Vol. 229 March 15, 2020 Beware the Ides of March

March 14, 2020

In Shakespeare’s play Julius Caesar, a soothsayer attracts Caesar’s attention and tells him:
            “Beware the ides of March.”
Caesar demands:

            “What man is that? Set him before me, let me see his face.”
When the soothsayer repeats his warning, Caesar dismisses him, saying:

            “He is a dreamer; let us leave him. Pass.”

When I started writing this blog a couple of days ago I was going to call it “A Politically Incorrect View of the Coronavirus” because I wanted to say that the virus will not be contained, that it will very shortly be community-wide,  and that we should marshall our efforts at monitoring, protecting, and treating the high risk people. But today, that is no longer “politically incorrect.” Many of our civic leaders and our leading medical scientists (Anthony Fauci, MD is my most famous medical school classmate, Class of ’66 Cornell Medical College) are now labeling COVID-19 as “community spread” , i.e. not containable through contact tracing since the sources are so numerous that we can not pinpoint a source, like the common cold and the flu.  We are now “mitigating” COVID-19, not “containing” it; just trying to “blunt the peak” on the graph of numbers of infected people.

The stakes are higher for COVID-19 (the name of the disease) then for the seasonal flu because it is more deadly to certain segments of our population. The name of the actual virus that causes COVID-19 is SARS-cov-2, and that is a real clue as to the nature of this virus given our experience with previous coronaviruses.

The good news is that the death rate is not expected to be as high as the past two coronavirus epidemics SARS (10% death rate) and MERS (35% death rate). SARS originated in Southeast Asia bats and civets (small, cat-like mammals) . MERS originated in Middle Eastern camels. SARS-cov 2 has been attributed at various times to be transmitted from bats, snakes, and now, pangolins (anteater-like reptiles with scales); all animals available in Southeast Asian “wet markets” of live animals. There is no evidence that implicates domestic dogs and cats as vectors for the virus. There is also no confirmed evidence that a mother can transmit it to her newborn during delivery.

As the number of identified cases increases (the denominator) we were hoping that the calculated death rate would decrease since the actual calculation =  #of deaths/#of cases. It appears now that the death rate could be between 1.6% (University of Bern, Switzerland estimate based on China’s CDC data) to 3.4% (WHO’s estimate from selected outbreaks), clearly at least 10 times the death rate for seasonal flu (0.1%). However, South Korea has the largest number of tested cases with cold symptoms (140,000) and their death rate is 0.6%. Of even more interest, of those 140,000 South Koreans with cold symptoms who were tested, only 4% were positive for SARS-cov-2, i.e. 96% of those with symptoms were infected with the flu virus or some other non-coronavirus.

The bad news is that about half of those in high risk populations who develop significant symptoms will require hospitalization.  80% of those hospitalized will be so sick that they will require ICU care for a number of days. The people at highest risk of requiring hospital-based medical care are those with underlying chronic diseases, called co-morbidities, like congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and those over 80 years old (a stage of life, NOT a co-morbidity thank you!).

Nearly 90% of COVID-19 cases have been in people between 30-79 years old. Less than 1% were in children under 9 years. Despite this fact that children are not the primary vector for this virus (unlike influenza), we are closing many elementary schools. In the swine flu epidemic of 2009 we closed 1300 schools for 7-14 days because of evidence that children were primary vectors for its spread. Despite the run on toilet paper resulting in empty market shelves, diarrhea is not a common symptom of the disease.

If COVID-19 is going to be as common as a cold or the flu, but has a lethal potential for select groups of people, how do we triage the people who think they have it while we wait for the coronavirus nasal swab test to become widely available?
The simplest triage diagram has just three branches in the decision tree:

  1.  If you have cold symptoms (but remember a runny nose is not a common symptom of COVID-19) — treat it like a cold with rest, fluids, and decongestants and try not to spread it to other people. (YOU wear the mask, not everybody else)
  2. If you have a fever over 101 and a cough — go see your primary care provider.
  3. If you have the above and feel weak or tired and are short of breath — the PCP may send you to the hospital.

How do people with COVID-19 die?  In the severe stage of the disease (called ARDS- Adult Respiratory Distress Syndrome) respirator machine support (a ventilator) in an ICU is usually needed. Another cause can be an overwhelming secondary bacterial pneumonia and sepsis later in the disease (similar to deaths caused by the flu) and, unexpectedly, some deaths have occurred without pneumonia or severe lung inflammation, particularly in patients with very high blood pressure or those on kidney dialysis.

Watch out for advertisements of fraudulent cures or “protections” from COVID-19. The FDA has formally warned 7 companies, including the Jim Baker Show, that their advertisements for “silver solutions” to kill the virus must stop. There is no evidence that solutions of colloidal silver can kill the virus. Vitamin C is no help either. If Purell with alcohol can kill the virus some people think that alcohol by mouth could kill it. Unfortunately alcohol does not kill the virus. Soap and water or bleach does. Do NOT gargle bleach.

The AMA has responded quickly to the epidemic and filed a request for a rush approval of a CPT code for COVID-19 testing (necessary for insurance reimbursement, hence maybe the urgency of the request). AMA President Patrice A. Harris, M.D., M.A. has said,  “By streamlining the flow of information on novel coronavirus testing, a new CPT code facilitates the reporting, measuring, analyzing, researching, and benchmarking that is necessary to help guide the nation’s response to the public health emergency.” Also as I said, health insurance companies will be asked to pay for the test.

Two surveys released this week show that the Corona beer brand is suffering from a negative buzz. A 5W Public Relations poll of 737 beer drinkers in the U.S. showed that 38% of them wouldn’t buy Corona “under any circumstances”, and another 14% said they wouldn’t order a Corona in public.  However, Corona beer and seltzer sales actually increased in February.


Vol. 192 May 1, 2018 Infections Going Viral

May 1, 2018

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“World conditions are ripe for a pandemic like the 1918 influenza epidemic, but we, the U.S. and the world, are not prepared to fight it.” – Bill Gates, April 27, 2018

Ten experts (three of them had British accents, so they were particularly believable) agreed with Bill Gates when he presented this warning in the 2018 Shattuck Lecture at the Massachusetts Medical Society Annual Meeting in Boston last week.

The 1918 influenza virus first appeared in the U.S. in New York City and within just 5 weeks it had spread across the country to California resulting in 670,000 U.S. deaths. As you know, the flu virus changes every year and we can’t start making a vaccine until we recognize and identify “this year’s mutation”. It then takes months to produce, distribute, and administer a vaccine, so consequently our flu vaccine is always playing catch up. Since 1918 we have developed anti-viral medicines and a number of different antibiotics to combat influenza complications, so a repeat of such a lethal flu epidemic is today considered unlikely.

But it is the other viruses, the “novel viruses”, that concern the experts at this conference. For instance, 1000 “novel” viruses from different species which could potentially cross over to humans and cause significant disease have been identified over the past 8 years . Of these 1000 “novel” viruses, 891 are brand new, never before identified. Advances in genomic sequencing allow the specific identification of potentially pathogenic mutations, but as one speaker noted it has taken the U.S. Weather Service over 50 years to build a data base that allows “reasonably good” weather forecasts, so our ability to forecast the effects of new virus diseases is considered to be woefully rudimentary. (1)

We will probably receive the earliest warning signs of any new epidemic from mining the “digital exhaust” of our social networks, “flu near you” apps, crowd sourcing of symptom reporting, net-connected thermometers. upticks in certain prescriptions, volunteered Alexa conversations, Google search statistics, bot-driven AI, and locations of Uber-delivered medicines. (2)

The reasons the world is ripe for an infectious pandemic are: increasing population, increasing urbanization in developing countries, continued poverty that promotes inter-species living, routine rapid travel between countries, increasing frequency of natural disasters due to climate change, plus potential bioterrorism. Several speakers used a military preparedness metaphor, consciously using the verb “fight” and the noun “war”. For example, “If we knew our enemy was developing a new military weapon we would be throwing all sorts of resources at analyzing what the threat is, how to detect it at the earliest possible moment, how to defend against it, and how to deal with its effects if deployed. We should be doing the same for future infectious disease epidemics, and we are not.” (3)

Bill Gates was most impressive with his command of diverse, seemingly obscure facts like the per cent change of Uganda’s GDP, the identifying numbers of a new unnamed TB antibiotic, the three viruses that could mimic Ebola, and that in a recent study 4 almost random doses per year of the antibiotic zithromax reduced childhood mortality in developing countries by 50% in 2 years! He remains a man of vision as well , made it clear that the Bill & Melinda Gates Foundation would continue its support of innovative health and education efforts, and describes himself as an optimist. He nonchalantly reported that his foundation had just granted $12 million seed money to a group working with Glaxo (stock-pickers take notice) to develop a universal flu vaccine, one that would be effective against all flu virus mutations. (Such a universal flu vaccine was the #1 fervent wish of the Deputy Director of the CDC when asked for her hopes for the next ten years.(4))

 Our pandemic preparedness is not just a task for the medical/clinical sciences nor just for “new” technology.  The “old” technologies of anthropology and the fine art of negotiation were vital to a successful defense against Ebola. It was not until we recognized the cultural traditions of burial rituals of some African tribes, and persuaded them to change them, that we were able to contain the Ebola epidemic. (5)

Pandemic preparedness is not only a multi-disciplinary effort. It must also be political. Even as science advances, there must be the political will to deploy the resources before a pandemic attack . Of course, “urgent” often trumps even important “long term” needs in politics, but a pandemic is the equivalent of a war. By the time the battle is raging it can be too late to effectively marshal all the troops and equipment necessary to win. (3)

The consensus of the conference was: “The U.S. should continue to be the leader in global health security.”

1. Joanna Mazet, DVM, MPVM, PhD, Professor of Medicine, University of California, Davis
2. John Brownstein, PhD, Chief Innovation Officer, Professor of Medicine, Boston Children’s Hospital
3. Jeremy Farrar, OBE, FRCP, FRS, Director, Wellcome Trust
4. Anne Schuchat, MD, Principal Deputy director, CDC
5. Mark Gordon, Esq. Co-Founder Vantage Partners

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