Volume 10, Letter 48 Coronavirus Update 23
November 16th, 2020
It is going to be very hard to find positives in the current COVID environment. It comes down to this. Can we all do our part now that things are not going as we had hoped? Each little step in the right direction can make a lasting impact.
This is another newsletter on the science behind the pandemic and strategies that seem to make the most sense for all of us.
Here we go. Unfortunately, the major wave that has happened in most previous historical pandemics is officially here nationwide. The combination of colder weather,
more indoor activity and pandemic fatigue has spawned a new and big emerging mess.
Crowds, indoor environments, poor ventilation and TIME remain the recipe for contracting COVID19 and potentially having a negative outcome.
Latest numbers show that we are rapidly accelerating in the wrong direction with peak daily case numbers nationally. Cases continue to move to the suburban and more rural areas previously uninfected. North Carolina has had a new peak in cases this week. The case increases began in early September and are showing no signs of turning the corner. Case fatality rates and infection fatality rates are improved month over month which is a blessing. Unfortunately, the virus is spreading more rapidly as the winter weather starts to set in making overall death numbers increase by sheer COVID case volume.
There is still no change in the knowledge that more than 80% of deaths are skewed toward the over 55 age group, 77% are obese 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.
Coronavirus Update 23
It is becoming ever more clear that we are not seeing re-spikes in areas previously hammered by this virus. This is a bit of good news in the otherwise dismal case volume. Herd immunity threshold, different then herd immunity, is a theory that has some solid evidence. It is basically the theory that if enough people have been infected coupled with effective masking, social distancing and protecting the vulnerable, we will see no further wild fire type spread. This is pretty much the Swedish experiment without the mask mandate. This is not to say that we will be virus free. The herd immunity threshold is not the same as herd immunity which we use to discuss the volume of individuals infected or vaccinated to stop the spread of the infection and allow life to return to normal. Roughly 70 or more percent of individuals need to be immune for this to occur, however, this is pathogen specific and we are no where near it for SARS2. On the other hand, if 30 percent of individuals are immune and the remainder of the population follows basic pandemic precautions including social distancing, mask wearing, crowd avoidance, isolation of the vulnerable, and self care then the virus will go into case decline and resolution can begin to occur once a vaccine is initiated. (Tilson Daily November 12, 2020)
It appears likely that this is exactly what we are seeing nationally. No significant spikes in previously pounded cities coupled with new spikes in previously unaffected areas.
1) Dr. Ng and colleagues found that there is a 4 times increased risk of contracting COVID19 at home than at work or with social contacts. (Ng et. al. 2020) This study yet again shows us that indoor, close contact activity is the biggest risk for transmission. In home activity raises the frequency and duration of exposure once someone contracts the virus outside. Thus, prevention for at risk homes needs to focus on the activity outside the house to reduce the viral access to the household.
2) Repeat from 2 weeks ago because of it's importance. 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.
Couple this information with the current experience in NYC with increased case volume and reduced morbidity and mortality from the Spring Experience and we have good news. (Goodman NYTimes)
3) Wearables are showing predictive value in COVID19 detection and tracking. In the DETECT study at the Scripps Research Translational Institute, the researchers identified ways for the trackers to detect early signs of respiratory disease and even COVID19. Leveraging wearables IS the future of medicine on many levels. This is only the beginning. (Scripps Research)(Scripps Research)(DETECT Study Joinup)(Quer et. al. 2020)
4) High dose intravenous Vitamin C reduced disease morbidity in COVID19 hospitalized patients. The primary outcome was invasive mechanical ventilation-free days. Secondary outcomes were 28-day mortality, organ failure, and inflammation progression.(Zhang et. al. 2020) The results were notable reductions in oxygen use and trends toward decreased mortality and organ damage. This research is inline with other studies of ICU patients treated with Vitamin C. (Hemila et. al. 2019) The cost of IV Vitamin C is cheap. The benefit is reasonable. Makes complete sense to start adding this treatment to the tool kit.
5) There is further evidence that being overweight and obese alone are major risk factors for a negative outcome with SARS2/COVID19. Seventy seven percent of COVID19 hospitalized patients were either overweight (BMI > 25) or obese (BMI > 30). In a nice article in Science Magazine, Meredith Wadman covers the why of obesity risk. (Wadman, M 2020) If you or someone close to you is overweight, this article is a concise must read.
The take home point is this, obesity causes: 1) mechanical pressure to restrict lung function 2) stickier blood cells prone to clotting 3) reduce number and function of immune fighter cells 4) low grade inflammatory state 5) mental stress from self-esteem deprivation 6) intestinal microbiome dysbiosis induced hormonal changes.
6) Low vitamin D status was associated with higher risk of admission to a hospital with COVID19. (Hernandez et. al. 2020) This is caused by one of 2 factors. One, the low vitamin D level is causing immune dysregulation diminishing viral surveillance and killing. Two, obese individuals have lower vitamin D levels compared to non obese people making it an association and not causation.
7) With autoimmunity rising in a subset of COVID patients, we need to identify the groups at risk. In my study of the basic science literature, I believe that the major risks for an autoimmune evolution are multifactorial:
a) strong family history of autoimmune disease
b) being female
c) baseline pro inflammatory physiology - metabolic syndrome/obesity/cardiovascular disease
d) high viral load/heavy exposure to infection overwhelming the immune surveillance and killing mechanisms - think front line workers
e) immune suppression from poor lifestyle decisions - chemical exposure and toxicity, sleep deprivation, chronic unremitting mental stress, micronutrient deficiencies - vitamin A and D, gut microbiome dysfunction from antibiotics/antacids/standard American diet
The mitigation steps need to be focused on reversing c/d/e as they are the only modifiable factors on the list. See the next post for more confirmatory evidence.
8) Targeted surgical decisions for reducing transmission continue to make dramatically more sense than lockdowns. In a study just published in Nature, Dr. Chang and team looked at mobility of 98 million Americans and SARS2 spread. They aptly state that: "Our model predicts that a small minority of “superspreader” POIs account for a large majority of infections and that restricting maximum occupancy at each POI is more effective than uniformly reducing mobility." They also noted that disadvantaged groups are more likely to live in more crowded environments and have to work in person as opposed to from home contributing to further spread. (Chang et. al. 2020) Thus, it is clear that we need a more nuanced approach to this pandemic moving forward despite the blunt tool of lockdowns being used again in Chicago this week.
See the data again in Sweden that shunned the lockdown. Overall, their case fatality rate is better than most countries in Europe and the United States. They don't even crack the top 15 of deaths per 100,000 or CFR. (Stralin et. al. 2020)(JHU Graph 2020)
We need to take a look at these data sets when making broad sweeping decisions. See to do below for more.
Ng Lancet Infectious Diseases
Quer Nature Medicine
Zhang Research Square
Wadman Science Magazine
Hernandez J of Clin Endocrinology and Metabolism