Tagged Coronavirus

THE ONLY THING WE HAVE TO FEAR…

I confess I am a relentless optimist.  The joke of the two boys, one an optimist and the other a pessimist, portrays the difference quite well.  The pessimist got a pony for his birthday.  He sat looking at his new pony with large tears running down his cheeks. “Why so sad?” he was asked.  “All ponies eventually die!” he blurted out between the tears.  The optimist was given a room full of manure.  He was happily throwing the manure up into the air, giddy with joy.  “Why so happy?” he was asked.  “With all this horse poop around, there has to be a pony somewhere!” 

Despite all the pessimism we are steeped in, I am optimistic. One of our biggest fears is fear itself, as said so well by one of the icons of our nation, Franklin Delano Roosevelt, who uttered those words during another crisis our country faced, different but yet similar in terms of even greater risk to life, lifestyle, the economy, and need for regulation of its citizens.  A lot of damage has been done by the panic of the coronavirus, which I feel has been whipped up by the media and a lot of craziness in the social media. The rumors that the virus was created by the Chinese, the Russians, the Martians, the Jews, or the US military, with one of their weaponizing projects gone rogue, is just insane. First of all, we are not that sophisticated to create viruses (yet), although the Martians might be if they existed.  And this would be a totally new way of terrorism that has never been accomplished by humans before.  The global stock markets have shed 6 trillion dollars, while the US markets own 2/3 of that loss i.e., 4 trillion.  This seems like another over-reaction in my view. Coronavirus (COVID-19) is nowhere near the aggressiveness of other pandemics we have had.  The mortality is going to settle out at less than 1%, and the older population, especially the ones with comorbidities, are at greatest risk.  The 1918 Spanish flu, which was the H1N1 swine flu killed 100,000,000. Both MERS and SARS were more aggressive, but peaked out before widespread epidemics. China has peaked out and is on the other side of the curve both in terms of the disease and in terms of its economy. Even their domestic air travel is showing signs of recovery.   South Korea is close behind in beating the epidemic. The warm weather is coming.  All previous viral epidemics showed an amelioration when the temperature went up, and this will likely do the same with this epidemic (something good that can be said about global warming).

I do have concerns about the wisdom of shutting down the whole country with its obvious detrimental consequences to the economy, when isolating the likely susceptible at risk are the only ones that really need to be. The rest of the healthy younger population could be getting herd immunity. But all the smarter people than me with a lot of data from other countries that have gone through this seem to think that the social distancing, the school closures, limiting the number of people gathering at no more than ten, and working from home, etc. are what is necessary.  In the meantime, there are at least ten vaccine candidates out there with Moderna, Inc (Nasdaq: MRNA) in Phase 1 trials that have started today. Several anti-viral drugs that are already available have proven some efficacy against the coronavirus, as does serum from recovered coronavirus patients. Our President and Chief of Optimism thinks by July this will be contained. I do believe that everything that can be done is being done, and a lot of very smart people are involved. There are reasons to be optimistic. There really are no other choices. 

CORONAVIRUS FOR DUMMIES

My last two essays were, you guessed it, on COVID-19. That is all you hear on the radio or TV these days. In keeping with the trend, I am continuing to stir the pot. It has gone viral.  Coronavirus, true to its name, is a virus that has gone viral! 

Viruses grow exponentially (J-shaped growth curve), the fastest growth rate there is, the larger the growing population, the faster the growth, as long as the food holds out.  When the food runs out, the curve then changes to a logistic curve (S-shaped growth curve).  This curve shows a slowing down of growth. So what makes the curve slow down?  There are only two things that make the curve slow down: #1 fewer in the susceptible herd are available (either through the susceptible making themselves less available or the process makes the susceptibles less available ).  #2 the rate of growth slows down.  This happens when it takes longer to infect the next person.  This could be when people wash their hands more often, don’t go out to spread the virus, or at least sneeze into a napkin. Ultimately when the food supply runs out, both mechanisms are at work, reducing the susceptible and the rate of spread.

The number of new cases will slow down, guaranteed! But will we still be alive to talk about it? I think we will.  There are several reasons I believe this.  We are worried about it, in fact too worried! As evidenced by the stock market!  The virus is not as dangerous as the news media tells us.  The mortality rate is likely not 9% as SARS was, it is closer to 0.1% as the last flu outbreak was. The measures we are taking to reduce the number of people exposed, and the rate of spread will reduce the number of new cases.  It is common sense not to go out and buy cruise trip tickets.  It is common sense to limit your unnecessary exposure to large crowds.  It is common sense to wash your hands often.  It is common sense not to bring the virus close to the places the virus gains entry to your lungs, like your eyes, your nose, and mouth. The virus stays active for a couple of days on any surface, such as a door nob, so washing hands is not only hygienic but important.

I have been in the doctor business over two-thirds of my lifetime, and have washed my hands to the point that I have scrubbed off my fingerprints. 

They always have trouble when I need to give a fingerprint for a passport or other ID, because I obliterated them off over the years. I first learned to scrub for surgery in my third year of medical school at UCLA from one of the icons of surgery. He put soot on our hands, then blindfolded us, gave us a brush and soap, and made us scrub our hands. You would be surprised how much soot stayed on our hands and the places that were most likely to remain black, the back of our hands, the webspace between the fingers, and the space between the wrist and the palm.   For medical students, it was a minimum of ten minutes (first scrub of the day) to get our hands clean. But for our purposes, washing for 20 seconds is generally enough.  I learned a nice little trick from my grandchildren’s primary school teacher, singing the “Happy Birthday” song twice (at regular speed) is precisely 20 seconds. 

You get the virus from another person, either through direct contact or through a surface, the infected person has left some body fluids.  Avoiding other people is one way to decrease contact.  I believe that shaking hands was an ancient, rather strange custom.  It goes back to the Middle Ages when you met someone in the forest. You extended your right hand, as did the other person, to show that they did not have a dagger in it.  It was somewhat awkward standing there with both your and his hands extended, so grabbing and shaking seemed like the right thing to do. As we don’t carry daggers any more, this Middle Age custom has outlived its usefulness and needs to stop.  I vote for the Mr. Spock handshake: right hand raised at your side with the index and middle finger spread form the ring and pinky finger in a V configuration.  This is necessary because if you don’t spread your fingers, it looks like a “Heil Hitler.” And if you leave just your middle finger up, it changes the entire meaning.

Viruses, like white men, can’t jump. Therefore a yard distance between people should be enough although the CDC in an abundance of caution has now revised it to two yards unless they are coughing or sneezing. If they are, you need to get out of that room, because the sneeze generates particles that are as small as 5 microns in diameter that travel over 100 miles per hour, and can stay in the air indefinitely like any pollen sized or smaller particle.

Masks are not very helpful, except for the ill person who coughs and sneezes.  It keeps the particles that are spewed out more confined.  Regular masks, actually, are not very effective in preventing inhalation.  For one thing, the sides allow fine airborne mist to enter the space behind the mask, which is inhaled. To be effective, it has to be a special mask fitted to the individual that allows only air that goes through the mask to get to the person using it.  Those masks do not let fine mist or small particles to go through.  These are called N95 masks.    

Hugging is another one of those human customs that should go away.  I won’t even discuss kissing.  Hugging and kissing ought to go the way of arranged marriages and should be relegated to the XO on the written word.

Good Luck!! Gus Iwasiuk XOXO

LIES, DAMNED LIES, AND STATISTICS

Mark Twain by A.F.Bradley ©       Benjamin Disraeli  Photos.com/Jupiterimages ©

“There are three kinds of lies: Lies, Damned Lies, and Statistics.” The phrase is often claimed to be one of Mark Twain’s quotes, who, in fact, attributed it to Benjamin Disraeli, who served Queen Victoria as Prime Minister of the United Kingdom.  This quote is not found anywhere in Disraeli’s writings, although he may have said those words. Regardless of who said it, the sentence argues that statistics are often the worst kind of misinformation because they have the authority of numbers; the sources are hard to pinpoint and dispute and therefore are believed.

I fell into this trap recently and exposed my ignorance by quoting the Coronavirus mortality statistics, as given in large part, by the Chinese government.  The clue to me should have been “Chinese government.” The number of deaths I saw in the news was 3,132 deaths of a total of 92,303 (the newest numbers 3,886 deaths and 111,650 total cases). Nevertheless, mortality rates remain close to 3.4%.  The number of people that died is probably accurate.  It is hard to fake death, and counting the dead is likely to be reasonably precise. If they don’t move, they are probably dead.  The denominator has grown to 111,650 people that have the disease and are almost certain to be undercounted.  Mild cases are frequently not diagnosed or reported.  A runny nose is a runny nose, not COVID 19, in most people’s judgement, but then again, it could be.  The denominator is likely a much larger number judging from statistical analysis of previous epidemics. This would significantly revise mortality downward.

That, however, is not the essential source of misleading information. To accurately estimate disease mortality, raw numbers give the wrong impression.  In the seasonal flu mortality, we see every year, and the numbers are more accurately reported remaining under 1% because:

  • We are in the USA
  • Our health reporting is mandated by governmental agencies (not necessarily a strong point)
  • We try to be scientifically as honest as we can with checks and balances that report dishonesty or ulterior motives for inflating or deflating numbers
  • The people in charge of reporting don’t have quite the hidden motives or pressures as an autocracy generates, who initially punished reporting physicians
  • Our system has multiple sources of input that act as an automatic control mechanism
  • Our math adds the mild cases and estimates of asymptomatic people to the calculations (although this has to be retrospective)

Almost all comorbidities affect mortality rates: heart disease, chronic lung disease, renal failure, liver failure, obesity, neurologic disease, diabetes, cancer, immune deficiency, pregnancy, age, etc.

Without knowing the demographics of the population under discussion, raw data mortality rates are almost meaningless.  In the 2017-2018 flu season, which was one of the most severe epidemics in the last decade, if you were a healthy person, not pregnant, under 65 years of age, your risk of death was under 1%, but if you had a heart problem and were over 65 your mortality was over 10%.

How can we interpolate all this to the Coronavirus?  The 3.4% mortality rate is a raw number for many (but not all affected people); the mild ones didn’t even get counted.  I hate to use the term “fake news” because of its political overtones, but I think it is justified here.  The news media has “hyped up” this issue with inflated numbers for reasons that are suspicious to me.  To sell more newspapers? To be ahead in reporting doom and gloom? (which seems to be a habit of the news media culture). Or is it to affect elections? To create panic? To develop financial uncertainty? To…?  A recently published editorial in the most prestigious medical journal in the world, The New England Journal of Medicine written by Anthony S. Fauci (the nation’s leading expert on infectious diseases), H. Clifford Lane, and Robert R. Redfield, https://www.nejm.org/doi/full/10.1056/NEJMe2002387 has stated, and I quote, “the case fatality rate (of Covid 19) may be considerably less than 1% (the bold letters are mine). This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%).”  So take everything with a grain of salt!

 

 

 

 

 

 

 

COVID 19

In 2017-2018 45,000,000 people had seasonal influenza in the US and 61,000 people died of it.

“Coronavirus,” the cause of COVID 19 (Corona Virus Disease 2019) at this point has infected 92,303 cases worldwide with 3,132 deaths, which is a 3.4 % risk of dying.  Taking all comers, healthy people have a 0.9% chance of dying, while people with heart disease have a 10.5% chance of dying. The virus has an affinity for lung tissue because the viral surface has little projections that fit precisely into mirror image receptacles on the lung cell surface. If it gets into the lungs, it takes over the lung cell’s DNA by inserting itself into our DNA and starts reproducing, as viruses lack the ability to reproduce without using cells of other organisms like us.  It’s all about reproduction! That process kills the lung cell, and we are left with fewer and fewer lung cells to exchange COfor O2.  When there are not enough lung cells to exchange the gases, we become hypoxic (not enough O2 for the brain) and we die.  97% of us can beat the virus by making antibodies, and we recover. Depending on what kind of other diseases we harbor anywhere from 3% to 10.5% of us can’t.  Coronavirus is more virulent than regular flu, but not as virulent as some.  There are plenty of other viruses that are worse.  Ebola, for example, kills 50% of its victims, and smallpox had a 20% mortality in unvaccinated individuals.  But the 1918 pandemic (Spanish flu)  killed 100,000,000 people, the worst pandemic in human history.

So far, COVID 19 has not been all that impressive in the US, 121 cases with 9 deaths.  Of course, that is not what could happen.  If we don’t take the correct infection control measures, we will be in a world of hurt, so to speak!  The steps that have been made so far exceed anything that has been done in the past. I believe that if we take the common-sense steps we are told to do, we will remain relatively safe. Ultimately a vaccine is the answer. 

We owe vaccination to Edward Jenner, a physician, who noticed that milkmaids who contracted a benign disease called cowpox from the infected udders of cows did not contract deadly smallpox. During Jenner’s time 1/5th of the English population secumbed to smallpox.  In 1796 Jenner took some of the pus from a milkmaid’s hand that had the cowpox variola and scratched the skin of his first patient, the son of his gardener, placing a small amount of the pus on it.  It produced a local infection but never spread to the whole person. It worked, and no one that underwent vaccination got smallpox.  Jenner is credited with saving more lives than any other human being in all of history. The Latin word for cow is vaca.  Hence he called his procedure vaccination. In the early 1970s smallpox vaccination was stopped, and by 1979 WHO (the World Health Organization) declared smallpox eradicated from the face of this earth. The virus is no longer present in our world except in one laboratory that keeps the culture under close guard primarily for the study of this once deadly killer that potentially could be weaponized. Anyone older than age 50 still bears the telltale scars of the vaccination that left two pockmarks, usually on the right upper arm.   Smallpox vaccination is the first vaccine and the only disease that has been eradicated.

Coronavirus, too, will take its place in the history books of vanquished viruses, and it will not be because of avoiding Corona Beer as 30% of the population has done.   Multiple laboratories around the world are furiously working on an effective vaccine.  Apparently, Israel is ahead of most, claiming a vaccine will be available in weeks to months. After that, we should be able to go back to our routine lives.