Pandemic Perspective #34   November 14, 2020

Covidiocy by the numbers

            San Diego crossed an important threshold this week; we have passed the magic number of 7 – the number of new cases of COVID-19 per 100,000 residents per day, placing the region in the tier that requires resumption of restrictions that are health-damaging and economically devastating. We are at 8.9 and various public venues will be on lockdown again beginning today. It is certain that some businesses will not survive this new clampdown, and some San Diegans will not, either.  

            It’s not my intention to dismiss the seriousness of the situation that we are in, a rise in cases that will strain healthcare facilities and personnel in several parts of the country, including ours. Influenza is joining the attack and that will certainly make things worse. My concern is that decisions are not being made thoughtfully, fairly or evenly and that such responses are inviting not only resentment but anger and refusal to adhere to the guidelines.

            The media report that hospitals are reaching capacity in some parts of the country but that is certainly not true in San Diego. According to the tracking information provided by the San Diego Union-Tribune (www.sandiegouniontribune.com/tracking-coronavirus-cases-san-diego-county) the county’s available bed capacity is approximately 2,000 while those currently occupied by COVID-19 patients is about 400.

            San Diego County is the second largest in the state both in area and in population. Public health authorities shouldn’t consider it as a single entity when assessing risk of coronavirus infection. For instance, most cases by far have occurred in the South County, where restrictions might have a greater effect than in North County, which has experienced many fewer cases and fewer deaths

            The strictures applied to different businesses and organizations are frankly bizarre. Consider that fitness centers are closed or restricted but casinos are open. My local fitness center clientele is predominantly young, healthy and not obese. The risk of death or serious illness among those who work out there is almost zero. There have been only four COVID-19 deaths in the entire county among those aged 20-29 since the onset of the pandemic.

            How about those casinos? Many if not most of their customers fit the all-American profile: older, overweight or obese, diabetic, smokers, with at least one marker of coronary artery disease. Does the term comorbidity ring a bell?

            Of course, if you are stressed out by fear of the virus or of losing your job you are welcome to stop by your local pot shop. It’s still open.

Pandemic Perspective #34   November 14, 2020

Covidiocy by the numbers

            San Diego crossed an important threshold this week; we have passed the magic number of 7 – the number of new cases of COVID-19 per 100,000 residents per day, placing the region in the tier that requires resumption of restrictions that are health-damaging and economically devastating. We are at 8.9 and various public venues will be on lockdown again beginning today. It is certain that some businesses will not survive this new clampdown, and some San Diegans will not, either.  

            It’s not my intention to dismiss the seriousness of the situation that we are in, a rise in cases that will strain healthcare facilities and personnel in several parts of the country, including ours. Influenza is joining the attack and that will certainly make things worse. My concern is that decisions are not being made thoughtfully, fairly or evenly and that such responses are inviting not only resentment but anger and refusal to adhere to the guidelines.

            The media report that hospitals are reaching capacity in some parts of the country but that is certainly not true in San Diego. According to the tracking information provided by the San Diego Union-Tribune (www.sandiegouniontribune.com/tracking-coronavirus-cases-san-diego-county) the county’s available bed capacity is approximately 2,000 while those currently occupied by COVID-19 patients is about 400.

            San Diego County is the second largest in the state both in area and in population. Public health authorities shouldn’t consider it as a single entity when assessing risk of coronavirus infection. For instance, most cases by far have occurred in the South County, where restrictions might have a greater effect than in North County, which has experienced many fewer cases and fewer deaths

            The strictures applied to different businesses and organizations are frankly bizarre. Consider that fitness centers are closed or restricted but casinos are open. My local fitness center clientele is predominantly young, healthy and not obese. The risk of death or serious illness among those who work out there is almost zero. There have been only four COVID-19 deaths in the entire county among those aged 20-29 since the onset of the pandemic.

            How about those casinos? Many if not most of their customers fit the all-American profile: older, overweight or obese, diabetic, smokers, with at least one marker of coronary artery disease. Does the term comorbidity ring a bell?

            Of course, if you are stressed out by fear of the virus or of losing your job you are welcome to stop by your local pot shop. It’s still open.

Pandemic Perspective #33   November 7, 2020

Antibody Angst

          There has been a flurry of worrisome articles suggesting that infection with the virus of COVID-19 produces antibodies but that they decline rapidly, possibly to unprotective levels. The implication is that a vaccine will either be ineffective or that it will protect recipients for only a short time. Although these conclusions are possible they are at the moment unknowable, and in my opinion, unlikely. Not only will we have to await the analysis of a large number of re-exposed individuals, current testing methods will have to be refined, meaning that they will become more accurate and reliable.

            Antibodies that the body makes in response to an infection or to a vaccine always decline eventually, sometimes to levels that are below the threshold of the laboratory tests that identify them. The immune system is remarkably complex, having evolved over millions of years to have many different mechanisms that provide redundancy that any engineer would be proud of. If you become a victim of the coronavirus your antibody response will depend on your genetic profile, your nutritional intake, your body fat percentage (obese persons respond significantly less well to vaccines than do persons of normal weight and possibly to natural infection as well), your level of physical activity and your past exposure to similar viruses. Then there’s the matter of the particular strain of coronavirus that you encountered and which mutations it has undergone.

            I have observed that pessimistic journalists’ reports do not mention another – and possibly more important — arm of the immune system, cellular immunity. Some cells of the immune system store information that can be retrieved when the same or similar virus tries to attack. Knowledge of how these cells work is limited by the fact that they are harder to investigate than the antibody system and there is as yet no test available to clinicians that would help them to evaluate the cellular immune status of their patients.

            There are silver linings behind the COVID-19 cloud. One of these is that in the next couple of years we will have detailed knowledge of how the body responds to infections in general and this novel coronavirus in particular. In the meantime, keep in mind that antibodies are only one element in a vast and incompletely understood response to infections.

In the news

The Great Barrington Battle

            The picturesque town of Great Barrington, Massachusetts has been sucked into the COVID-19 maelstrom. A document entitled The Great Barrington Declaration was released on October 4, 2020, authored by scientists from Harvard and Stanford universities and the University of Oxford. Co-signers include more than forty scientists whose interests involve microbiology, epidemiology, psychiatry, genetics, medical ethics, immunology, vaccine technology, biostatistics and public health policy. More than 500,000 persons have voiced support of the declaration, including more than 40,000 physicians and other scientists. These are arrayed against large numbers of individuals of similar backgrounds, also respected experts in their field, who are opposed to the opinions expressed in the document.

            The main elements of the declaration are two-fold: those who are at minimal risk of death should return to a normal way of life, are likely to experience infection and thus eventually build herd immunity; those who are at high risk, namely persons who are older, obese, diabetic or who have other comorbidities, should be protected, a concept called Focused Protection.

            Opponents claim that about 60 percent of the population has comorbidities such as being overweight or obese and having diabetes, and that it is simply not possible to protect these and the vulnerable elderly. They include Dr. Anthony Fauci, Dr. Adhanom Tedros, an immunologist and Director-General of the W.H.O., as well as spokespersons of the Infectious Diseases Society of America. With such acknowledged authorities so heatedly opposed to each other, what is the public to believe about an issue that is clearly having a serious impact on the health, finances and morale of the entire population?

            Like so many contentious issues there is truth on both sides. First, the mortality rate among the youngest of our populations is vanishingly small: as of late October the CDC has reported only 79 coronavirus fatalities among children below the age of 15. Among those below the age of 25 the number is only 462 and a large percentage of them also have comorbidities, including heart and lung disease as well as obesity. In four recent publications the percentage of children who died with comorbidities ranged from 22 to 83 percent. These are tragedies to be sure but only a tiny fraction of the more than 235,000 Americans who have succumbed to COVID-19 since the start of the pandemic. If all children are able to return to regular classrooms their risk is small but that leaves open the possibility that they will infect older relatives and teachers who might have comorbidities.

            Herd immunity is a major point of dispute. As I noted in an earlier blog the likelihood of herd immunity as a result of the natural spread of infection is nil or nearly so. Barely three percent of the U.S. population has been infected to date. Only a vaccine can accomplish herd immunity and there is no certainty that most people will receive or even want to receive the vaccine and that the vaccine will provide long-term protection. On the latter point it will take most of 2021 before we can have solid information regarding the duration of protection; only natural challenges among vaccine recipients will reveal that and the wide diversity of vaccine types will obscure the results even longer.

            In my opinion, opening schools will expose some susceptible persons to infection but keeping them closed has its own perils and appears to be a greater risk. The vast majority of outdoor venues should be opened with the same caveats that the elderly and medically compromised among us should limit their exposure. Weight-challenged persons will suffer inordinately but they face the same perils from influenza – and children die in much greater numbers from influenza than from the coronavirus — and those annual epidemics that carry off on average about 40,000 Americans every year have not required schools and businesses to close.

            As always, I appreciate your feedback.

Lifestyle

Dr. Phil’s Senior Shake – an antidote to some of the Annoyances of Aging that have been reviewed in this blog.

            Geriatric specialists are well aware that older persons, especially those who live alone, tend not to have a well-balanced, nutrient-rich diet. Here’s my breakfast recipe – an easy way to start the day that will provide you with some important dietary factors. These include protein, fiber, healthy carbohydrate, calcium and antioxidants.

            I use an ordinary kitchen blender with a capacity of six cups, a three-day supply. I start with about four ounces of orange juice or one of the OJ blends (strawberry, banana, mango, etc.) to give it some extra flavor without much sugar and add about 16 ounces of water.

            Add a banana and some colorful fruit such as blueberries, strawberries or raspberries. The more color, the more antioxidants. They also provide flavor and fiber. Frozen packages of mixed berries are especially convenient.

            MOST seniors don’t get enough protein that is so vital for tissue repair and a strong immune system, so I include at least 30 grams of protein powder (that comes out to about 10 grams per serving) of which there are many types in every supermarket or health food store. Stick to name brands with no added flavor. (You’ll get plenty of that in the fruit.)

            Yogurt is next, mainly for the protein but also for the calcium. My favorite is Trader Joe’s Greek non-fat. There are so many different flavors that you’ll never get bored.

            The last three ingredients are for intestinal health: Miralax, Metamucil and a probiotic powder. You might not need the first two but hardly anyone gets enough of the good bacteria that are so essential.

            If you’re looking for more information on protein powders and probiotics a reliable source of unbiased information is http://www.consumerlab.com.

            What about veggie shakes? They sure worked for Jack LaLanne! He made it to his mid-90s!

Pandemic Perspective #32   October 31, 2020

Long COVID – an attempt to shed a little light

            Among the many new features of COVID-19 is a condition referred to as Long COVID. Persons recovering from infection with SARS-CoV-2, even those who have had no symptoms but who have evidence of recent infection with this new coronavirus may develop long-lasting symptoms that include severe fatigue, shortness of breath, chest pain, muscle weakness and inability to concentrate. Many of these victims are unable to return to work and complain of a poor quality of life.

            Chronic fatigue that lasts for months has been observed following viral infections such as infectious mononucleosis and even the SARS outbreak of 2002. The massive number of COVID-19 victims has resulted in so many people with this new syndrome, Long COVID, that it has become relatively common, affecting more than 80 percent of persons in one study who were sick enough to be hospitalized. The actual number will never be known; many victims of the current coronavirus have no symptoms and the condition can easily be attributed to other conditions including another poorly understood illness, chronic fatigue syndrome.

            There is concern in the medical community that this condition may last not for months, but for years. Considering that so many victims of COVID-19 are elderly and have one or more underling conditions, including hypertension, heart disease, disorders affecting the brain, chronic lung or kidney disease and diabetes, the picture becomes extremely complicated.

            There is another long-lasting condition following severe coronavirus among persons who have required ventilator therapy. In addition to the damage caused by the virus itself, there are sometimes adverse effects from the high pressures needed to provide lifesaving oxygen. Recovery from the damage may take many months but it is not to be confused with Long COVID, although some patients may experience both conditions.

            There is yet another long-term problem that may occur in the course of a COVID-19 illness although it is not unique to this disease. The enormous number of persons who have required management of their illness in an intensive care unit has brought increased attention to the problems experienced by such patients. Whether admission to these specialized units is required after COVID-19, an automobile accident, a severe infection or a heart attack, survivors sometimes experience months of depression, weakness, anxiety, poor sleep and nightmares. It is known as PICS (Post-Intensive Care Syndrome).

            The coronavirus pandemic has delivered an unwelcome cornucopia of unforeseen complications, disappointments in attempts at treatment and wavering faith in the opinions of medical experts. The New Year bringing the promise of effective vaccines can’t get here soon enough!

Pandemic Perspective #31 October 24, 2020

            Medicine’s Great Imitators now include COVID-19.

            Since late in the 19th century medical students were warned that syphilis, at that time a disease without a cure, could mimic a host of other diseases. Sir William Osler’s well-known aphorism, “The physician who knows syphilis knows medicine” was still being taught during my medical school years in the late 1950s. By the time that lupus was recognized as a serious disease, especially among young women, its various manifestations and resemblances to other diseases made it known as another Great Imitator. Although SARS-CoV-2 emerged barely a year ago it has earned that sobriquet as well.

            The classic features of COVID-19 are fever, cough and shortness of breath. Perhaps as many as one-half of its victims don’t have these symptoms at all yet some of them have developed heart and lung damage. We have all been subjected to temperature screening by one of those hand-held electronic thermometers but the disease may progress for a day or two with complaints merely of headache and fatigue, and no fever. Early in the pandemic the senses of smell and taste were noted to have diminished markedly in some patients, sometimes slowly or never to return. These losses may occur in as many as one-half of patients in some population groups.

            Almost everyone develops a couple of viral illnesses in any given year whose symptoms include fever, cough, runny nose, redness of the eyes, headache, sore muscles, vomiting, diarrhea and a rash. All of these occur in COVID-19 as well so that unless there is shortness of breath severe enough to warrant at trip to the local emergency room where coronavirus testing will be done there is no way of knowing that the pandemic virus is the cause.

            Like syphilis, lupus and a host of other diseases, the SARS-CoV-2 virus can affect the brain. It may cause a generalized inflammation of the brain known as encephalitis or it may affect the nerves, causing paralysis that begins in the feet and travels upward, sometimes paralyzing the muscles that make breathing possible.

            Pediatricians were surprised last spring when they encountered children who had what came to be known as MIS-C, multisystem inflammatory syndrome-children. Not long afterward the condition was described in adults.

            Without doubt, more surprises are in store. Dr. Osler would salivate at the thought of another Great Imitator!

Pandemic Perspective #30 October 17, 2020

            Something to keep in mind when you don’t feel like exercising.

            I know, I know – I’m nagging! But I just learned something new about the value of exercise: some people have fat lungs!

            We were only a couple of months into the COVID-19 pandemic when it became clear that not only were persons over the age of 70 more likely to have severe or fatal infection, but younger people who were obese or overweight were too. In an article published just last month entitled A Preventive Role of Exercise Across the Coronavirus 2 (SARS-CoV-2) Pandemic in the journal Frontiers in Physiology, an international group of scientists gave two reasons why this is so. First, the tiny spaces in the lungs that allow the transfer of oxygen into the bloodstream become surrounded by fat in persons who are overweight or obese, thus hindering delivery of oxygen. Second, the more fat cells in the lung the more receptors for ACE2, (Angiotensin Converting Enzyme 2) which not only facilitate the entry of coronaviruses into cells but through a complex mechanism also contribute to destruction of lung tissue. That helps to explain why so many victims of COVID-19 end up on ventilators, often with fatal outcomes.

            The influenza season has begun just as coronavirus cases are ratcheting up in several parts of the country. Just like the coronavirus, influenza attacks the lungs and those most affected are the overweight or obese. This should be be a wake-up call to become more active, not only to get rid of some of those fat cells but also because exercise itself boosts immunity for reasons not yet fully explained.

            How much exercise do you need? The authors of the article suggest 150 minutes (2 ½ hours) per week consisting of both aerobic (walking, jogging, etc.) and resistance exercise (weights, elastic bands, machines, etc.) Lest you fret that it’s already too late for you to lose enough weight to matter, you should know that losing only about 10 or 15 pounds has been shown to lower blood pressure and blood sugar – elevations of both are also risk factors for serious disease from the coronavirus. By exercising the recommended amount and cutting back on about 500-1000 calories per day you can lose about two pounds per week. New Year’s is only about ten weeks away so you can do that before the peak of the flu season arrives.

            Oh! And did I mention that you also must get the flu vaccine?

In the news                  October 15, 2020

            Two coronavirus vaccine programs have been paused because recipients have developed serious medical conditions that might have been caused by the vaccine. What does that mean? How concerned should we be?

            The development of a vaccine is not as simple or straightforward as producing a new version of an iPhone or Samsung Galaxy. Though complex, a smartphone always conforms to physics; biological systems do too but the variations they share are complex beyond imagination.

            There is no one on the planet who is exactly the same as you, not even if you are an identical twin. We carry about 25,000 genes, each of which not only has several versions but whose functions may be turned on or off by environmental factors. You might think that fingerprints or retinal scans are unique but that is nothing compared to the enormous complexity of our immune system. No two people on the planet have had the identical exposure to viruses, bacteria, fungi and parasites so each of us has a unique immune system. When confronted by a new agent in the form of a vaccine, no two people will react in the exact same way. Therein lies the challenge for vaccine developers.

            One coronavirus vaccine recipient has developed a condition called transverse myelitis, a condition in which inflammation damages an area of the spinal cord. This can have multiple causes, usually a virus but sometimes a vaccine. The current case is being investigated but it’s not yet been determined if it was caused by the vaccine. If another case pops up among the next few thousand vaccine recipients the game will change dramatically.

            There have been more than a dozen cases of transverse myelitis due to naturally acquired SARS-CoV-2. If the vaccine mimics the natural infection, it’s possible that it will cause similar complications, although hopefully at a much lower frequency.

            The pause in the trial of this vaccine should be encouraging, not the opposite. It is the way that vaccine trials are designed and such interruptions are the norm in vaccine development. That’s why they usually take so long, sometimes years.

            Among the more than 150 vaccines now in development there are some whose design is unique, innovative and therefore unpredictable. Somewhere among them we might discover a silver lining.

Lifestyle

            See what happens when you change a dietary habit.

            Americans eat about six times as much sodium as hunter-gatherers and we pay a high price for that. Among African hunter-gatherers who take in about 600 milligrams of sodium daily the incidence of high blood pressure (hypertension) is zero. Their genetically identical cousins in the U.S. average about 3500 milligrams a day and hypertension is a leading cause of death in that group.

            Our taste for salt is acquired but if you go on a very low sodium diet for about six weeks by avoiding most fast and processed food and putting away the salt shaker you’ll find that when you eat a pretzel or a potato chip at the end of that time you won’t enjoy it! You might also discover that your blood pressure has come down a few points.

            The average sugar intake in the U.S. is more than 150 pounds per year; in colonial America it was about six! Try the same test with sugar. Stop eating candy, dessert and soft drinks for a month; don’t add sugar to your coffee. I’ll bet that you won’t be able to finish a Krispy Kreme donut by then.

            Heart disease is the number one cause of death and type 2 diabetes has moved up to number three! Two thirds of Americans over the age of sixty have at least one marker of coronary artery disease and a similar number at that age have either type 2 diabetes or prediabetes.

            You can’t change the world by cutting way back on salt and sugar but maybe you can change your world! Is it worth a try?

Pandemic Perspective #29     October 10, 2020

Hydroxychloroquine: on again, off again, on again???

            Well, it’s another head-spinner! Hydroxychloroquine (allow me to abbreviate it to HC), a medication that has been used by physicians to prevent and to treat malaria and in the treatment of several other diseases since 1955, fell victim to politics and the media with the arrival of SARS-CoV-2.  

            In 2003 an article in Lancet, a respected (until recently) British medical journal, described the drug’s antiviral and immune-boosting properties and suggested that it should be considered in the treatment of AIDS and SARS. A section of the paper entitled Safety considerations noted its “low incidence of adverse events during chronic administration” and “the safety of a high dosage of the drug even during pregnancy.” It can cause damage to the retina of the eye in persons who have been taking the drug over five years. The WHO placed it on its List of Essential Medicines, the safest and most effective medicines needed in the health system.

            Early in the pandemic several groups published their experience with HC in coronavirus patients, especially when given with Azithromycin and reported a significant decrease in viral load and earlier discharge of ill patients from the intensive care unit.

            But then the HC hit the fan when Donald Trump sang its praises and reports emerged of its cardiac toxicity and ineffectiveness in the treatment of COVID-19. Rheumatologists, who have had decades of experience in treating patients with lupus, rheumatoid arthritis and other autoimmune diseases, were aware of its potential to cause abnormal heart rhythms and noted the importance of monitoring patients with known heart disease. Like every other prescription drug, by the time millions of doses had been given for malaria and the diseases mentioned, other side effects emerged but when given for a short time these were usually limited to abdominal cramps, nausea, vomiting, diarrhea and headache.

            Goodbye HC. But wait! In a report from the David Geffen School of Medicine at UCLA, although individual trials of HC did not show a “statistically significant impact on prevention or treatment,” when these trials were pooled into a meta-analysis, early use of the drug yielded a “significant 24% reduction in risk of infection, hospitalization or death.”

            One of the authors of the study noted that when the results of this meta-analysis are combined with the results of seven nonrandomized controlled trials “This is extremely strong evidence of benefit.”

            Stay tuned. Who knows what next week will bring?

Pandemic Perspective #28         October 3, 2020

            The latest on coronavirus vaccines.

                A former colleague, Dr. Stephen Spector, a pediatric infectious diseases specialist at UCSD gave an excellent overview of the status of coronavirus vaccines in an online presentation on October 2nd.

            Of more than 150 vaccines under development only a handful are in the final phases prior to release. As noted in earlier blogs, some are using unique and innovative methods and the range of techniques is remarkable.

            Dr. Spector could not predict when the first ones will be released but he did offer some encouraging news that all of us should be aware of. The best news, in my opinion, is that the vaccines provide antibody responses similar to those of natural infection. That could mean long-lasting immunity. Protective levels are reached in about 14 days.

            To date there have been no reports of serious side effects. The most common one is pain at the injection site in about 50 percent of recipients and many persons have some muscle aches for a few days. Some vaccines require two doses but the good news is that side effects do not increase with the second dose.

            The target effectiveness – the level of protection that the developers expect in a best case scenario — is only 60 percent, a little better than most influenza vaccines. We’d like for it to be much higher (the current measles, shingles and hepatitis vaccines are protective in more than 90 percent of recipients) but it’s likely that even at that level it will modify the disease enough to prevent hospitalization and severe complications.

            One downside to most of these vaccines is the need to maintain storage at very low temperatures, making it a challenge for developing countries that don’t have the freezer technology required.

            Another challenge is matter of acceptance by the public. Only 40 to 60 percent of persons report that they will get the vaccine. Acceptance differs considerably between members of the major political parties. And no, I won’t go there!