Tuesday, September 1, 2020

2019 Novel Coronavirus (CoVID-19): Part XIII

2019 Novel Coronavirus (CoVID-19): Part XIII 

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 1, 2020 update Part 13

Paul Herscu ND, MPH

Herscu Laboratory

This is the thirteenth piece of writing on the current epidemic. Please read Part 1Part 2Part 3Part 4Part 5Part 6 Part 7Part 8Part 9 Part 10Part 11, and Part 12 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.

 Eight months!


It has been, as one might count for the USA, roughly 8 months since SARS-CoV-2 virus causing COVID-19 has struck the world, and as I mentioned in the first of these blogs in January, February, and March, that it was probably earlier, but that is another story for another time! I wanted to catch us up to where we are, within the context of the past, as a way to help us gauge where we are going. As usual, I think understanding the underlying issues should make us be less lost when hearing or reading the bombarding news. I have conducted dozens of interviews, webinars, conferences on this topic, but since it has been a while writing here, please indulge me going into each of these matters, in brief. It should help! I will delve into them in the next updates, which will be posted soon. 


The Virus 

There are many things one could say. The main points I want to highlight are:

1.     The first point I made when this began is that we have to think of this virus as different than other viruses we have experienced. This is not one that is going to come and go by itself, rather, it is the ‘birth’ of a new virus that is going to be with us, with ups and downs, but be with our species for the time being. And the point I made is that for many of us, except for those dealing with AIDS) we have not really experienced this concept of a new disease as an epidemic. We really have not. 

2.     As discussed early on, while the virus mutates, like all viruses, the part that is most lethal to humans seems, unfortunately to date, resistant to change. 

3.     With these two points in mind, I urged us to consider that this is not something that we can wait out and it will not just go away but rather, we need to be proactive. There are essentially a few essential levers to pull here, as described earlier: 

a.     Vaccinations to make people either not catch the virus or not have it be so problematic (This is being worked on intensively)

b.    Develop nondrug therapies to make people either not catch the virus or not have severe symptomatology.

c.     Change the virus to make it less problematic (To my knowledge this is not being worked on. If it is, the likely place would be at military facilities)

d.     Wait until it evolves or we evolve, a coevolution so that it is less problematic to us (This does not seem practical)

e.     Develop drug therapies that can treat the unwell person (This is being worked on intensively)

f.      Develop nondrug therapies that can treat the unwell person


The main point here is that it is an unavoidable problem we have to come to decisions on how to address. This really has not changed. I know this had gotten politicized, early on, and it seems as though people are digging their heels in, as to how they would think about this virus. But the reality on the ground is still the same. I will come back to B and F above below. Onward. 


The Irony of Losing From Success

This one is an observation based on the historical record. Generally speaking, it is almost always the case that those in charge during an epidemic get skewered, for either making mistakes OR for doing the right thing. Obviously, those that make mistakes allow for an epidemic to become worse than it could have been, and so the fault is very easy to see, to demonstrate, to point to and to blame. But consider the alternative. If someone acted perfectly, early on, then what? Consider this possibility in an alternate universe. In that universe, in early January the USA spends 1 trillion dollars in a variety of ways (let’s skip how for a second) and we shut down the world as best we can for a couple of weeks (let’s skip how for a second) and the virus is stopped, disappears. There is no epidemic then. There is no pandemic then. There are few deaths. At those times, traditionally, people come out of the woodwork blaming those folks in charge for overreacting, for catastrophizing a simple situation, etc., for putting the average citizen in difficult situations and causing harm to the economy. In other words, instead of celebrating the success of ‘nothing happened’, the politician gets blamed. Really, the only way that that stops is when there is a recurrence from reversing the initial work that was successful, and seeing the problems reemerge. I am not going to mention the list of world leaders under attack now for having originally succeeded, or for originally failing, but the point I wanted to make is that in general, it is hard for people to celebrate the near misses as they did not experience the horror of it and cannot appreciate fully the benefit of actions taken. It generally is a no-win situation for the folks that do a great and a difficult job. The only exception is in those island states that can easily demonstrate the benefit by comparison to the rest of the world. 



One point I highlight when discussing public health situations is the concept of Person/Place/Time or Who/Where/When. When dealing with public health issues, being food, water, or germs, understanding these three moving variables helps us to identify what is really going on and how to address it. For example, if I said gay men/San Francisco/early 1980’s, you would say AIDS. These are moving variables. For example, black/inner city/1980’s you can see how that is different than white/suburban/2010’s regarding opioids. Which then allows health care providers and public health systems to better address the situation. Which means that what you might want to do at one point may no longer be reasonable at another time.  


What to do

I know I have heard for the past months that there were no choices on to how we deal with the situation since it was unpredictable and no one could have known that things were going to be so bad. Actually, that is not totally correct. There were hundreds and thousands of scientists that described what was going to happen and why. No real surprises. Me being one of them. But what I would like to do is describe what should be done, and of course it will sound just like what I said at the start of all this, focusing on Pathology, Transmission, Prevention, Diagnosis, and Treatment, taken one at a time, below. I could go into great detail on each of these topics, but at this time, will touch upon only highlights for frame of reference. 



As highlighted months ago, it seems as though the main processes leading to death are still the same ones: Cytokine storm, difficulties with ventilators, and most especially clotting/vascular issues. Treatment modifications should be aimed at these three locations. As I mentioned before, while we are in the midst of the scary times, what bothers me most is the long-term effect of having gotten this virus. I think, months later now, we are starting to hear more and more about these patients with post –Covid symptoms, which I will post about soon. 



Understanding the mode of transmission of a bug is vitally important to understand prevention. And while I have focused on this in great detail in classes and webinars over the past decades and in these updates (in Update VIII on March 18th, 2020 specifically) there is only one part to underscore: Contact versus Noncontact transmission, and specifically of all the different types, I want to focus on one variable here: droplets versus aerosolized transmission. This primarily has to do with the size of the droplet. If droplet >5 µm (as with COVID-19), it tends to fly about one yard, more or less for the most part, and we call it contact. For airborne or aerosol the size is <5 µm droplet or dust, which we call noncontact. I know the media and reports from different people sort of intermix these terms but they are actually different and the difference is not just academic, but vitally important. Large droplet contact transmission means that you basically have to be near the person to ‘catch it in the air.’ Traditionally we say one yard, and if you are a few yards away you would not get it from the air (as with COVID-19). Aerosolized particles can travel, far, in ducts, in vents, throughout a hall or building, which is why we say noncontact. With aerosolized germs, you just can’t even be in the same hall without risk of getting sick. 


From the start we believed that SARS-CoV-2 was transmitted by large droplets, which is why the public health measures around the world have settled on the 6 feet/2 yards/2 meter concept of one yard/meter for sure and one yard/meter just in case for good measure. 


Nevertheless, 8 months into it, it is still confusing as it does not behave as only a large droplet bug. It seems as though it can get aerosolized in some certain instances, as for example I mentioned before, during some ER procedures. I wrote about this half a year ago. And now in September we are still fighting on whether this is airborne or droplet. I think the answer remains that it is primarily, and to the greatest extent droplet, with occasional airborne. At the very least this is on how most scientists have settled on. 


Prevention. In many ways, this is the trickiest piece to describe, as the strategies suggested at one point shift as the epidemic shifts. Please see below. These are strategies to use to calm an epidemic down. Other countries such as Sweden, are going a different path, to attempt to create enough herd immunity so that the epidemic is contained. More on this below. 

There are a few pieces here:

1.     Social distancing. This primarily makes sense if you see this as a droplet transmission and not as an airborne transmission. One yard/meter for sure and one yard/meter just in case for good measure. This makes sense to diminish the transmission in hopes of another more permanent solution being developed. In other words, a waiting situation. Other countries, as for example Sweden, are managing social distancing differently, to work toward herd immunity. Which might or might not work, this depending on whether people who had the virus are immune for a long time. More on this later as well. 

2.     Masks. The concept of masks is so that the person who has the virus is less likely to pass it on to someone who does not have the virus. As an analogy, if you think about the transmission description above, it is sort of equivalent to adding another yard or two to the distance between people. And if this were a droplet situation only, this would make sense, in keeping with the rest of the strategies developed. Here, I am skipping problems with masks, problems with oxygenations, problems with ineffective masks, problems with poorly worn masks, problems with people wearing masks and therefore not doing anything else that is preventive. I am just describing the concept behind their use. 

3.     Other contact forms. Touching other people/touching surfaces. While the other forms of contact are absolutely possible, as for example touching infected people, touching surfaces touched by infected people, it seems that the majority of transmission by far is by breathing in the virus from being near another person who is transmitting it. In other words, the majority of your prevention work should revolve around being apart from the other people versus spending the majority of time cleaning surfaces. 

4.     Soap and water. It still remains true that washing your hands with soap for at least the time it takes you to sing “Happy Birthday” twice is an important mechanism to cut down the spread of germs. 

5.     Isolation/quarantine/lockdown, etc. I wrote a lot about this 6 years ago with the Ebolavirus and even here, earlier in the updates. And I would like to discuss this again, but here just in short form. Remember what I wrote above, the P/P/T, or W/W/W. There are great times to do these Isolation/quarantine/lockdown and there are terrible times to do these. Here, let me say that one terrible aspect of quarantining too early is that people become restless, feel isolated, become fatigued by this way of life, grow angry by this, and then leave quarantine at the wrong moment, too soon, ruining the overall impact of that tool. This is known. For a long time. And therefore, you want to employ this at the right time. Needless to say, this has not gone as well as it should have. 


Broadly speaking these are the tools that we may employ, leaving out vaccinations or other nonpharmacological agents that may be used in prevention or in lessening the disease burden. I would like to delve into some of these in detail, but will do that piecemeal so that we don’t lose the bird’s eye view of the discussion. What is striking is that none of these interventions are ground breaking concepts. They have been public health measures around for a thousand years. What is at the crux of it all is not whether these exist or work, but when to apply them. And sadly, this became politicized by the right and the left, by politicians and public health authorities, almost universally. And frankly, I am confused by the why of it all. It does not seem to me as though there are any winners here. I am not sure why common sense was not enough. 



Diagnosing the disease remains, oddly, somewhat troubling, in technique, costs, speed of delivery and speed of receiving results. Broadly speaking, there are numerous tests available. And as I mentioned when this began, there should be a great deal of energy put into shortening the time to diagnosis, making the test more affordable, and easier to administer. More on this another time. The main point that I made, in the first update, half a year ago, is that the most important aspect of the discussion should not be which test is the best. The most important aspect and the best way to end this epidemic is repeated and frequent testing. This is more important than which test you administer. Repeated frequent testing does and has worked around the world, and now we have even seen it modeling in the “Bubble” events run by professional sports leagues like the NBA. Frequent repeated testing was, and remains the best way to have ended this pandemic before it even became a pandemic. This is not a debatable point. The proof is that even in the USA this worked very well when applied. We are now seeing universities applying this concept. Repeated and frequent testing is the best way forward. More on this at a later time.



Treatment has gotten better. The use of ventilators has improved. Symptomatic treatment has improved. That said, not by much. Too many people are still dying. When the virus was just identified I described several directions of drug treatments that should be looked at and many are, including the convalescent blood that is being debated just now. That said, currently, there are still no good drug treatments approved that clearly prevent death, though some seem to lessen likelihood of death when on a ventilator. 


Sadly, therefore, not much has changed since January. Despite all the news. Instead of only several thousand people dying in the USA, we are nearing 200,000. This is heartbreaking especially as it seems pointless and avoidable. The science has always been there. We seem in abeyance, holding our breath until some new invention saves us. But is that enough? Is that all we could do? Are there no nondrug therapies to treat the unwell person that would make people not have the virus be so problematic?


In the USA, the treatment of disease can only occur by an FDA approved treatment. Natural substances have not gone through rigorous drug trials, as it is impossibly expensive to spend hundreds of millions of dollars per vitamin per indication. It can’t work. What is interesting though is that there are many licensed naturopathic doctors/homeopaths/acupuncturists/integrative medical doctors giving natural substances to people and by and large from those reported, it seems like individuals taking those substances have less severe outcomes. What we do not know is, are they better off because of the substances, or is this a self-selected group that have other characteristics that would cause them have a less severe outcome. We need proper trials to see if any of these interventions actually change the outcome of this disease process. 


Now here is the crux of the problem. Science proceeds by having an observation, describing the observation, which then gets properly tested. The problem is that in the last 4 months, the government has asked many of us to stop saying anything about prevention or treatment, about anything that we are doing in our clinics. Which is hard to understand, really. Also important to note, the rules are being applied unfairly here. I could describe the unfair handling here, but suffice it to say that I believe that this silencing effect has led to further unnecessary deaths. If we cannot say what we are doing and what we are seeing in the clinic, how will these approaches be tested. We are in an odd situation here. Those with means, those with education, those with access are able to see these practitioners, but those with little means or those without access just don’t know, and therefore cannot take any other action, but to wait. We need a better solution. 


In the next update, which will be very soon, I want to go into each of these topics in detail, one at a time. 


Until then stay safe, stay healthy, and please get some fresh air and sunshine, while the weather is good. 


Paul Herscu ND, MPH