Coronavirus/2019-nCoV/Wuhan Flu Virus Update

Man in mask

The Problem

Coronaviruses are a FAMILY of viruses that have been present for many years in animals and humans. Some strains are zoonotic (meaning they can be transmitted between animals and humans). There are 7 STRAINS of Coronviruses that affect humans - 4 of which cause "cold" symptoms primarily (although can cause death in higher risk patients), and 3 of which are "bad": MERS, SARS, and SARS-CoV-2 (aka 2019-nCoV or "novel coronavirus 2019" or COVID-19) and have much higher risk of severe symptoms and death. 

COVID Origins

The 2019-nCoV coronavirus is thought to have come from bats, but to have first passed through an intermediary animal - speculated to be the Pangolin (the most illegally traded mammel in the world). Additionally, there is evidence that this virus was being studied at the Wuhan Institute of Virology - physically near a large "wet-market" in China. The "wet-market" collects a wide variety of live different animals (usually wild but comingled with domestic). The cages are stacked, and fluids easily intermix. In addition, the animals are slaughtered on the spot or eaten alive. This allows for cross exposures of fluids, viruses, bacteria etc that do not occur in nature and can easily allow for human exposure. 

2019-nCoV infections in humans originated in China in the later part of 2019. Precisely how this occured is being studied since it is very important to understand the dynamics of how human infection started (in order to prevent other viruses from following that path if possible). The fact that the virus existed, and the fact that the virus was easily transmitted person to person was not disclosed by China for weeks to months - allowing infected persons (but perhaps not symptomatic) to widely disseminate the virus around the world - leading to the current Pandemic

As of today: 

COVID-19 StatisticsNo vaccine available

Location:

Confirmed Cases COVID-19 Total Deaths COVID-19
WorldWide 1,715,143 103,874
USA 501,680 18,780
Spain 161,852 16,353
Italy 147,577 18,849
North Carolina 3,809 74
Wake County, NC 391 0

Data per ncdhhs.gov: For North Carolina, 423 currently hospitalized, and 57,645 COVID-19 tests have been done.

 

Influenza Deaths: Vaccine was/is available

This season to date: 29,000 to 59,000 have died due to influenza. Influenza mortality rate approximately 0.1%. 

2018-2019 Flu Season: 34,200 deaths, 35.5 MILLION cases (USA)

2017-2018 Flu Season: 61,000 deaths, 45 MILLION cases (USA)

 

What is COVID-19 Fatality Rate?

Definition: Case Fatality Rate = the percentage of all reported deaths divided by the number of reported cases

Definition: Infection Fatality Rate (IFR) = the percentage of all reported deaths divided by all those with infection (both detected and undetected - ie asymptomatic and not tested group included)

COVID-19 Case Fatality Rate and IFR: HIGHLY variable depending on sources for information. Complicated by general lack of data concerning how many people have/had the virus since testing of a large percentage of the entire population is not yet possible. 

Estimated COVID-19 Case Fatality Rates per CEBM Research (Oxford COVID-19 Evidence Service) is 0.51% (the lowest end of the current prediction interval and in line with several other estimates). 

Estimated COVID-19 Infection Fatality Rate (IFR) = 0.1% to 0.39%

 

Some Mortality Data to compare...

Virus Death Rate
SARS

9.6%

MERS 34%
Swine Flu 0.02%
Seasonal Flu 0.1%

 

 

 

 

 

Problems with Determining the Fatality Rate

Remember, the Infection Fatality Rate (IFR) is the number of deaths in persons testing positive for COVID-19 divided by the TOTAL number of COVID-19 cases - with or without symptoms.

 

Problem #1: We do not know the denominator (TOTAL number of COVID-19 cases.)

Thus if LOTS of us have/had the virus and were not tested, the denominator being used will be much too low and thus the Infection Fatality Number will be falsely high. Evidence is suggesting that MANY more people are infected then tested. 

Solution #1: We need to test many more people with no or few symptoms. ONLY then will we be able to accurately know the Case Fatality Rate. Until we get more data, we will only be able to use statistical models that, to date, have given us divergent results.

 

Problem #2: HOW are COVID-19 deaths being counted?

Currently we are OVERESTIMATING the number of cases - physicians are directed to count (as a COVID-19 death) most deaths in which the deceased had COVID-19 virus regardless of whether the death was CAUSED by COVID-19 (vs a death AND ALSO HAS COVID-19) - thus we are seeing a miscalculation/overestimation of actual COVID-19 deaths. This will then distort the numerator of the IFR calculation and lead to a falsely high number.

It is essential to ascertain whether people are dying WITH or FROM COVID-19. These factors will affect the IFR (Infection Fatality Rate)

Professor Walter Ricciardi,  Scientific Adviser to, Italy’s Minister of Health, reports,  “On re-evaluation by the National Institute of Health, only 12 per cent of death certificates have shown a direct causality from coronavirus, while 88% patients who have died have at least one pre-morbidity – many had two or three.”

Recording the numbers of those who die with Coronavirus will inflate the CFR as opposed to those that died from Coronavirus, which will deflate the CFR.

Report from the Italian National Institute of Health: analysed 355  fatalities and found only three patients (0.8%)  had no prior medical conditions. See Table 1 in the paper; (99% who died had one pre-existing health condition):  49%  had three or more health conditions; 26% had two other ‘pathologies’, and 25% had one.

Solution #2: We need to go back to classifying deaths more appropriately and not assess all deaths in individuals WITH COVID-19 as being FROM COVID-9.

Antibody testing will provide more accurate data as to how many people have been infectied so far, and will permit a more accurate IFR estimate.

We need to know what proportion of the population have COVID-19 and are assymptomatic.

https://www.cebm.net/covid-19/covid-19-what-proportion-are-asymptomatic/

We need to track excess mortality data

https://www.cebm.net/covid-19/england-and-wales-mortality-during-the-covid-19-outbreak/

 

Who/What is Susceptible?

Per CDC: 90% of those hospitalized have pre-existing conditions (similar to that for influenza) including Hypertension (49.7%), Obesity (48.3%), Chronic Lung Disease (34.6%), Diabetes Mellitus (28.3%), and Cardiovascular Disease (27.8%). 

AGE also plays a role in hospitalization rates: 74.5% age 50 or older, highest rated over age 65. 

Men>Women (men = 54.4%)

Animals: A tiger at Bronx Zoo tested positive for COVID-19. There are a few reported cases of domestic animals having coronavirus in other countries, but this has not been seen in the USA.

Per veterinarian Sara Ochoa, DVM - "Currently, veterinarians in the US aren’t seeing domestic cats and dogs being infected with COVID-19"... “However, it’s possible that pets may temporarily have the virus live on their coat and not show any signs of illness.” 

Per health.com: "All the information available from the USDA, the Centers for Disease Control and Prevention (CDC), and the American Veterinary Medical Association (AVMA) state that there’s no evidence COVID-19 can be spread from pets to humans. But there’s still a lot scientists don’t know about the disease, and research is being done to try to determine whether a pet could be an asymptomatic carrier of the virus."

 

Incubation, Symptoms

COVID-19 mean incubation period is 5.2 days with 95th percentile of distribution at 12.5 days

For seasonal flu, incubation is 2 days (1-4 day range)

Mean duration from onset of symptoms to death = 17.8d, Mean duration from onset to hospital discharge = 24.7d

COVID-19 Symptoms: Fever (83%-98%), Dry Cough (76%-82%), Shortness of Breath, Fatigue (11%-44%), Headache, Sore Throat, Abdominal Pain, Diarrhea, Loss of Sense of Smell. 

 

What Can Be Done?

We have all heard about properly washing hands with soap and water (the best way to destroy the virus on your hands - better then sanitizing chemicals) - but this needs to be done properly - cleaning all angles of your fingers, hands and distal wrists. This effectively eliminates the virus from your hands that you might have picked up anywhere. 

Be conscious of keeping your hands away from your face, nose, eyes, mouth - as these are the portals of entry for the virus that may be on your hands. 

Keeping an adequate distance from others (unknown to have or not have the virus) is a good idea - 6 feet is cited since that is the distance from which you can be infected from a cough or sneeze improperly done (ie if not coughed or sneezed into the crook of the elbow). I am not concerned about lingering airborn virus generally speaking (ie I am concerned if I am working around a ventilated patient or working with nebulized medications etc). 

If you feel masks protect you - by all means go ahead and wear masks (properly made and with proper materials). There is little evidence that home constructed masks will protect you although they may reduce the risk that YOU pose to others IF you have the virus. 

Treatment Protocols (for physicians) are available listing multiple treatment options based on patient status. Remember, there are NO FDA-approved treatments for COVID-19 BUT physicians are free to use medications as they determine as needed. Per Yale New Haven Hospital, therapeutics include Hydroxychloroquine, Tocilizumab, Remdesevir, Sarulimab all as first line, with Azithromycin and others as second line. 

There have been multiple reports from physicians directly working with patients of good results with Hydroxychloroquine and I am excited to see that it can indeed reduce the severity and intensity of the COVID-19 infection.

It is thought to act by reducing Phospholipase A2 levels in the cell, which makes it difficult for the virus to replicate. Interestingly, this is the same mechanism by which it is proposed that Citicoline (a supplement that has some in-vitro data in reducing corona virus but no data specifically with COVID-19) reduces viral replication in cell cultures. 

There are multiple drug candidates currently in the developmental stage

There are multiple vaccine candidates in the developmental stage

 

Heard of HERD IMMUNITY?

Herd immunity occurs with a critical number of the population becomes immune to a given disease (ie COVID-19). When a disease spreads from person to person, once sufficient people get the disease and become immune, then the disease has nowhere to go and drops into insignificance. 

Traditionally, vaccinations are used to insure herd immunity, although natural immunity can serve the same purpose. 

At this point, we do not have a vaccine for COVID-19. It is unclear as to how effective natural HERD immunity will be with COVID-19 but I feel it will play a major part in the ultimate defeat of COVID-19

 

What About Prolonged Home Quarantine/Economic Shutdown?

Currently most of us (@75% of the USA) are essentially quarantined at home, and millions of people are out of work. We moved in this direction in the hopes of "bending" the curve of infections and avoiding overloading our hospital systems - and we are seeing positive result for our efforts. 

A recent paper https://www.pnas.org/content/early/2020/04/02/2004064117 outlines the need to reduce pressure on hospitals by working to reduce COVID infection rates.

To date, we see reduced hospitalizations in New York, and in the USA, all hospitals have been able to provide ventilators and beds for those that need them. The hardest hit hospital in New York (Elmhurst Hospital) is located in the poorest and most diverse part of New York City according to The Guardian and was already operating at 80% capacity even before the COVID-19 crisis hit. 

The data is moving our way. In many areas, the curve is bending and the peak is behind or nearly so. 

Now what? This is the key issue we all have to grapple with - and none of us has ever had to deal with this in our lifetimes (that is, a global pandemic). Is it realistic to remain quarantined for many months? Is it necessary to do this to effectively deal with this particular virus? Must we completely destroy our economy and bear significant consequences secondary to that?

 

Is a complete economic shutdown needed or desired? 

We need a plan for a plan to move forward from here. Indefinite lockdown vs indiscriminate largess are not the only options according to Dr. David Katz - who has worked to develop a framework to reduce risk and allow us to safely get back to our lives. 

https://www.linkedin.com/pulse/proposed-framework-risk-based-interdiction-david/

https://www.linkedin.com/pulse/responding-covid-19-case-dcisev-action-david/

 

We have seen a tiered approach to dealing with COVID-19 in several countries that has been quite successful (Sweden, South Korea, Germany).

While the specifics are varied, the overall approach has been to continue to allow economic activity while successfully containing/controlling COVID-19. 

We need business to operate to allow us to obtain and purchase food, necessities, power/energy, water, etc. We see that they can operate in a safe and effective manner, otherwise you would not be seeing food in your local grocery store... 

To be clear, we need to have a discussion on what is needed to both continue to contain the COVID virus and allow our economy to reopen.

None of us wants to allow COVID-19 to spread and cause morbidity and mortality. In addition, none of us want to force a depression and the extreme pain and suffering that mass unemployment and bankruptcy will surely bring as well. 

Its not an either/or - its not exchanging business for lives. We can do better, and we must do better then that. 

We know that we can reduce viral transmission with intelligent application of social distancing, cleanliness, and maintaining our health on a basic level (ie the 5 boxes of Nutrition, Toxins, Sleep, Movement, Stress). We also know that we can operate business in the era of COVID-19 safely and effectively. Lets start there... 

It is my sincere hope that we work together to examine what works and move to rapidly implement it in a graded fashion. In that way we can defeat the COVID-19 threat and not allow our economy to be destroyed. 

 

 

https://academic.oup.com/aje/article/162/5/479/82647

 

Author
Michael Citron, MD Michael Citron, MD, is a functional medicine specialist practicing at FoundationMED, located in Raleigh, North Carolina. Dr. Citron has been practicing medicine for over 30 years and is committed to helping patients address the underlying conditions that impact their health. Dr. Citron began to explore how physicians might do better at preventing the need for visits to the emergency room and discovered functional medicine. Now, he focuses his practice on identifying and then eliminating or minimizing the root causes that eventually lead to health problems and the need for reactive health care.

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