Thursday, February 20, 2020

2019 Novel Coronavirus (2019-nCoV): Part III

2019 Novel Coronavirus
2019-nCoV (first named); COVID-2019 (later- named disease); SARS-CoV-2 (final name of the virus causing COVID-2019):
February 19, 2020 update Part 3
Paul Herscu ND, MPH
Herscu Laboratory

This is the third piece of writing on this current epidemic. Please read Part 1 and Part 2 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. For this epidemic, I will keep the sections consistent. Also, please be aware that I am keeping the same sequence of comment topics, for ease of read from one installment to the next.

2019 Novel Coronavirus (2019-nCoV; COVID-2019):

Comments I shared here over the past weeks remain true and are seen in writings coming from across the globe. I want to focus on why this is of outmost importance to you!

Official Numbers: First, I applaud the Chinese government’s response to pressure to recalculate and reclassify patients to share data that is closer to what is likely the truth of the matter related to incidence of cases. As I mentioned last time, learning the true numbers out of China is always tricky. That said, the number of cases are clearly growing, as Chinese official numbers are approximately 70,000 cases, as we read, with at least 1,800 deaths. These are close to the numbers I mentioned before, 75,000. I still have real questions around this number, but let me pass on that for a moment. And to the more official numbers from the WHO as of today, inside China we hear 74,280 infected, with 2,006 deaths, or a mortality rate of 2.7%. If this were the case, that would be really bad for all of us. However, I think this number is still really wrong, maybe by as much as eight to ten times. From the WHO, as of today, there are 924 confirmed cases in 25 countries outside of China, with 3 deaths, or 0.32% mortality rate. Please note that what I mentioned 2 weeks ago was a 0.3% fatality rate, which is what we have now outside of China. A bad number for sure, but MUCH less severe case fatality ratio than a horrific epidemic would have. I think the case fatality number will settle around 0.2% to 0.5%, again much less than what China is reporting.

While I am still not sure what the current Ro number is for real, it does seem like we can start to draw a proper epidemic curve and it looks like we might just miss another scary global epidemic here. Let me say, right now, here, that I believe there is good news finally, though not yet reported.

As before, knowing the real number of infected is essential so that descriptive analysis can lead to mathematic modeling of how average or how highly infectious this epidemic is. With this information in hand, better predictions from those infected outside China can be made. I mentioned that the mortality rate and disease burden outside China is the one that really matters to science and to us as it is more likely accurate.

I was going to headline this episode Better Late than Never, to highlight that much of what I wrote about over the past weeks is actually what occurred, is what NGOs and governments are now beginning to say, and that, well, being late is not that bad, (the most important one being what the total numbers inside China might really be). But in fact, being late is not always OK. This is a really important point. Let me give an example. Decades ago, I read a report that there was a new virus found in birds in Hong Kong that was killing many birds as well as sickened people. 1.5 million chickens were slaughtered and that was the end, it seemed. I wrote then (as can be read in Herscu Letter #70) that they should try to kill all of the birds right then and there. This was, at the time, an island issue, and that if they did not kill those millions of birds, many billions would die later, and make the possibility of transferring to people greater. I received hate mail over this suggestion. Well, those birds were not killed, and soon that virus spread all over the world, killed billions of birds, and passing on the virus to people, where some people died, many were ill and putting that virus in the cycle of returning germs. In hindsight, killing those few birds to stop the many other birds from dying really seemed like a better idea.

The reason I mention this history is that being late is not always OK. The reason I mention this now has to do with trying to get the right numbers and its import. When looking at an epidemic you try to map out an epidemic curve, which will more often than not help you guess what the causative method of transmission is, and predict the type of growth, the type of spread, and how lethal the epidemic will be. And while it is a sort of backward indicator, showing what has happened, after many epidemics as example, you can use this information to have an educated guess as to how things will proceed, and how to appropriately prepare. But this is only true if everyone plays fair and shares the available data. It is not clear to me that this has happened in this case, from the governmental point of view.

Separately, what has not yet fully been considered are the number of people who have caught this virus but are either asymptomatic, and therefore may not be counted, or have very mild symptoms, and therefore may not seek treatment, or are scared to tell authorities that they are unwell, in which case the numbers may well be additionally inaccurate. This is where epidemic curves come in handy, as they help you ‘fill in’ the missing data.

Yes, there is much we do not know yet, but looking at the epidemic curve from the data available today, that can be drawn today, things are looking better than they had a couple of weeks ago. Below is what they look like, from the WHO data. From prior epidemic maps this is signaling that this first wave of the epidemic and its growth is soon going to collapse. It is most likely to end, sooner rather than later. That is the good news, according to my read. Not right away, for sure, but definitely ending sooner than the apocalypse vision some had. As of today, most if not all people are still predicting a worldwide epidemic of tremendous proportion. I am guessing others agreeing with this assessment will follow in 1-3 weeks’ time. I have lectured extensively on the topic of how to read these epidemic curves elsewhere. At least if nothing else changes, this first wave should wind down.

There is some potential bad news, though. As with the bird flu I mentioned above, this virus has escaped the region. And if we leave off why this happened, and just focus on the reality, it is no longer isolated and is too big to be isolated now. Yes, we should isolate those that are ill, to slow down and limit spread, but if the numbers that China reported are partially true, and if there are numerous people who are asymptomatic or partially so that they do not even know to self-isolate, then it is not likely to have the virus die out due to its level contagiousness. Also, we are not completely sure which animal vectors are involved with this virus so cannot take precautions there. In other words, what is likely is that this virus is with us, for the duration, with ups and downs, with bigger epidemics and smaller ones, but following us the way influenza or the common cold does. It is just that we, as humans seem to have always known the flu and the common cold as part of reality, and this time, this virus we have seen at its very genesis. Biologically, evolutionarily interesting, but nevertheless sad. So, that’s the first bad news.

The second part of bad news has to do with two populations. As I mentioned the first time, there seem to be some folks that are more susceptible to dying from this virus than others. From the current numbers, which I think will eventually be found to be fewer, but still high, about 15-20% of those over 80 years old that get sick die from this infection, as do many people with heart disease or diabetes. These numbers are striking in the face of the heart disease and aging population around the world. In other words, we, as a group, are getting older, and if this statistic holds, and if the virus returns over and over, then there will in fact be many more deaths than this go-around. Lots of ‘ifs’ but the point is that unless something changes this may be the future. Just as we currently find many, many thousands dying of influenza every year, we may find a yearly death from this virus. Not the hundreds of millions in a year as was feared, but nevertheless a number of yearly deaths. What is frustrating is that proper monitoring and open intergovernmental cooperation could have stopped this in its tracks.

Relatedly, I prognosticate about the next 2-15 years: if the virus stays as virulent and episodic, and if it remains the case that older people and chronically ill are more likely to have bad outcomes, then it becomes very likely that, A., a vaccine is developed, and B., every health care worker will have to have this mandatory vaccine. Elderly sick people visit doctors. They may carry this virus. The doctor may be exposed and not know it, and pass the virus along without knowing it. Just as a reminder, one may carry the virus for 5-6 days before becoming symptomatic. This seems to be the average. But we still do not know how many people carry the virus and do not get sick at all, and are just walking around not knowing they carry the virus. Therefore, a vaccine will be developed and will be given as a mandatory precaution to health care workers to solve for these many unknowns.

Lastly, here is a hope I have. I hope that the virus coevolves, as I mentioned before, where the lethal nature of it diminishes over time. This happens. Often. It could happen here. I think since biology can make this happen, and nature often makes this happen, I hope that science work towards ‘encouraging’ this, rather than focusing solely on a vaccine solution. I think we can all agree that having a ‘friendly’ virus around is better than having to fend off constantly a threatening virus by developing and having to constantly change the vaccine. Biologically speaking, a much better solution.

But as I mentioned from the first, personally, I believe that these mortality prediction numbers will be much lower than currently thought by the 2.5% numbers out of China.

The Physical Crisis

Regarding the actual disease, when it shows itself in a severe form we see:
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 the most dangerous

A. It seems as though there are reports that some specific antivirals are working well enough for the situation at hand. Not perfect, but perhaps well enough, here thinking of Protease inhibitors like Lopinavir/Ritonavir, similar ones that were used in SARS. Recall the natural antivirals, too.

B. With regard to limiting the cytokine storm, one solution being tried is plasma exchanges, as were tried in Ebola, and other severe infections for similar reasons. While at first glance it might seem unusual, the science is sound. ‘Borrowing’ the immune system response of someone who survived this infection to fight more appropriately the same infection makes good scientific sense.

Regarding the suggestion I made that a company such as Cytosorbents could use their technology to limit a cytokine storm: A week after I wrote that, they published a paper that showed this possibility. Not in this epidemic, but the science of limiting the cytokine storm is clearly possible and now there is a sort of proof to have them try. IF ANYONE KNOWS PEOPLE AT THIS COMPANY, PLEASE PASS THIS SUGGESTION ALONG.

C. Here, I still believe both checking the level of serum C1-INH in the most ill patients and then giving those with a relative deficiency of plasma C1INH more C1-INH is a workable, affordable, targeted solution. I hope they will soon start to measure C1-INH in severely ill patients, using it as a sort of biomarker for treatment and prognosis. IF ANYONE KNOWS PEOPLE TREATING THESE MORE SEVERE PATIENTS PLEASE PASS THIS SUGGESTION ALONG.

The role of those practicing in naturopathic, homeopathic, and integrative medicine settings in general and during the time of 2019 Novel Coronavirus (2019-nCoV; COVID-2019), February 19, 2020:

The main point I made earlier is still relevant. Follow WHO/CDC guidelines as to best practices. As well, physicians who use integrative methods may offer many, many other tools that help the immune system better address both prevention and treatment of viral infections in general. There is a RICH history of many tools that help here, with a variety of mechanisms of action to help the host better respond to the offending germ. I believe it is not that science is lacking here, but only money to test out safety and efficacy to see if any of these old tools may help in this case, in this infection. We simply do not know at this time.

Regarding the comments I made on the mask situation, now that the panic is soon to lessen, we read more on the observation I made, that the masks most often used are both inappropriate, ineffective, and in many cases may worsen the situation by placing proven hygienic measures (such as handwashing), in second place, as demonstrated by the comments others made last week that I reprinted. As importantly, more focus is currently being placed on the mask I mentioned before, the R95. It is a better solution, if one is going to use a mask at all.

The role of those practicing homeopathic in general and during the time of 2019 Novel Coronavirus (2019-nCoV) in February 19, 2020:

I want to start by saying that the comments I made last week are still the most important ones for us. Good public health measures that you can take will slow down and eventually stop this epidemic. Follow WHO/CDC guidelines here. They will help to keep you safe. Every organization has the same comments. Keep to them, and share them with your patients. They are important to you and to your family. But onward now.

As a group, homeopaths have not seen patients with this infection. We have to wait until we do. If my assumptions are correct, as in the past, then it is only a matter of time until homeopaths start to see actual patients with this virus. If you recall my comments on the 4 different responses of contending with the virus, asymptomatic, mild symptoms, severe acute, and life threatening, I believe that homeopaths will eventually have some patients with this infection. Most likely not the most severe forms at first but clearly carrying and contending with the virus. I think it will be most beneficial to everyone involved, the homeopath, the patient, and science, to properly document both the diagnosis (via confirmed lab results) all the treatments, the symptomatology, and outcomes. A case series or a pooled data set will help us all. As we gather more natural history of current cases, a better picture will develop.

The bottom line as of now, is do the hygienic measures that are within your control. The most important piece of the puzzle is limiting person to person transmission. This will not be enough to keep it from coming back, but it is the quickest way to end this first wave. Primarily try to avoid those that are sick. If you are sick stay home and keep your family away from you. Self isolate. And DON’T travel. Everyone, wash your hands often, 20-30 seconds, with soap and water. (Sing the happy birthday song twice, that is about the right amount of time, which is easier than counting). Wait until we get the number outside of China to see how problematic this epidemic will be, and take appropriate action. I believe these lethal percentages will begin to diminish in this first wave.

I ended the last update by saying that by the time I write this third update people will begin to lose interest in this epidemic, as it will begin to wind down, in terms of the lethality. I think we are just at this point now. I predict that within a week or two of this post, people will start to talk about the fact that while we still need to stay vigilant, it looks like this is not as lethal as we feared to the whole species. Unless something changes, they will say that while it is virulent, and passes along easily, which makes it hard to eradicate completely, you should primarily practice safe hygienic practices as we look toward a vaccine or more effective drug treatment. I think that is how it will go. I also think, personally, that there are MANY tools that we have at our availability now that help people lessen the likelihood of infections to germs in general or that modify outcomes of those infections. To close on a positive, I think this first wave will end without tremendous global tragedy, though of course very, very sad for those who have lost their lives and the people they leave behind. The very largest percentage of people, even in China will never meet anyone with this disease during this first wave.

Wish list. If I had a wish list here, that is easy to implement now, today, it is this:
  1. Get the full real numbers.
  2. Specifically, how many real cases in China?
  3. Of those infected, how many become seriously ill?
  4. How many closed cases?
  5. How many in the epicenter are completely healthy yet carry the virus? A good epidemic curve will guess at this, but this is an easy number to get. Just test a sample number of people in the epicenter that are considered healthy.
  6. Pass along the suggestion to Cytosorbents.
  7. Pass along the suggestion to test for and monitor C1-INH levels.
  8. As work continues to develop a vaccine, begin work on modifying the virus itself.
  9. As work continues to develop a vaccine, begin work on germ to germ controls. Which other virus or bacteria can fight with the virus to control it. Work in science should not solely be placed in the vaccine solution.
  10. Have proper funding to test out methodically natural solutions that may currently exist.
In any case, stay tuned!

In health,
Paul Herscu ND, MPH