Friday, February 28, 2020

2019 Novel Coronavirus (CoVID-19): Part IV

2019 Novel Coronavirus

2019-nCoV (first named); COVID-2019 (later- named disease); SARS-CoV-2 (final name of the virus causing COVID-2019): 


February 27, 2020 update Part 4
Paul Herscu ND, MPH
Herscu Laboratory

This is the fourth piece of writing on this current epidemic. Please read Part 1, Part 2, and Part 3 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.

LASTLY, I am going to deliver a presentation next week, Saturday March 7, 2020 at 3:30 PM at Bastyr University in Kenmore Washington (just north of Seattle). This topic is part of a broader course we teach there, and I will discuss how to understand and deal with epidemics in general and this one in particular. Due to the current environment, this lecture is open to all. Join us if you can. Details & RSVP here.

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

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

Official Numbers: My previous comments about the Chinese government’s handling of the numbers is echoed across the globe. China mishandled the epidemic and misrepresented the numbers at first. I know it sounded sort of odd when I started with that, but at least we all agree on this fact now. And the main reason this is important is that reality helps model what the likely progression is. More on this specifically during next week’s talk, but the point here is that public health authorities agree that China misrepresented the truth. And to the more official numbers from the WHO as of today, inside China we hear 78,191 infected, with 2,718 deaths, or a mortality rate of 3.47%. If this were the case, that would be REALLY bad for all of us. However, I think this number is still wrong, maybe by as much as a factor. From the WHO, as of today, there are 2,918 confirmed cases in 37 countries outside of China, with 44 deaths, or 1.5% mortality rate. A really bad number for sure, but MUCH less severe case fatality ratio than a horrific epidemic would have. I think the fatality number will settle around 0.2% to 0.5%, unless the numbers released are way off, again much less than what China is reporting. More on this below.

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

As before, knowing the real number of infected is essential in order for descriptive analyses to 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 going to come from more accurate reporting. Though now, we must add Iran to the country whose numbers are suspect and should not be used.

Under the Better Late than Never part that I wrote about last time, the main point I made was that if China handled it properly, gave us the real numbers, we would have only had a tiny outbreak and that would have ended it, not just locally but globally in a permanent fashion. Again, more on this when we discuss epidemics next week. But this is not possible when they do not share accurate numbers. (And just to add to this, we see exactly the same behavior in Iran, with again troubling numbers and problems caused by secrecy). Proper numbers lead to proper epidemic curves that help us model and understand an epidemic. It would take into account even the asymptomatic, i.e., those who may not be counted, or those who have very mild symptoms, and therefore may not seek treatment, or are scared to tell authorities that they are unwell, in which case reported numbers are also inaccurate. This is where epidemic curves come in handy as they help us ‘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, things are looking better than they had a couple of weeks ago inside China. Below is what the epidemic curve looks like, from the WHO data from outside China. From prior epidemic maps this is signaling that this first wave of the epidemic and its growth is soon going to collapse in Wuhan. It is most likely to end, sooner rather than later. That’s the good news. Last week I said I think others will follow the same observation in 1-3 weeks’ time. It is now a week since and pretty much everyone is saying that the Wuhan numbers are in fact clearly dropping. The only caveat is this: Can China maintain their hygienic closed model or will it spread beyond the outbreak areas. (It will!) And when it does spread, will they have the political will and science-backed policy to do what is necessary to stop a new outbreak from taking off in a similar fashion that Wuhan had or will they repeat the same mistakes? Will Iran needlessly go through this nightmare? The answers to these are political, not scientific, and therefore I have no idea, but I hope they choose wisely. 

The comments about the bad news are becoming more and more real though. As I mentioned before, this virus has escaped the region, and became too big to contain. Yes, we should isolate those that are ill, to slow down and limit its 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 disappear because of its easy contagiousness. Also, we are still not completely sure which animal vectors are involved with this virus so cannot have clear impact there to actually get rid of it completely. 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 are seeing at its very genesis. Biologically, evolutionarily interesting, but nevertheless sad. So, that’s the first bad news. I mentioned this before, but now WHO and CDC are saying the same thing as are many infectious disease researchers.

The second part of bad news that I mentioned is that if this infection does come back, after this first wave is over, then unless something changes we will see deaths every year. Not in the hundreds of millions but still. What is frustrating is that proper monitoring and open intergovernmental cooperation may have stopped this in its track. Iran should really pay attention here and learn from the mistakes China made.

Relatedly, the comments on vaccine development and mandatory immunization for health care workers is ever more likely. Vaccine research is in full swing at an accelerated rate.

Lastly, my hope to have scientists work on virus coevolution to make the virus less lethal has not gotten any traction yet, though I really hope it does. It may be that vaccines will help with this infection. But it is also possible that COVID-19 vaccine may not work out very well, and it would be prudent to have a second option such as this. Methods learned here could modify other bugs that are pathogenic to us and in so doing add an additional method of disease prevention. More on this interesting topic next week.

But as I mentioned from the first, personally, I believe that these mortality prediction numbers will be much lower than currently thought by the 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. Antiviral clinical trials are occurring now.

B. The plasma exchanges are still occurring. Sadly, filtering out part of the cytokines is still not occurring which is sad and this delay may be causing unnecessary deaths. I think the sooner the better here.  

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. They are mostly reconfirming that these are the most effective methods to slow down and stop the progression of this disease.

Regarding the masks in use and copper. For the past 4 decades, in fact before medical school, I was enamored by the anti-germ properties of copper and when I used to teach on medical history, I highlighted the use in ancient times of copper in makeup and pipes to limit germs (though they did not know it at the time.) A few years ago, I began to write on the topic, highlighting the benefits of copper to limit and end transmission of germs. The issue of epidemics will not go away, always replacing one bug with another, but copper seems to work impressively well against them all. The point I made in different writings is that it is very simple intervention and has already been tried for years to change surfaces towards copper infused products and paints. These have been added to curtains in hospital wards as well as surgical masks. This would cut down transmission by a lot. But more on this whole topic next week when discussing transmissions.

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 but clearly carrying and contending with the virus.” I made this comment before and can say that at least for the lesser severe cases, thus far, this is still true. The vast majority of people seem to stay within their chronic state

But for now, as help to the community 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.

DON’T PANIC. The bottom line as of now, is do the hygienic measures that are within your control, that really, truly work. The most important piece of the puzzle remains to limit 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 if unwell. 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 last time saying that within a week or two people will start to lose interest as the outbreak will lose steam. I thought 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. I think this is still the case. But as I said, it is likely that we are seeing the genesis of a new annual disease. I can well imagine the second wave. And if that is true, we need to be able to better deal with it. As it winds down in the northern hemisphere, it will give us 6 months or so to develop a better strategy. Remember that in the terrible influenza epidemic of 1918 more people died in the second wave than the first. A friend asked me how many people are going to die of this virus in the USA from now until November, 2020. I said I thought the most possible will be around 4,000-5,000 dead but that it is most likely to be much, much less, like in the hundreds at most. But that is with really smart public health measures continuing to be enacted.

I ended with a wish list before, which I would like to update:

1.              Get the full real numbers. We are getting most of these numbers from outside China, and outside Iran. The only number I am missing is the number of asymptomatic people who carry the virus, see below.
2.              Specifically, how many real cases in China? We may not get this number. Ever. But there is a number that really interests me and is not that difficult to get, either in China or in Italy. In those closed cities, if they test a sample size, what percent of people are carrying the virus but are completely asymptomatic. And of those what percent stay asymptomatic after 2 weeks, even though they carry the virus. This is a very important number for public health preparedness. Perhaps the most important number right now. But it is not being shared. Not sure why. In my next update this is the number I am going to focus on the most.
3.              Of those infected, how many become seriously ill? It seems as though this number may be around 20% from the numbers from China. This number should drop, I believe. Also, this number is much higher in Iran, much, much higher, suggesting either a misrepresentation of the total exposed and ill, or else incompetence in treating them and therefore dying. They have a pretty good health care system, so I tend to think it is the same underreporting that we saw in China.
4.              How many closed cases? It seems as though over a third are considered closed cases, with 8% of those ending in death, which again, I believe is a number that will drop significantly.
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. Someone should still do this please.
7.              Pass along the suggestion to test for and monitor C1-INH levels. Someone should still do this please. I think it will save lives.
8.              As work continues to develop a vaccine, begin work on modifying the virus itself. Someone should still do this please.
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. Someone should still do this please.
10.           Have proper funding to test out methodically natural solutions that may currently exist. PLEASE!!!

In any case, stay tuned!

In health, 
Paul Herscu ND, MPH