Image by muhammad rizky klinsman from Pixabay

 Novemeber 2nd, 2020

Crowds, indoor environments, poor ventilation and TIME are the recipe for a negative COVID19 outcome based on your personal risk.

Latest numbers show that we are rapidly moving in the wrong direction with case numbers nationally. Cases continue to move to the suburban and more rural areas. North Carolina peaked on July 23rd and is now in the middle of a second spike in case volume that began in early September. Importantly, deaths are not following the increase in case volume as I will explain below. Multiple tracking sites are showing no current correlation between case number and the 2 week tracking death risk as was seen early in the pandemic. This is improved news for us moving forward. Hopefully, this is the new norm from now on as we work to get case numbers down. The other side of the coin, however, will be the recovered long haulers.

There is still no change in the knowledge that more than 80% of deaths are skewed toward the over 55 age group and 94% of all deaths occurred in a person with a co-morbid chronic health disease. More biological antibody medicines are on the horizon that may along with a mixture of vitamin A , D, zinc and melatonin be employed for a safe resolution to COVID19. If you did not read the newsletter about an Integrative approach to health in the COVID era, read this link and this link.

As with the first newsletter on this topic, keep solace with the fact that there is a 99+% chance of survival for all of us.

  A pattern is developing in the United States. Areas that are previously hit hard by COVID19 do not show major second waves. As we live through this next wave of disease this fall, we hope to see similar burnouts and hope that this remains true. If these rural areas get hit and then decline as was have seen in NYC, Texas, Florida and Arizona, then hopefully we will have the burden behind us before the winter respiratory viral seasons comes to pass.
Google Tracking site

 

1) Dr. Yang and colleagues looked at the mortality risk from COVID19 in hard hit New York City this spring in the Journal Lancet Infectious Diseases. They employed a model based analysis of the NYC data to find a perceived infection fatality rate, IFR (number of deaths from all infections not just ill and tested), which they calculated at 1.39% for all inhabitants. This number is significantly higher than many previous estimates of 0.26% to 0.85%. From the article directly: " During the period March 1 to June 6, 2020, 205 639 people had a laboratory-confirmed infection with SARS-CoV-2 and 21 447 confirmed and probable COVID-19-related deaths occurred among residents of New York City. We estimated an overall infection-fatality risk of 1·39% in New York City. Our estimated infection-fatality risk for the two oldest age groups (65–74 and ≥75 years) was much higher than the younger age groups, with a cumulative estimated infection-fatality risk of 0·116% for those aged 25–44 years and 0·939% for those aged 45–64 years versus 4·87% for those aged 65–74 years and 14·2% for those aged 75 years and older. In particular, weekly infection-fatality risk was estimated to be as high as 6·72% for those aged 65–74 years and 19·1% for those aged 75 years and older." (Yang et. al. 2020)

Whether these numbers play out nationally is still in question. If the 1.39% IFR is true and everyone gets infected in the United States (which won't happen), then 4.6 million people could die by the end of the pandemic. I seriously doubt this number is even close to a possibility for many reasons. NYC had a much more severe case fatality volume based on densely packed urban city based risk factors increasing viral load and higher than average co morbid disease rates worsening outcomes. At this point, this is just pure data and nothing more. Time is the only arbiter of how this IFR will look at the end. However, see this next piece.

2) New data out of New York City shows a dramatic decline in death for hospitalized COVID19 patients. According to Dr. Hurwitz and colleagues, the death rate has dropped from 26% to 8% from the start of the pandemic to this past August. (Brumfiel, G. 2020) An 18% or 2x drop from 26 per 100 to 8 per 100 is massive in the admitted case fatality rate, which also means that the above NYC infection fatality rate from the early spring is a gross over estimation by their modeling as it was based on a higher death per hospitalized person from the time when death was 26%. This lends even more weight to the argument that the true IFR is likely much less than 1%. The article in NPR is worth reading as it lays out the fact that deaths are mostly down because of improved medical care as critical care providers have learned how to handle this infection in vastly better ways since February.

This fits in line with the way we as Americans do everything. We identify a problem and throw everything at it. We wait to see what sticks and keep iterating until we are in a better place. We repeat the process over and over again until the issue resolves. It has been a fascinating experience at the clinic level as we iterate constantly for patient safety and our own front line physical and mental health.

3) The CDC is asking all public transportation riders to wear face masks over their nose and mouth during the duration of transportation to and from desired locations. This only makes logical sense as this virus is definitively spreading through contact aerosol droplets. This should not be a politicized issue. High risk individuals with co morbid metabolic diseases should consider adding another layer of protection by using N95 masks. The early data on airplane travel looks good when proper mask use occurs.

4) Newborns born to mothers that are COVID19 positive at delivery are not developing COVID19 themselves. This mirrors our experience in clinic. We have had a few COVID19 positive mothers deliver and nurse their infants without issue of symptom or positive test result. (Dumitriu et. al. 2020) It is likely that the virus cannot latch on to the infant's cells because a relative lack of ACE2 receptors and breastmilk antibody exposure (hypothesized answer).

5) Are there advantages to having children in the house in regards to SARS2 immunity? The simple answer is yes as children provide a route for constant immune priming to circulating coronaviruses and other respiratory infections. In a study by R. Wood and colleagues we see data supporting this hypothesis. From the study itself: 241,266 adults did not share a household with young children; 41,198, 23,783 and 3,850 shared a household with 1, 2 and 3 or more young children respectively. The risk of hospitalisation with COVID-19 was lower in those with one child and lower still in those with two or more children, adjusting for age the hazard ratio (HR) was 0.83 per child. On additionally adjusting for sex, socioeconomic deprivation, occupation, professional role, staff/non-staff status, the number of adults and adolescents in each household, and comorbidity, the HR was 0.89 per child. (Wood et. al. 2020)

On balance, it appears that front line workers are at less risk of dying from COVID if they are teachers, pediatricians and other workers frequently exposed to young children, especially the less than 5 year old group. This truth appears to be predicated on viral load exposure and each person's immune health. Otherwise, being on the front line is an increased risk overall.

6) COVID19 induced economic damage has had effects on the physical health, mental health and lives of millions of Americans There needs to be a strong look at this side of the coin. The preponderance of the media coverage is one sided toward viral associated death. In a balanced world, there would be a constant weighing of the scales for all outcomes as previously stated, COVID is a lose lose so let's look at all sides when choosing policy. In a Wall Street Journal article, we see the other side of the coin. It is worth the read for balance if nothing more. (Chaney et. al. 2020)

7) It appears, as crazy as this sounds, that the United Kingdom is going to test healthy young individuals for the volume of SARS2 necessary to get an illness. They will have a purified strain of live virus blown into their anterior nares while being tested over time for development of viral infection. (Booth et. al. 2020) While the data from this study will be invaluable for understanding transmission, I hope that they are checking these individuals for single nucleotide polymorphisms that could predispose a young person to a negative outcome.

8) It appears that the pre-symptomatic 1-2 days of COVID19 disease is the biggest risk for spread. Asymptomatic carriers may but rarely do spread the virus. (Cevik et. al. 2020)

9) "Severe SARS-CoV-2 infection is linked to the presence of autoantibodies against multiple targets, including phospholipids and type-I interferons. We recently identified activation of an autoimmune-prone B cell response pathway as correlate of severe COVID-19, raising the possibility of de novo autoreactive antibody production during the antiviral response. Here, we identify autoreactive antibodies as a common feature of severe COVID- 19, identifying biomarkers of tolerance breaks that may indicate aggressive immunomodulation." (Woodruff et. al. 2020)

This was a serious concern of mine early in the pandemic. COVID19 causes a massive inflammatory response in hospitalized individuals leading to native tissue and cellular destruction. This is the point at which the immune system can over react to our own cellular proteins leading to autoimmune diseases and prolonged dysfunctional symptoms. More on this topic next week.

 

Dr. M

Yang Lancet Infectious Diseases
Brumfiel NPR
Dumitriu JAMAPediatrics
Wood MedRxIV
Chaney Wall Street Journal
Booth Washington Post
Cevik BMJ
Woodruff MedRxIV