Pandemic Perspective #15      June 27, 2020

Will wine kill the coronavirus?

Well, alcohol kills the coronavirus, so maybe this is one more health benefit of wine. If only!

As the pandemic rolls on, medical workers are getting more innovative and desperate to find some way to stop it. To date there have been more than 100 studies designed to evaluate the possibility that rinsing the mouth with various chemicals, alone or in combination, might reduce the number of virus particles. These include hydrogen peroxide, povidone-iodine, chlorhexidine and cetylpyridinium chloride – and ethyl alcohol, a component of many of our favorite adult beverages.

If you have visited your dentist recently you probably were given a mouthwash that includes hydrogen peroxide, fortunately in a low concentration that doesn’t cause gagging. Healthcare workers such as dentists, their assistants and ear, nose and throat surgeons who spend long periods only inches away from virus particles that might be escaping from their patients’ mouths are properly concerned about becoming victims of the new coronavirus. If you visit one of these practitioners you’ll be given a slug of mouthwash before anything gets done.

Of the scores of studies done so far there is no clear consensus that any of the preparations will work. Some studies have only been done in vitro (the Latin term means in glass, not in a human or animal body) so that the results are very preliminary.

What researchers have found so far in studies with real people is that an oral rinse (mouthwash) does seem to have some beneficial effect but it’s not ready for prime time. It’s somewhat like the situation that I have described in earlier blogs regarding face masks: it depends. Wearing a mask does prevent some spread of virus particles from the wearer and does offer some protection to an exposed person but the devil is in the details. (Sorry for the cliché.) An infected person sheds some virus from the lungs, not just the mouth or throat. Sometimes the virus is present in the salivary glands so that using a mouthwash has only a temporary effect. We don’t know how often a rinse is necessary. Is a minute of swishing the stuff around enough or does the user have to gargle? Some of these chemicals cause allergic reactions and hydrogen peroxide can cause tissue damage in concentrations of more than 5 percent. (For reference, the hydrogen peroxide on the drugstore shelf has a concentration of 3 percent.)

But getting back to wine – it does have an alcohol content of between 5 and 20 percent. Better yet, the alcohol percentage in scotch ranges from 40 to 63 percent! Research studies – yes, they do pay scientists to study these things – show that mouthwashes containing 21 to 27 percent ethanol (as in wine and one-third as much as in Johnny Walker) combined with essential oils, reduced levels of influenza virus by a whopping 99.99 percent!

The next goal of the scientists: is red wine better than white wine? Salud! I hope that this helps you to get over the COVID-19 blues!

Pandemic Perspective #14    June 20

Face masks forever?

The confusion and contradictory advice regarding face masks is never-ending and the varying rules among several state governors about wearing them might go on forever too! How long are you willing to wear a mask whenever you are outside your own home or vehicle? Are you thinking about having your mask-defying neighbors over for dinner anytime soon? That last idea might get you arrested, or at least cited. Dr. Wilma Wooten, San Diego County’s public health officer, says that getting together with someone not in your own household would likely be banned until we have achieved herd immunity.

That last point is crucial. In order for herd immunity to effectively slow down the spread of the coronavirus it would probably require that at least half – and perhaps as many as 70 or 80 or 90 percent! – of persons in the major population centers of the world would have to have recovered from the virus or to have received a proven vaccine.  Fewer than 10 million cases have been identified so far out of a global population of more than 7 billion! Like so many issues involving this new coronavirus, no infectious disease or public health expert has any idea of what herd immunity means for COVID-19.

But wait a minute! The more we succeed at limiting spread of the virus by shutting down the world’s economy the longer it will take to achieve herd immunity. Even if the most optimistic estimates pan out it will be a least a year before an effective vaccine will reach most of the industrial world.

And here’s another fly in the face mask ointment. On June 16th Greek researchers reported that coughing through a face mask could propel virus-carrying droplets as far as four feet. As one of the study’s authors noted, “The use of a mask will not provide complete protection.” That has been tragically obvious among healthcare workers who spend days on end within inches of the faces of infected patients, wearing masks that are nearly 100 percent effective. Some virus particles are eventually going to get through and long exposure to high concentrations of a virus can be deadly.

And here’s something that is hardly ever mentioned: there is an enormous difference between a properly fitted medical grade N95 mask and a cloth mask.

A headline in the San Diego Union-Tribune (June 19, 2020) reflects the confusion: Muddled mask messaging may be haunting coronavirus re-openings.” The article describes the masks being recommended: “…cloth coverings – homemade masks, bandanas, gaiters, scarves” and that medical-grade masks commonly known as N95, “should be saved for healthcare workers.” It’s very clear, however, that simple cloth masks are not very effective. Bandanas? Scarves?

The Keystone Kops (yes, that’s the way they spelled it in the early 1900s) had nothing on the coronavirus experts of 2020.

In regard to the term “forever” in the title of this blog, here’s a cheery note. In a survey by the New York Times more than half of more than 500 epidemiologists and infectious diseases experts said that it will be at least a year before they stop routinely wearing a mask.

My suggestions – at least for the moment:

Follow the rules and wear a good mask; stay away from anyone who is coughing.

Come out of isolation whenever you can to preserve your sanity, especially if that involves being outdoors where the risk is close to zero.

Accept that you might become infected with the coronavirus. It’s part of being human and you are adding to herd immunity.

In the news

When epidemics form a perfect storm

The climatologists who coined the term “perfect storm” probably never imagined that it would be applied to epidemics. Yet here we are, as the global community is experiencing a collision of three epidemics: obesity, type 2 diabetes and the SARS-CoV-2 coronavirus. The last one struck swiftly; the first two have been gnawing away at humanity for more than a half-century but health authorities classify them as epidemics. As they collide we are experiencing a perfect storm.

Almost any group photo from the era around World War Two seldom includes an obviously obese person and even fewer show more than one. In 1950 the rate of obesity — somewhat arbitrarily defined as thirty pounds over normal weight for height – was only ten percent. According to the Centers for Disease Control and Prevention (CDC) the rate of obesity – now defined as a Body Mass Index (BMI) of thirty or greater — in the United States is forty-two percent! It is even higher in some southern states. More than seventy-five percent of our population is either overweight or obese but both groups are affected by what I will discuss below.

The rise in type 2 diabetes began later but in 1950 it was diagnosed in only one percent of the population. It was called adult onset diabetes in order to differentiate it from type 1 diabetes, known as juvenile diabetes. Both terms are obsolete as the type 2 form is now common in adolescents; the current incidence in the U.S. population is an astonishing twelve percent. In persons over the age of sixty it is nearly three times as high.

Most persons with type 2 diabetes are overweight or obese. A few not so classified have excess body fat, which has similar consequences. They all have dysfunctional immune systems that put them at high risk from various types of infectious diseases, especially influenza and COVID-19. Soon after health authorities became aware of the scope of this new coronavirus they recognized that obese persons had a higher risk of dying than those of normal weight. This was exaggerated among the elderly, who not only tended to be overweight or obese as well as diabetic, but suffered from the complications caused by excessive weight, diseases of the heart, lungs and kidneys. Those who suffered greatly from these chronic diseases lived in senior facilities. It is no surprise that so many deaths from COVID-19 occurred among this group.

A fat-laden body carries more than engorged fat cells. That tissue harbors cells of the immune system that produce inflammatory chemicals known as cytokines. Inflammation is part of the normal response to infection but during a viral infection in some obese persons, inflammation goes out of control, producing cytokine storm. The flood of cytokines wreaks havoc among normal organs, causing them to fail and resulting in death.

What if today’s Americans had the very low levels of obesity and type 2 diabetes of 1950? There would be fewer persons at risk. There would be no economic paralysis. COVID-19 will eventually fade away as a result of herd immunity, vaccines, new antiviral agents and more sensible public health measures. But obesity and type 2 diabetes are here to stay. And the next pandemic, likely to occur before the end of this century, will terrorize the world again.

Lifestyle

Depression – it’s more than just an annoyance of aging.

Depression often accompanies the aging process for several reasons: loss of a spouse, the onset of chronic or life-threatening disease, financial difficulties and loneliness. It is often unrecognized by the patient and by health professionals who miss some of its signs such as poor appetite, disordered sleep or loss of interest in previously enjoyed activities.

The current COVID-19 pandemic and the resultant shutdown of the economy can only exacerbate the problem, even as it extends to younger persons.

As I have pointed out in several of these annoyances of aging, depression may be a symptom of some other illness or even a side effect of a prescription medication. It can be a sign of thyroid disease, a neurological problem such as Parkinson’s disease or multiple sclerosis or even chronic infection such as Lyme disease. Each of these conditions is notorious for being missed by health professionals, sometimes for years. The range of prescription drugs that are linked to depression is remarkably diverse. It includes sedatives, anticonvulsants, heart medications and many more.

A sad element of depression is that the victim is often in denial. Treatment is a challenge; anti-depressants often have serious side effects.

What appears to be depression should always prompt a search for an underlying cause even if there appear to be life-related issues.

Pandemic Perspective #13      June 13

          This Saturday’s blog is part of a sort-of-regular newsletter that I provide to persons in our church congregation who have taken our CPR course – more than 700 since the program began in 2001 – or who have expressed a desire to take a class. Learning basic CPR is one of the most valuable things that you will ever experience. The fear, anxiety and paralysis that affect most untrained persons when a loved one collapses will no longer affect you after a mere three hours of training.

          I’m sure that many of you have been concerned, as I have been, about the risk that we might be taking these days if we provide CPR for a person whose COVID-19 status we don’t know. Some authorities tell us that many persons with the infection are asymptomatic although that is conjecture with mixed opinions from scientists. The conflicting statements from the W.H.O. are clear evidence of that. A seemingly similar conjecture appeared in a http://www.medscape.com article this week.

An analysis from Seattle concluded that providing CPR during the pandemic carries little risk. I want to emphasize – as the analysts themselves honestly do – there is no real evidence for the numbers that they provide. However, it is somewhat reassuring, although it is based on “compressions only” (known as “hands only”) in which there are NO rescue breaths (mouth-to-mouth) given. The assumption is that ten percent of victims are infected and the assumed risk for acquiring infection is ten percent by rescuers NOT wearing masks (PPE – Personal Protective Equipment). In other words, your risk of getting infected is one out of a hundred.

If the risk of dying is one percent (or 0.01 percent in the opinion of some epidemiologists), your risk of dying if you give someone compressions-only CPR is one out of ten thousand!

I’d like to offer a couple of points:

You can’t give rescue breaths through a mask. But the analysts suggest wearing one if you only provide compressions.

The victim might need rescue breathing!! Not all unconscious, non-breathing victims have a heart problem. A person might have a heartbeat but no breathing if they have had a stroke, were electrocuted or have had a drug overdose.

If more than about four minutes have elapsed since the victim stopped breathing, they will require oxygen via rescue breathing. If professional responders have not arrived by then, what will you do?

Do you have a barrier mask with you at all times? The smallest packets with a simple plastic mask are a little bigger than your thumb and are easy to carry in your pocket, purse, car glove compartment or console, or on a key ring. They cost about $1.00 on Amazon. You might not find them at your local CVS or Walgreens.

Finally, if you are under the age of 60 and don’t have any heart, lung, kidney or immune system disorders, your risk of serious disease in doing a FULL resuscitation are vanishingly small but immensely rewarding.

Pandemic Perspective #12      June 6

Today is a very special day, the 76th anniversary of the Normandy invasion. Let’s take a moment to remember and to thank all those who died, and those who carried the physical and mental scars for the rest of their lives.

COVID-19 Lemonade for the Workplace

Yesterday’s good employment news made the likelihood of a V-shaped economic recovery look better than it did just a few days ago after the widespread and violent protests that followed the tragic death of George Floyd in Minneapolis. Still, businesses that had expected to be closed temporarily may never recover from the looting and destruction. The untouched shops and restaurants around them might not survive either.

Closely-packed, maskless, shouting demonstrators are sure to spread the virus. It seems that the bug can travel a long way from the throats of loud talkers and singers – note the extreme spread among two choir groups a couple of months ago – it’s one reason that we are going to have limited singing at our church services. Even though the protests have been out in the open we can expect more cases among those enthusiastic participants.

I’ve been tracking the case numbers in New York City, Los Angeles and Minneapolis since May 31st; by mid-June we should know if those cities and their suburbs will experience an even worse rebound than some health authorities warned us about because of premature reopenings.

Businesses are already revamping their workplaces on a massive scale. I know of at least two that have told nearly all their employees that they will be working from home until the end of the year. It will probably be a couple of years before things become stabilized but there will be some advantages to these changes.

The main reason for working from home is obviously the reduced risk of SARS-CoV-2 infection from co-workers but it goes beyond that. The influenza virus spreads through office spaces nearly as rapidly as this new coronavirus and so do the many different cold viruses. (Mild forms of the coronavirus cause about one-quarter of common colds.) That adds up to less absenteeism and higher productivity during the next cold and flu season that begins in just a few months. Keeping preschoolers at home makes getting things done more complicated but the kids won’t be bringing germs home from daycare and infecting their parents and older siblings. During my practice years I often had to explain to parents that the average preschooler acquires a respiratory or intestinal infection about once every five weeks; if they are in day care the infection rate nearly doubles. Keeping them at home will also improve the family’s cash flow considerably.

Americans eat nearly half their meals outside the home and much of that is fast food. For the homebound worker that’s probably healthier and it’s certainly less expensive. You’ve seen the cartoons and jokes about quarantine weight gain, such as Batman and Mona Lisa who now each check in at about 300 pounds. Expect to see a lot more TV ads for weight loss programs.

Every part of the auto industry is taking a hit, from manufacturing to sales to repairs but the upside is cleaner air and less traffic-associated stress. One tankful of gas lasts a month. I have an all-electric vehicle and I don’t expect to recharge it until July! We have already received two credits from our auto insurance company because their claims have fallen. And we welcome the drop in motor vehicle-related deaths and injuries.

Next week I’ll discuss facts and foibles regarding how to prepare for the next pandemic, including what steps to take if the current one has a severe and extended surge. It goes beyond toilet paper, rice and peanut butter!

In the news

 Will the fat lady ever sing?                

   “It ain’t over ‘til the fat lady sings,’ attributed to sportswriter Dan Cook, 1976.

            If this well-worn saying refers to the coronavirus pandemic we may never hear her final aria. SARS-CoV-2 is here to stay. It differs from the SARS coronavirus that surfaced in 2002 and MERS (Middle East Respiratory Syndrome) that was first identified in 2012. Unlike those two versions it has a low mortality rate except for elderly persons with underlying medical conditions. This strain is much more contagious and has rapidly infected more than one-half billion people around the globe in a little more than six months. In that brief period it has forever changed the world’s economy, challenged healthcare systems and profoundly altered how humans interact and communicate with each other. It will be a long time before the pandemic subsides and we can feel that life has settled into the next version of normal.

The good news is that the proverbial silver lining is already evident. Vaccine technology, accelerated by advances in genetics, may yield a SARS-CoV-2 vaccine in months, not years. Anticipating success, some manufacturers have already prepared millions of doses that can be distributed immediately as soon as their candidate is found to be safe and effective. Nothing like this has happened since Dr. Edward Jenner developed the first safe and successful smallpox vaccine late in the 18th century.

Social distancing has accelerated the move toward digital communications. There could be a reversal of the steep upward trajectory of college costs as online presentations replace lecture halls and classrooms. Zoom conferences don’t require business travel. Some healthcare providers already report that ninety percent of routine patient visits no longer take place in the office but via the telephone or computer. Devices that transmit vital signs such as blood pressure, temperature and oxygen levels are no longer Star Trek imaginings and they will proliferate.

How long will the fear of crowds affect our behavior? What will happen to events that by their nature draw large numbers of people? Will sports teams and entertainers be able to fill stadiums and arenas? Will movie theaters be able to survive when even the least tech-savvy among us have finally learned how to navigate our smart TVs to find the latest releases on Hulu, Apple TV or scores of other streaming services?

Almost no government, business, institution or individual was prepared for COVID-19. A few national leaders did foresee a pandemic scenario – Bill Gates and Marco Rubio come to mind – but no one heeded their warnings. Worse, federal and state administrations allowed stockpiles of medical supplies to dwindle. This time people and governments will listen to the prophets among us. The “prepper” movement will gain new adherents; to the mantra of “beans, bullets and band-aids” they will add “toilet paper”. Financial advisors who have warned us for decades that having one year’s income in savings was prudent no matter how difficult, will see that many families are following their advice. Fifty governors will ensure that their citizens will have ventilators, medical supplies and other essential items before the next pandemic arrives.

We might see the eventual reversal of the twin epidemics of obesity and type 2 diabetes. Early in the pandemic it became clear that the elderly were those at highest risk. It was not because of their years, it was because they had comorbidities that included overweight and diabetes and other conditions that included lung disease, high blood pressure and chronic kidney disease, all of which are almost entirely the result of lifestyle and are thus avoidable.

Physicians will develop new insights into viral diseases, how to treat them and how the human body reacts to them. They are learning how to use mechanical ventilators more effectively and how to prevent or treat the aberrant immunological response to infection known as cytokine storm.

The pandemic has accelerated research into dozens of antiviral drugs, novel applications of drugs that were developed more than a half-century ago and innovative diagnostic methods. Since the Renaissance era, wartime diseases and injuries have accelerated medical progress. This new war will do the same.

The fallout from the coronavirus pandemic will shadow us for years, possibly decades. If that view is correct, the fat lady will be waiting in the wings for a very long time.

Lifestyle

We’re all concentrating on avoiding the coronavirus and in keeping our sanity in this prolonged loss of social contacts. Routine doctor visits are being postponed but sometimes urgent problems override caution. One of the annoyances of aging, (the 17th in our series) kidney stones, is one of those. The severity of the pain that they cause is almost never life-threatening; it just feels like it.

Most kidney stones are composed of calcium oxalate and thus we can avoid them with minor changes in our lifestyle. Some are caused by a genetic biochemical defect and a few accompany gout, a painful condition of the joints.

The single most important factor in the development of kidney stones is dehydration, a condition that is common among older persons but that is almost always avoidable. When we get behind in our fluid intake the body responds by conserving water, thus making the urine more concentrated. Some of the solid materials that have been filtered through the kidneys also become more concentrated. As they coalesce they form itty-bitty (a scientific term) particles within the kidney that grow larger as dehydration persists, eventually forming stones. The tiniest leave the kidney and depart harmlessly when we empty our bladder. When larger stones exit the kidney via the ureter they encounter a couple of narrow sections and cause severe pain as they squeeze through. That’s not the end of the story. If they make it to the bladder they make the voiding process similarly painful.

The rough surface of a kidney stone that causes severe pain often scratches the walls of the ureter enough to cause bleeding. Sometimes blood in the urine is the first sign of a stone and is always an indication for a visit to the doctor.

Once upon a time doctors told patients who had suffered from kidney stones to reduce their calcium intake in order to prevent a recurrence. Just the opposite is true; taking too little calcium will encourage stone formation. The culprit is not calcium but oxalate. Oxalate is a constituent of many plant foods, especially rhubarb, spinach, strawberries and chocolate. (Sigh!)  Calcium in our food binds oxalate so that too little calcium allows excess oxalate to be absorbed into the bloodstream where there is plenty of calcium. When the calcium oxalate complex is filtered through the kidney it will precipitate out to begin stone formation if the urine is not dilute enough.

Dietary calcium is rarely a problem but persons who take large doses (more than 1,000 milligrams) of calcium, especially with vitamin D are at increased risk of stone formation. The guidelines to follow: never take more than 500 mg. of a calcium supplement at a time, never exceed 1,000 mg. per day and never take it at bedtime.

Water intake is critical but there is no magic formula. You will avoid dehydration and kidney stones if you drink enough water so that your urine is always light yellow with only a mild odor.