Wednesday, March 18, 2020

2019 Novel Coronavirus (CoVID-19): Part X

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 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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