession. To be clear, this is not to claim that we have experience with the killing of this virus. What we do have, for over a 100 years, is a great deal of experience with helping the immune system respond appropriately, read: not over-respond or under-respond, to certain situations. And while the germ has its own virulence, which I discuss below, what I want to highlight is that helping the immune system develop an appropriate response is paramount. This is something we can support our patients doing and do for ourselves. While on the one hand this is a lifelong exercise for everyone, there are some things to do right now.
The simplest one is to make sure that your immune system is not being stressed by other illnesses. In other words, try to get other chronic ailments under good control. In most years, those with prior chronic illnesses are more at risk of a lethal form of any influenza or virus than those that were previously healthy.on how to help here, including diet, botanical, nutritional supplements, sleep, etc. By so doing, if exposed to this virus you will hopefully suffer a lesser course of the disease rather than the lethal course. This part is within our control. To be sure this will not be enough by itself, absolutely not enough, but it will help! It’s not nothing!
While this has been the main domain of naturopathic physicians, most other medical professions have also taken up this call. Homeopaths since the time of Hahnemann, osteopathic physicians, chiropractic doctors and increasingly medical doctors are offering whole-person, natural medicine modalities as non-pharmaceutical interventions for some of our most troubling chronic conditions, focusing on appropriate immune response. This is important work overall and becomes even more important during times of epidemics.
2019 Novel Coronavirus (2019-nCoV):
At this point, late January 2020, it appears as though the virus is both novel and very problematic to our health. By problematic I mean two separate things. First is how infectious it is. In other words, if someone carries the disease, how many people will they pass it to? The second point is how severe the symptoms are for some people.
With regard to the first point, how easily is 2019-nCoV passed? In medical terms we are referring to its basic reproductive number. The higher the number, the worse it is for the spread. At this moment, 2019-nCoV is estimated to have R0 of 2-5, meaning that each person may infect 2-5 people. This number is concerning. If these numbers actually hold, then this bug will go global and will be difficult to stop. Think of the flu every year, which has a slightly lower R0 number and skips easily around the world. As of this writing reposted cases in China are estimated at around 6000. There is very good reason for me to believe that this number is closer to 40-50,000. That said, it is still very early in the epidemic and the R0 number will likely rise or drop precipitously.
In contrast, during the 2014 Ebolavirus epidemic, early on I commented that, amongst other things, this was not the epidemic to really fear for the world. The main reason was that Ebolavirus, for the most part, was and is a direct transmission bug. It does not generally pass via airborne transmission. The ones we have to fear are the airborne droplet transmission epidemics which is what we have with 2019-nCoV. These are almost always worse than direct transmission infections.
I believe in coevolution, that basically, the virus in most instances will evolve to become less virulent over time. Which is what happened with SARS, where the transmission dropped over time. Let’s hope for the same here. We need to keep track of and see how succeeding generations of the virus evolve and how the R0 number shifts.
The second point, how sick do people get and what percent of those that are exposed and become ill will die. It is possible that the number that is floated around just now may near 5-10%. If these numbers are true then this does not bode well at all. But it is also extremely possible that the number will be much, much less. As an example, during the influenza pandemic a decade ago, where many people were terrified about this new flu strain, the patients I attended seemed to have a milder form than usual. In other words, while more people got the flu, they suffered less from it. It took a year before that overreaction to the flu that actually occurred was discussed (though I wrote about it within the first weeks). So, severity is the other number you want to keep track of, the actual percent of people who have the disease who die. And for a variety of political reasons, the most important numbers are the ones that come from outside China, not from inside China, as the succeeding generation of the virus unfolds, we will want to keep track of see how lethal it really is. Personally, I believe that this number will be much lower than currently thought.
Until you have accurate numbers, prudence is in order, but not panic. Take care of your overall health, practice good public health measures, and let’s see how this develops.
The Physical Crisis
I want to focus on those patients that develop the worse form or presentation, the sad, scary, side of this infection. Here, I do not care if we are talking about millions, thousands, or even a single individual, the principles are the same, and they are general, not just to this virus. Accordingly, this section describes the serious health crisis itself, which has three related parts, none of which are being discussed at length at this time but ought to be:
A. the direct damage of the virus upon the organs, such as the lungs
B. the cytokine storm that threatens the life of the patient
C. the after-effect of the cytokine damage, which is potentially most dangerous
A. The direct damage to the lung is partially related to the viral load. Here finding the specific antiviral will limit the damage. Short term damage may have occurred and has to be dealt with, with or without the virus present. In other words, even if all the virus is gone, we have to address the acute damage to the tissues. It is like someone who has severe smoke inhalation, but survives. There is damage there, even after the smoke is gone. Only focusing on the virus at such a point is not enough. This is true if you use pharmaceutical agents, or natural medicine products.
B. With regard to the cytokine storm, I believe there are two major ways to deal with this life threatening reaction to the virus. First is to try to stop the storm itself. In fact, I don’t believe that the science is fully there yet, but it is possible that a combination of medications may be of use. The second approach would be to actually remove enough of the cytokines from the blood stream to shorten the length and severity of the storm. We have the technology to do this now! Though the technology is not readily available, this is one solution alongside other therapies. Remove enough of the cytokines to let the body’s immune system deal with the infection, but not kill itself in the process. There is an easy way to do this now, though not yet considered by the treatment teams. And in time, it will be cost-effective, if provided to those that are severely ill or predicted to become severely ill.
C. I would like to highlight the damage itself. One of the most likely lethal natural courses is the development of lower lung involvement, leading to pneumonia, followed by Acute Lung Injury (ALI,) then Acute Respiratory Distress Syndrome (ARDS,) and possibly death. To be clear, here the problem is not so much the bug itself, but the damage that has been caused by the immune system interacting with the bug, effectively drowning the patient with fluid in their lungs. I wrote and spoke about this during the SARS epidemic, and believe this to be true here, too.
Since the first time I wrote about this kind of damage to the body from infections, I have been involved in a number of different projects. Most importantly was a study on patients with sepsis, many with ALI and ARDS. Our hypothesis was that the inflammatory response used up too much C1-INH and that patients were dying due to drowning in lung fluid since enough C1-INH was missing to limit vascular permeability. The clinical trial was successful and the paper was published in Critical Care Medicine. Later, a post hoc analysis showed the same results when we looked at only the ALI/ARDS patients. In layman’s terms our hypothesis was this: In the midst of an inflammatory response, different molecules create vascular permeability opening up spaces to let more of your immune system into the damaged area. C1 is one of those molecules. At a certain point you have to close the gaps to stop the fluid from pouring into the area. That is the job of C1-INH. What we found, in a clear dose dependent manner, is that when you use up too much of the C1-INH, you might develop a ‘relative deficiency’, and when that occurs, fluid just keeps pouring into the inflamed area, here the lungs. By measuring the levels of C1-INH, in relationship to the other inflammatory markers, it may be possible to predict who is likely to have their infection turn lethal. If this test could be administered it could be essential information to understand who is most at risk. Sadly, they are not measuring this molecule yet, but this week, we have sent a letter to stakeholders and hope that they begin to measure this in the blood of patients with 2019-nCoV.
This information is not only a predictive diagnostic tool, but could impact the treatment of those patients with severe illness. Such patients can be given C1-INH so that they are no longer deficient. We did this in 9 ICUs and found a large statistically significant benefit to these patients over those normally treated, when looking at the usual 28 day all-cause mortality numbers. Further, we hypothesized, though did not test for this in our trials, that C1-INH may help remodel the cell surfaces in the lung, assisting recovery from the damage itself.
This is one way to think about those in the most dire situations, and an area to explore to make this and other potential epidemic less lethal.
The role of those practicing in naturopathic, homeopathic, and integrative medicine settings in general and during the time of 2019 Novel Coronavirus (2019-nCoV) in January 27, 2020:
The highest level of any physician should be to function at the primary prevention level. Dr. Amy Rothenberg described basic preventive measures in her short article. Aside from those comments, the natural medicine community has a role to play.
The natural medicine community, like any organization of individuals can and should bring its political voice to bear urging politicians in charge of the purse strings to adequately fund prevention protocols.
Like every other medical and nonmedical organization, civic group or religious community, at the very least, we can assist in the collection and distribution of products needed to decrease exposure. Here I mean even simple cleaning agents such as soap. Assisting with the removal of potentially exposed substances and surfaces will also be needed. Please remember that these ‘simple’ acts will and most often save the most number of lives. This has been true in every epidemic to date.
Further, those trained in public health measures can assist within the current public health command. This means everything from assisting in surveillance, finding both exposed and sick individuals, transporting exposed and ill patients while limiting travel of those individuals and providing quarantine assistance, helping with communication of status in a defined area, and assisting in the safe removal and processing of the remains of the deceased. Simply put, as is true in every large-scale emergency, either be part of the larger command and control or try to stay out of the way. There is always a great deal of confusion on the ground; we do not want to add to it. Very often integrative practitioners are ‘outside’ the basic command and control and hierarchy of public health. Our medical societies should integrate within the larger community. For example, in the naturopathic community, which are regulated by state boards, the state boards should be in close communication with the state public health authorities and funnel information up and down the chain of command.
Integrative practitioners can help provide lower level medical support such as rehydration and palliative care. And if during this time, one has the opportunity to treat an ill patient and/or presented with a person who was exposed to the virus, then I believe that an integrative or natural medicine approach, such as a homeopathic remedy, or a combination of botanical medicines, etc., can and should be given. The FDA is in support of many therapies that may yet to be proven during times of epidemics. Indeed this is why so many antiviral drugs as well as many other pharmaceuticals are currently being tried with patients though research has not supported their use.
Anything short of allowing access is an example of the ‘tomato effect’ seen in people acting unscientifically, and not in keeping step with the rest of science at the moment as it relates to 2019 Novel Coronavirus (2019-nCoV). In fact, I would say that in the circumstance I described above, where the patient is receiving the best care possible, given the resources available, it would be interesting for everyone to test out whether a safe natural or integrative approach like homeopathic medicine actually provides benefit. This would be interesting for all; likewise, if the substance is completely useless, this would be valuable information, too. Join me in this call for a rational approach, unfettered by bias. Rational prudent thought should prevail.
The response of all natural or integrative approaches to the 2019 Novel Coronavirus (2019-nCoV) epidemic should be to help highlight and advocate for prevention, assist in identification of those infected, stabilization and quarantining of exposed and ill individuals, and support cleaning and disinfection processes, as well as providing natural and integrative aid where and when appropriate. There should be a push from every medical community to their government to support relief efforts.
In the next update, we focus on some of our main treatment options.
Paul Herscu ND, MPH