People have been asking me about a story that came out in the last few days about 94% of deaths having co-morbidities. The implication many have made is that most don’t really die from COVID, they die from something else, and they also happen to have COVID.It’s certainly true that contributing factors can make symptoms worse, and many of those with symptoms have another underlying issue. But I think it would be a mistake to think that this means COVID can be dismissed as no big deal. The fact is, the list of contributing factors is long, and includes the following:
age asthma or COPD heart conditions kidney conditions liver disease high blood pressure diabetes obesity auto-immune disease use of NSAID anti-inflammatory medications being immunocompromised (HIV infected, undergoing cancer treatment, under medication for a transplant) vitamin-D deficiency type A blood (Type O appears to be protective)
A lot of people are on this list, including me, since I have Celiac Disease, an auto-immune disease. Think of it this way. If someone dies because they got pushed in front of a train, did they die because of the train, or because someone pushed them? Well, both. Getting shoved generally doesn’t kill you, but it does if you get shoved into a train.COVID on it’s own may not be very deadly on it’s own, but it is in combination with a lot of other conditions.
The good news is, COVID is getting more survivable as treatment gets better, and also perhaps since people are getting exposed to lower viral loads because of mask wearing. We should be concerned, but not fearful, and we can also be optimistic that things are getting better!
I’ve also been asked by several people recently about a vaccine. You may remember my post about ADE, Antibody Dependent Enchancement. It’s a rare phenomena in which a virus can use an antibody against a previous infection to infect the immune system (link to my original post below). This can make a second infection much worse than the first. This only occurs with a small handful of viruses, but SARS, MERS, and likely SARS-2 are some of them. Because of this phenomena, I am suspicious of vaccines against SARS-2, and will wait to see what happens before I get one for myself, or recommend others do. I am not an anti-vaccine person in general! I have gotten the annual flu shot many times! But SARS-2 is different. If someone involved with the vaccine creation process can convince me it’s safe, I will certainly let you know.
This long post will be a summary of what we have learned so far about the Coronavirus, and I’ll make some predictions about what to expect next. Since I’ll be sharing so much information, I won’t give references for everything here. I also have to make the disclaimer that new studies are constantly being done, and some of the below information may need to be revised later. To make my standard disclaimer, I am not an epidemiologist or a physician. I have a Ph.D. in molecular biology, and my specialty is infectious disease testing. On much of the below, I have an informed but not expert opinion.
Coronaviruses: Coronaviruses are a large group of viruses unrelated to the flu. What we think of as the common cold, are actually member of several classes of viruses like Adenovirus, RSV viruses, Rhinovirus, and several Coronaviruses. Many Coronaviruses cause diseases no more virulent than the common cold. However, just like novel flus can cause extra trouble, so can novel Coronaviruses. The first SARS virus was much more lethal that the SARS-2 virus, but because SARS had a short incubation period and made almost every infected person sick, it was much easier to contain. The Middle East Respiratory Syndrome (MERS) Coronavirus infects a few people every year, and is very lethal, with a fatality rate of 34%, but it also has not made a global impact. The reason SARS-2 is so dangerous is that it’s VERY infectious (Ro of between 2.5 and 5.7) and has a VERY long incubation time (2-14 days), making it very hard to track. Plus, it’s at least 2x as deadly at the annual flu.
Name: The official name of the virus is SARS-2-CoV (for Severe Acute Respiratory Syndrome-2 CoronaVirus). The official name for the disease it causes is COVID-19 (for COronaVIrus Disease-2019). You may notice that the term SARS actually sounds a lot like a disease. You would be right. So why did they need a different disease name than SARS-2, or SARS-19? I don’t know.
Spread: Early reports were that SARS-2 mostly spread like a flu, with droplets spreading from coughing or sneezing. It became apparent later that the virus was also spread through aerosols by laughing, singing, shouting, or even just talking in close proximity for long periods. As further study was done, it appears that most infected people don’t infect anyone else. Rather, most infections come from “super-spreader” events, in which a single person infects a large group of people. This usually happens indoors (at least 19 times more likely) during activities like fitness classes, funerals, concerts, and choir practices. While outdoor activities aren’t completely immune to these events, they are much more rare.
Viral load upon exposure appears to be an important determinant of how severe a case will be. Basically, this means that if you’re infected by a “low dose” of virus, your disease is likely to be less severe. I have several physician friends who have stated that it seems to them that cases in the hospital are less severe than they used to be. One likely reason for this is that since more people are wearing masks in public than early on, those who are infected are being infected by a lower viral load.
Early studies demonstrated that viable virus can exist on objects for hours or days. However, it does not appear that a substantial number of people are being infected because they have touched a contaminated object.
The WHO made a confusing claim recently that asymptomatic people cannot spread the virus. While this is technically correct, they were not clear that “asymptomatic” is a technical medical term meaning someone who does not have, and will never have, symptoms. Another group is “pre-symptomatic”. These are people who currently don’t have symptoms, but will develop symptoms in a few days. As it turns out, pre-symptomatic people do spread virus, and are likely responsible for up to 80% of new cases. So yes, people without symptoms can and do pass the virus to others.
Risk Factors: Many believe that only old people are at risk. While it’s true that age is a dominant factor, other risk factors are important, and younger people have also experienced severe symptoms. Other risk factors include respiratory conditions like asthma or COPD, heart conditions, kidney conditions, liver disease, diabetes, obesity, auto-immune disease, use of NSAID anti-inflammatory medications, being immunocompromised (HIV infected, undergoing cancer treatment, under medication for a transplant), vitamin-D deficiency, type A blood (Type O appears to be protective), inadequate sleep.
Always check with your doctor before changing your medications. I have an auto-immune disease and take daily anti-inflammatories, but my doctor has advised me to continue taking these unless I experience COVID symptoms.
Make sure your doctor is aware if you have any of the above conditions.
Symptoms: Many people who have SARS-2 experience no symptoms, or experience mild flu symptoms. If you have ANY cold or flu symptoms, contact your doctor and see if you can be tested. If you live in San Diego County, and your doctor cannot offer you a test, call 2-1-1 to get a free test from SD County Public Health. If you have additional symptoms like shortness of breath (you just can’t seem to get enough air), loss of smell or taste, nausea or diarrhea, contact your health care provider or an urgent care immediately.
In severe cases, the virus can do wide spread and permanent damage to multiple organ systems. Early treatment is necessary to prevent the most severe symptoms.
Precautions: While lockdowns may have been effective in the US during the early stages of the pandemic, especially at a time when masks were hard to come by, recent evidence suggests that lockdowns provide only a moderate benefit over other means of control. Here’s what appears to be beneficial:
Masks: Masks are not all the same and some are better than others. Their main benefit is that they stop, reduce, or slow the travel of virus from infected people. This prevents surrounding people from infection, or lowers the viral load of exposure. Some, but not all, also prevent the wearer from inhaling airborne virus. N95 style masks without a valve are best if you can obtain one.
Social Distancing: Aerosolized virus can travel through the air. Staying 6 ft away from others helps prevent infection.
Adequate sleep: Sleep is very important for a wide variety of body functions, including the immune system. Get 7 – 8 hours of sleep per night. A 26 minute power nap during the day is also beneficial if needed.
Vitamin D: Several studies have suggested that patients with the most severe cases of COVID also have the lowest levels of Vitamin D. Because of our often indoor lifestyle, most Americans are Vitamin D deficient to some degree. The best way of getting some Vitamin D is to make it yourself by going outside in shorts and a T-shirt for 30 minutes a day. This is because Vitamin D is manufactured in our skin in response to sunlight. If it’s not practical for you to do this, consider a Vitamin D supplement. Darker skinned people are more likely to be Vitamin D deficient in the US.
Home isolation: If you have cold or flu symptoms, contact your doctor immediately and see if you can get a test. Tests are much more available that early in the pandemic, and you should be able to get a test by request. Also, if at all possible, isolate yourself from the rest of your family until you can be tested as negative. Many new infections are taking place among family members.
Testing: There are several kinds of tests, and they tell you different things.
PCR: These tests use material collected from the nose and need to go to a specialized laboratory for processing. They are very sensitive and specific, and indicate whether the patient is currently infected. This is the most common kind of test.
Antibody: These tests detected antibody from a patient’s blood to see if the patient has been infected for at least a few days. IgG tests may also tell if a patient was infected weeks or months previous, but are no longer infected. Some patients do not mount an immune response that will provide long term antibody.
Isothermal amplification: The Abbott ID Now COVID tests uses this relatively new technology. These tests are similar to PCR and are both sensitive and very fast.
If you have cold or flu symptoms, contact your doctor immediately and see if you can get a test. Testing is much more available than it was early in the pandemic. San Diego County is encouraging anyone who wants a test to be tested.
Treatments: Treatment for COVID is complicated and not all patients can be treated in the same way. Additionally, treatments are evolving rapidly, and your doctor many not treat you in the ways listed below.
Ventilators: Some doctors now state that ventilators carry risks that may be unacceptable for COVID patients. Many doctors now favor a nasal cannula, using ventilators only as a last resort if breathing is labored.
Hydroxychloroquine, Azithromycin, Zinc: Several doctors from several countries have reported success with this combination. Studies on the effects of these drugs have as yet still been non-conclusive. Some positive studies suggest that Zinc is the main virus fighter of the treatment, with Hydroxychloroquine allowing better penetration of Zinc into cells. Unfortunately, the debate on the efficacy of this regimen has taken on a strongly political tone, which almost always interferes with the scientific process. Now pundits, as well as scientists, weigh in on this regimen. I’m still holding a “wait and see” posture with this treatment.
MATH+: This regimen uses Methylprednisolone (an anti-inflammatory), Vitamin C, Thymine, and Heparin, as well as optional other treatments including Vitamin D and Zinc. Early reports suggest success with this treatment.
Vaccines: Each spring, scientists learn which flu is likely to be prominent by the following Fall. They make some guesses and create a vaccine for the flu season. The manufacture process takes a few months. But it’s only this short because they already know how to make a flu vaccine. Development of a brand new type of vaccine takes between 4 and 30 years! There are many methods to make a vaccine, and scientists must try many of them before finding one that works. Then they must try the vaccine on patients and make sure they are relatively safe. Every vaccine carries some risk of side effects.
Early estimates for a Coronavirus vaccine were around 18 months. My guess is that this is too optimistic. Personally, I wouldn’t count on a vaccine for at least a few years. In addition, some studies have suggested that Coronavirus vaccines in particular may cause side effects that may make vaccine development challenging. My standard practice for my family is to wait on new drugs for a few years before using them myself. While I pro-vaccine in general, I would personally recommend waiting for a few years before getting a Coronavirus vaccine.
Herd Immunity: Some are promoting herd immunity as a way to move through the crisis faster. The idea of herd immunity was popularized in pre-pandemic discussions on vaccines, promoting the idea that the more people are vaccinated, the more protection for those who can’t be. This is a good idea when a vaccine is available, but not when there is no vaccine. Putting many people in harm’s way to protect fewer others is not wise and is not standard medical practice.
The Future: Of course, it’s impossible to know what will happen next. My initial prediction was that the first wave would be over by July, and at this point, this doesn’t look likely. New confirmed cases have started to rise or rise faster in the 3 areas I monitor most closely, the US, California, and San Diego County, and cases are rising fast in some countries previously unaffected, especially Brazil, Russia, and India. So I’m starting to think we may not be out of the first wave before the Fall season.
In addition, RNA viruses, such as Coronavirus, can mutate very quickly because the proteins used to copy their genomes are very error prone. This means that a virus may change to a new form that can re-infect a person who has already had a previous version. Some reports suggest that this may already be happening with SARS-2. Some good news is that on the very long term (years), novel viruses tend to evolve to be less virulent, because it’s not in the “interest” of the virus to make the host very sick. The message is, we may need to adapt to a new reality for the next few months or years. We can’t really afford to be “locked down” anymore, but mask wearing and elbow bumps may be a part of the landscape for some time.
Yesterday right after I posted, Mark Rasmussen sent me an article that ran in Science Magazine, one of the 2 most highly regarded science journals in the world. It’s a news article, not a peer-reviewed journal article, but it attempts to pull together information from different sources, and I think clarifies the picture regarding SARS-2 viral spread. The take-away message of the article is that while the R0 appears to be between 2.5 and 3 (more on that later), it’s not true that the average individual will pass the virus on to 2 or 3 others. Rather, most infected people don’t pass the virus on to anyone at all, rather a few infected people are “super-spreaders”, infecting a large number of people at once. There are many documented cases of super-spreading, from choir practices, funerals, concerts, fitness classes, and meat packing plants. The commonality appears to be indoor locations with lots of people in a small space, with some of them shouting or singing. While the risk in outdoor venues isn’t zero, indoor venues account for 19 times the number of super-spreading events, according to a Japanese study.
According to the article, SARS-2 has a tendency to cluster in this way more than other respiratory diseases such as the flu or colds. This may be partially because of the “viral load” effect mentioned in the Erin Bromage article I posted on May 12th. In that article, it appears that the initial number of viruses an individual is exposed to partially determined if they will be infected, and how sick they will get. This also explains why so many medical workers in Italy got very sick or died in the early stages of the pandemic. Many medical procedures such as intubation create a bloom of floating virus from a sick patient, exposing unprotected workers to high viral loads.
The science article suggests that while the virus is still dangerous and outdoor venues are not completely without risk, it may be appropriate to relax restrictions on some outdoor activities. So here’s my informed but not expert advice on how to adapt to life with COVID:
Staying at home all the time may no longer be the best approach, although it was probably very helpful in the early stages of the pandemic. Going outside to get some fresh air and exercise is probably a good thing, although still not without risk.
When doing outdoor activities, it’s probably OK to not wear a mask, but maintain at least 6-10 ft from others you don’t live with. Locations with a gentle breeze will help move virus away from you!
At work or shopping, wear a mask when around others to reduce the viral load that you are wafting into air should you be infected without your knowledge. Any reduction in viral load will help.
If you suspect you may have been exposed, contact your physician and see if you can get a test.
If you have a yard, invite a few friends over for lunch or dinner at a safe distance. Since Summer is starting, an evening outdoor dinner will be a welcome break from the isolation. You may want to have your guests bring their own food and utensils. Don’t invite a large number of friends, and sorry to say, don’t invite those friends who can’t resist hugging everyone! Young children may require supervision to be safe.
Now that restaurants are open in California, I would personally only be comfortable with outdoor seating at the moment. If you’re comfortable, visit your favorite local restaurants to give them some business, sit outside, and leave your server a big tip if you’re able!
I am a church goer, and I want to see my peeps again, but singing in a congregation is still a high-risk activity. Churches will need to be creative to open up again safely. Consider lower density services without singing, and/or hold services outdoors.
Regarding the R0 value for SARS-2. I saw a CDC website last week that gave the R0 value as 2.5. After 10 minutes of looking, I couldn’t find this site again. The Sanche paper I’ve referenced before (High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2, EID, July 2020), published in the official CDC journal, Emerging Infectious Disease, gave the R0 as 5.7. So the CDC itself seems confused about what the R0 number is. My guess is, it’s somewhere between 2.5 and 5.7. That was a joke. Obviously, this range is far too large to be useful, and 2.5 and 5.7 are very different as applied to an R0 number. 2.5 is a very infectious disease, 5.7 is a super-infectious disease.
I’ve mentioned this before, but I want to remind everyone. Herd immunity is only a goal when a vaccine is available. Seeking herd immunity when there is no vaccine is not a good idea, because it will put large numbers of people at risk. Additionally, I am generally very pro-vaccine, but because of the risks of side-effects with this particular virus, a vaccine may not be available for several years. We will need to adapt to this reality. My hope is that we will start seeing daily cases come down this Summer.
Good morning, Friends, It’s good and bad news this morning. The good news is, our recent trend of a reduction in the rate of new cases in the US is holding! We’ve gone from being consistently in the 40% range, to consistently in the 20% range. This is good, but the bad news is, because our numbers are getting high, a lower daily percentage of new cases still means an increase in daily cases. Plus, in California, where many of you live, the rate has not trended down.
Unfortunately, the US now has more confirmed cases than any other country, surpassing China on Thursday.
So we doing better, but we need to to better still. The numbers are impacted by several things of course, one being our much improved testing rate. This certainly drives the numbers up, but I’m cautiously optimistic that the lock-down many you are experiencing will lead to big improvements soon. So keep it up! Your efforts are not in vain!
A few days ago, I mentioned that those with auto-immune disorders (like me) may be at higher risk. I still have not found an authoritative source for this. Since then, several news organizations have posted reports of people doing worse if they had taken non-steroidal anti-inflammatories (NSAIDs), including ibuprofen. Since auto-immune sufferers often take these medications, this may be part of the reason for their higher risk. This information is evolving, and will likely continue to change for awhile. Myself, I have quit taking one of my anti-inflammatory medications. Check with your doctor before you stop taking a prescription!
Don’t fear, but be smart! Erik
PS If you’re wondering why testing in the US was so slow to get rolling, check out yesterday’s post.
I know I’m not exactly Mr. Fun these days, but I have another little update. According to March 16th paper in Science, one of the worlds 2 leading scientific journals, asymptomatic people who are infected with the SARS-2 virus are about half as contagious as sick people. However, because there are so many of them, asymptomatic people account for 80% of new infections! (Li et al, Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2), March 16, 2020, Science Magazine).
The take away is, yes, even if you are not sick, you can spread the virus! So please stay home, and protect your neighbors!
Just a little up date from last week’s talk. I mentioned in the talk that I saw a 10 fold increase in cases since I gave my first talk to a small audience on March 3rd. The US had 125 cases on the 3rd, and 1762 cases on the evening of March 12th. This morning, March 21st, the US has 19,931 cases, another 10 fold increase since my talk last week! Some of this is because of increased testing, but there are certainly many, many cases we don’t know about yet.
The caseload has been going up consistently by about 34% more each DAY in the US, 6000 new cases just yesterday March 20th. We NEED to get the rate of new increases to come down. Increased social distancing measures will help, but because of the long incubation time, it may take a few days or weeks to see a benefit.
Autoimmune disease: There have been recent reports, that those with autoimmune diseases (like me) are at special risk because our immune systems are already overactive, and will do extra damage to our bodies while trying to combat the SARS-2 virus. In a brief search online, I have not been able to find confirmation of this report. If you have Celiac Disease, MS, some kinds of Diabetes, or other autoimmune disease, take special care.
My state, California, has instituted a voluntary ban on non-essential outing from your house, except for:
Getting food Care for a relative or friend Get necessary health care Go to an essential job
If your job is essential, you know it by now!
Going for a walk is still a good idea if you keep a safe distance (at least 6 feet) from neighbors.
Also, consider texting neighbors, or using Nextdoor or a similar site to try to find people in your area who maybe do not have social connections and may need extra assistance, like food and supply delivery. Ding dong ditch!
I also heard a good idea about buying gift cards from your favorite stores in town to support them until things get back to normal.