Islon Woolf MD
Updated: Apr 15, 2020
How spread is the virus in the US?
3,244 confirmed cases in the US and 62 deaths as of yesterday. However, up until now we have not been aggressively testing. Most of the patients getting tested are the ones sick enough to go to the ER. Most people with this virus are not that sick. Therefore, the 3,244 cases represent only the tip of the iceberg. This means that, at present, there must be tens of thousands of cases in the US.
What about the prevention strategies and treatments people are texting each other?
There has been an onslaught of different recommendations sent to us through viral texts, emails, and videos. The following is a very partial list (I did not want to bore you - the actual list is much larger and keeps growing):
Kills or washes away virus before entry
Breathing in sauna air
Drinking hot water frequent
Rubbing your hands with a copper thingy for $69.95
Boost immune system
Ultra high dose ozone therapy (oxidant to kill virus)
VItamin C (antioxidant to kill virus)
IV vitamin drips
Suppress immune system
Interferon beta 1a
Prevent viral replication
Tamilfu (inhibits neuraminidase only found on influenza virus)
Avoid ACE inhibitors and ARB
Oscillococcinum (duck liver diluted to nothing)
The first problem you will notice is that some of these treatments are based on directly opposing ideas. Ideas that are mutually exclusive; for example, some boost the immune system while others suppress it, some are antioxidants and some are pro-oxidants. Confused? You should be.
Aside from the problem of opposing ideas, what is the evidence that any of the above treatments work for COVID-19? Basically, it comes down to one of three forms of evidence:
Anecdotes - Example: Korean doctors in a single hospital used Chloroquine in a few COVID-19 hospitalized patients and they got better.
Arguments from physiology - Example: hot water and acid denature the virus in a Petri dish, so drink and swallow hot water frequently. Silver also kills the virus in a Petri dish so drink that too.
Touted to work for other viruses - Example: zinc may work on COVID-19 because it can treat the common cold.
The problem with these forms of evidence is that they mostly generate false positive results. They make treatments look effective when they are not. We have learned this from EBM (evidence-based medicine):
Anecdotes - It is hard to know whether a treatment works without a control group. The majority of COVID-19 patients get better regardless of treatment. If a doctor in a hospital starts using Chloroquine and patients “get better", it is very possible these patients got better spontaneously. The only way to really tell if a treatment is working is to use a control group - which means a clinical trial.
Arguments from physiology - 10-25% of physiology experiments cannot be replicated. Even if correct, a compound killing a virus is in a Petri, is far from proof that it will be both safe and effective when ingested by humans. In general, less than 1% of drugs that work in the lab turn out to be both safe and effective in humans.
Touted to work for other viruses - These statements are mainly false. In fact, there is an old joke in medicine, “The common cold lasts a week without treatment and only seven days with”. It is still true today. Most trials show treatments like vitamin C or vitamin D do not work for influenza or the common cold. Even the occasional treatment that has evidence of efficacy, like Tamiflu, barely works - and regardless, is very specific to the biochemistry of the influenza virus, not COVID-19.
The most reliable form of evidence is a clinical trail. In fact, if tested in clinical trails against COVID-19, the vast majority of the above treatments would likely fail - over 99%. This is the historical failure rate of any new medicine. Unfortunately, trials take time, and time is something we do not have.
In the absence of good clinical trials, some of you find it acceptable to speculate and use the above treatments. The reasoning being, "What do I have to lose?". However, here are the problems with that approach:
How do you choose which treatment? There are hundreds of treatments proposed for COVID-19 based on lower forms of evidence. How is one anecdote better than another, or a viral email more reliable than another, or a maverick Harvard professor smarter than a maverick Stanford professor? Maybe you could take all of the treatments at once and hedge your bets?
Side effects. There is no such thing as a medicine, natural or not, that does not have side effects. A treatment that is strong enough to heal you is strong enough to harm you.
Worsen the infection. Certain treatments could potentially make the viral infection more deadly (see next section on "boosting" the immune system")
Weighing the risk. There is a 99% chance of recovery. Is it worth risking side effects for a treatment with a less than 1% chance of success, in a disease with a 99% chance of recovery?
Do you want a treatment that “boosts” the immune system?
Before I try to answer this, there is a problem with the question. It reduces one of the most complex biological systems on the planet into a single variable. Turn the volume up, “boost" immunity, or turn the volume down, “suppress" immunity. In reality, the immune system consists of hundreds of different cell types. These cells monitor the billions of cells in your body and all of the foreign invaders. To communicate with one another and the rest of the body, they produce thousands of kinds of signaling molecules known as cytokines. Each kind of cytokine works in feedback or feedforward loops to up-regulate or down-regulate other components of the immune system. It is an exceptionally delicate and interconnected system. I don’t understand the immune system and I’ve been studying it for 30 years.
Asking "Do you want to boost your immune system?" is akin to asking, "Do you want to boost your iPhone?"- it is a meaningless question. What part of the iPhone? Which of its thousands of functions? It's hardware, it's software? What do you mean by "boost"?
But let’s say the immune system is something simple that can be “boosted” or “suppressed”. I can see how a “suppressed” immune system would be responsible for a virus getting into the body and allowing it to replicate. But, what about a “boosted” immune system? Could it cause any problems? Yes. In fact, a "boosted" immune system may be the cause of death in many viral infections. Some viruses stimulate the immune system too much. This leads to an overproduction of cytokines - a situation known as “cytokine storm”. The resultant swelling and circulatory collapse kills the patient. In viral pneumonia, the immune system signals the normal lung cells to secrete so much fluid that one drowns in his own secretions.
Antioxidants like vitamin C supposedly “boost" immunity. But theoretically, they may do just the opposite. Antioxidants neutralize one of the most potent components of the immune system - free radicals. During the process of phagocytosis, it is free radicals that immune cells release to destroy pathogens. Do you really want to disable phagocytosis? In fact, one of the other proposed treatments for COVID-19 is high dose ozone therapy. It claims to "boost" phagocytosis by increasing free radicals. This makes it the opposite treatment. It is not an antioxidant, but with the ultimate oxidant - oxygen.
Confused? You should be.
It is also well established that the immune system is tied to the coagulation system (blood clotting). Shortly after an infection, like pneumonia or the flu, there is a marked increase in risk of heart attack, stroke, and blood clot. This is thought to be due to increased clotting from an activated or “boosted” immune system.
So once again I ask you: do you want your treatment to “boost” the immune system? Or maybe for COVID-19 you should “suppress” it? The take home message: the immune system is so complex we cannot figure out whether a treatment is going to work simply by mapping out a pathway on a chalkboard or watching it in a Petri dish. The only way to figure it out is to perform a clinical trial in real life patients. I am sorry to belabor this point, but I don’t think I can stress it enough.
What is the best treatment?
Relying on one of the above treatments can be dangerous in other ways. It may lull you into a false sense of security, eschewing the best treatment - actually the only effective treatment - public health measures. Public health measures prevent people from being exposed. If you keep away from the virus you can’t get it - it is as simple as that. Public health measures were invented six centuries ago in the first European Plagues. They work exceptionally well. China has been on lock down with barely any new cases in the last 4 weeks (China is in orange in diagram below).
What are the different public health measures?
Containment - Preventing travel in and out of infected countries
Mitigation - Social distancing - avoid crowds, not shaking hands, washing hands
Quarantine - Isolating exposed persons until the end of the incubation period
Isolation - Isolating laboratory conformed cases until they are tested negative
The more the virus spreads, the greater the governmental reaction, and the stronger the enforcement of the above public health measures. Expect more public health measures as the days go by.
Are you part of the AT RISK population?
It seems rather clear that the fatalities from this viral infection occur in the elderly and/or patients with underlying medical problems. This is the AT RISK population. These people should adopt something similar to “Universal Precautions”. When the AIDs epidemic hit in the 1980’s, healthcare workers didn’t know who had AIDs and who did not. Which patient required precautions? The answer - all of them. We adopted “Universal Precautions”. This means: pretend all patients are HIV positive - everyone wears gloves at all times etc. Likewise, the AT RISK population should pretend that everyone around them has COVID-19. They should practice social distancing, avoid shaking hands, avoid crowded places, and wash hands.
The AT RISK populations should also make sure they are in peak health: eat healthy, continue exercising, and make sure all of their medical problems are well in order. For example if you are a diabetic make sure your blood sugar is controlled.
What if you are not AT RISK?
Younger people and people without other medical problems do very well with this virus. However, since the AT RISK group will likely be practicing mitigation, the not AT RISK group will be the reservoir of the disease and cause its spread. This is why I think that even now, the not AT RISK group should practice mitigation - wash handing, avoid crowds and especially avoid AT RISK individuals. This way, the not AT RISK group can help SLOW DOWN the spread of the virus - which is very important. The slower the spread, the less the burden on the healthcare system at any one point in time. (see graph below)
Can you travel?
Even if you are in the not AT RISK group you should avoid all non-essential travel. Although the combined probably of getting COVID-19 AND it killing you, is very low, the likelihood of being stuck in some place due to a quarantine or a containment measure is likely. So avoid travel, for convenience sake alone. It also helps with containment of the virus in the world at large. Remember - we are all in this together.
What should you do if you get symptoms?
Don’t panic. At this point in time it is most likely a regular cold or flu. Stay at home and contact me. We will figure it out together. It’s on a case by case basis. The situation changes from day to day. Your risk of infection changes from day to day, and your health risks and your families health risk are unique. A personalizes approach is warranted. (Obviously, if you are severely short of breath, call 911 and go straight to the ER.)
Should you get tested?
The message from the CDC, the Florida Department of Health, and private labs like Quest has been confusing and inconsistent on the availability of testing. Currently, the entire country is only able to process about 1,000 tests per day. This is certainly a failing in the system as head of CDC, Anthony Fauci, admitted at Wednesday’s House Committee hearing. This will change and hopefully be rectified in the next week or two. Right now the goal is mainly to test high risk individuals and individuals that are sick - not healthy people. Eventually the goal with be surveillance - testing healthy people. The more tests we do the better we can understand the scope, infectivity, and natural history of this virus. But not until more testing capacity becomes available.
The test consists of a swab in your nose, your mouth, and a sputum sample. It is sent to a lab for a DNA test. It is extremely accurate. Tests done through the CDC have a one day TAT (turn around time). Tests done in an outpatient setting may have as much as a 4 day TAT. Please contact me if you think you want or need to be tested.
What is the overall prognosis?
I suggest you don’t run out and get IV infusions of vitamin C - which ironically exposes you to healthcare facilities and other people. You may be losing site of the actual risks and what really works. The two main issues are public health measures and, to a lesser extent, testing. As each country is learning from the experience and mistakes of the other, our nation will hopefully do a better job with a swifter response. As the cases grow in the US, we will start to test more, and we will discover the rest of the iceberg. As this happens, more and more draconian public health measures will be implemented. Eventually the cases will drop to near zero. My guess is that it will play out over the next 3-6 months.
If you are young and healthy you will be ok, if you are old and unhealthy you will be okay as long as you practice mitigation and social distancing. Just be patient. Viruses are like forest fires. Once they burn through an area they are done. The can’t burn through that area again. When viruses go through an area, people build up immunity. It does not have to be everyone. As soon as a certain number of people are immune, there are not enough hosts for the virus to propagate - this is known as ‘herd immunity’.
Remember, the situation changes all the time. I promise to be there for you and keep up to date. Please contact me if you have any questions or concerns.
Try to see the bight side. Unlike post-hurricane, we actually have power and water. Use this time alone as a time of reflection or a sabbatical. Start that autobiography you always wanted to write, read the piles of books next to your bedside table, learn how to meditate, do a Jane Fonda 1980's workout, or start watching an on-line course on the History of Epidemics in Western Society Since 1600 - its fascinating.