COVID thoughts 29 March


Hi, I’m Dr. Thomas Hoffmann. I am a Rheumatologist and prior Special Forces medic. Here are my thoughts on COVID and interpreting the conflicting opinions in the media. As a Rheumatologist, I regularly provide care for people with immune problems. As a prior Special Forces soldier, I have learned to operate in confusing and dangerous situations.

First, some basics: COVID is a RNA coronavirus that is very contagious. When people are infected, most show symptoms in 2-5 days but to prevent transmission we are using a two week quarantine period for possible exposure. Many people have minimal or no symptoms when infected. Many people have a mild cough, diarrhea, or congestion but these symptoms also frequently come from a regular cold or allergies. Severe COVID comes with a fever, cough, and half of people have diarrhea. Some people get a viral pneumonia and some of these people get severely sick, need a ventilator, and die. More people who are old, have diabetes or hypertension, smoke or have immune problems get severely sick and die but anyone can have bad disease. So far, it seems like people who have recovered do not get sick again but we don’t know if their immunity will last. When people have COVID, they have virus in their mucous, secretions and stool.

The world is scrambling to adapt and respond to COVID. Regular procedures for medical care and research are being quickly adjusted to allow more effective response to the pandemic. Different countries have used different strategies or had different resources to respond. These differences help us learn what works and what does not. However, all of the information is early and, by normal medical standards, incomplete.

One of the differences between countries has been how quickly and easily testing is available. Some countries, like Korea and Germany have been able to do more testing sooner. This has helped those places control and reduce the “crisis” period of the pandemic. In those places, the number of people who have mild disease is higher, and the death rate is lower. The numbers from these countries is a better estimate because these are the only places that have been able to test widely. Their numbers are that only 3-4 people out of 1000 die.

In China, where COVID started, it took 4-6 months to get through the initial “crisis” period. By crisis, I mean the time where the regular medical system was being overwhelmed, and extra people died because they did not have access to the treatment (especially ICU care and ventilators) that might save them. ICU care requires many specially trained nurses and doctors and requires extreme amounts of money and resources.

There are three main factors for a population being able to reduce the “crisis” period. These are the presence of immune people in the population, quarantine, and treatment. One factor is the amount of the population that has been exposed and become immune (at least for now) to COVID. The other factor is the “social distancing” or quarantine measures used. As background, for a population to have “herd immunity” – where enough people are immune to prevent rapid spread of the disease – most (i.e. 80-95%) of the population need immunity. The quarantine factors – how much regular interaction and business is reduced, how well do people maintain social distance, what sort of protection measures are used help but the effect is hard to measure. Treatment- how people get tested and treated when required also affects the crisis period.

At this time, the only people in the population immune to COVID are survivors of infection. Vaccines are in development but are expected to take 12-18 months for availability. One of the treatments under evaluation is convalescent serum – using the blood plasma/serum from patients who have recovered from COVID to treat new patients. This is similar to a blood transfusion.

The quarantine factors are one of the differences between countries. Some countries, like China and Italy have strictly enforced quarantine with the police. Korea and Singapore have populations where more people where masks when concerned about infection. Korea and Germany have had more testing available. Korea used cell phone location data to track sick people, which is very effective but illegal for privacy reasons in other countries.

There is also confusion about protective equipment and how well it works. To prevent virus from being transmitted, full protective suits and N95 masks or full respirators are required. However, most transmission is from droplets (a cough or sneeze droplet with virus in it) or from touch and then face contact.

Shortages of protective equipment are one of the limiting factors that facilitate the spread of COVID. Dr. Atul Gawande, the famous surgeon and author, spoke to senior health officials in Korea and Singapore, where the quarantine measures have worked well. The used 2 levels of protection. When dealing with “lower” risk events like seeing patients with low risk of infection they used only mask and gloves. This protects against droplets, not virus. “higher” risk events are “aerosol generating” – actions that produce finely vaporized virus – this includes intubation, mechanical ventilation and CPR. These procedures require full protective gear including N95 masks or respirators.

The world is scrambling to make and produce more protective gear, testing supplies and medicine. Using the above two level approach to use of protective gear will provide better protection for more health care providers for now. Hoarding and using more protection than required is contributing to shortages of critical protective gear now.

Regular handwashing with soap and water for 20 seconds will kill and remove virus. Regular disinfectants like bleach or alcohol based hand sanitize also work. Here is my approach to protecting myself and my family: Reduce exposure, reduce risk of bringing virus into the home, protect our general health and immune function, and be prepared to seek testing and treatment if needed. I will go through each of these issues.

Wash your hands a lot! Especially if you have been around other people. The real risk for all of us is being near people who are infected but don’t know it – they don’t feel sick yet and are not coughing or having fevers so they don’t look sick to you.   Maintain your social distance and reduce “close contact” with people. This does not mean complete isolation. 6 feet apart is good protection. 6 feet apart outside is better than 6 feet indoors. When you touch thing that are handled by other people, especially money, wash your hands! These thing all reduce your exposure to virus. Consider wearing a mask if the virus is active in your area. To reduce the demand for regular medical masks, you can use a bandana or scarf. Washing clothes or scarves should disinfect them but this is unproven. Definitely wear a mask if you have a cough, fever or concern that you are getting sick.

To reduce bringing virus into your home, do extra handwashing before you leave to come home and consider using a disinfectant cleaner in your vehicle – clean all the parts your touch regularly – steering wheel, controls, shift lever, door handle, etc. This gives you a second chance to remove virus from outside and prevent it from coming into your home. This is also a good time to wipe down your phone! If you are concerned about virus exposure – you have a mild sore throat or nasal congestion but are not “bad sick”, you can gargle with a disinfectant mouthwash, like Listerine. If you want to disinfect your sinuses, you can try the nasal rinse NeilMed – this will wash out congestion, but is not an active disinfectant – it may prevent later infection by clearing out mucous, etc. that can make it easier to catch something.

Inside your home, it is also sensible to do mild disinfection as a preventive measure. The key areas are the kitchen, dining room and bathrooms as most contact transmission of illness occurs with spread from toileting and eating. While your home is still “low risk”, meaning there is no one infected (either known or suspected), a daily swipe don with bleach or a regular household disinfectant cleaner – the food prep and eating surfaces, sinks and toilets is all that is required. This is basic Army field sanitation and is part of how the Army reduces infection while troops are living in unclean areas with lots of disease. IF you have a sick person in your home, it is “high risk” and active disinfection needs to separate areas of the home with the sick person from the rest of the home.

The basics of protecting your immune function is to maintain basic health – Think of this as trying to do all the “basic health” things regularly. Eat healthy: that is lots of vegetables, minimal junk. Protect your sleep, using OTC supplements or medicine if needed. Work to maintain your mental calm and relaxation – this really does protect immune function. Use whatever technique works for you – meditate, pray, ride your motorcycle. Do mild to moderate exercise – do not just sit on the couch – go for walks in your neighborhood, check on and converse with the neighbors but don’t get close enough for long enough. If you are in good shape, go for run but no one should exhaust themselves. Stay apart if you are going to talk for minutes or longer, but don’t worry about a few seconds near someone who is not coughing. In the Singapore experience, they used 15 minutes in close conversation as the definition of “close contact” or high risk. To boost the immune system, you can add supplements but these are not as powerful as the basic health issues above. If you wish, try extra vitamin C 1 gram, and you may take this 2-3 times/day. Daily zinc can help the body protect against other viruses – it is probably already in your multi-vitamin. Quercetin has claims but less evidence, but is safe to take if you wish. It’s also in apples, so you can just eat an apple a day!

When to seek testing or treatment is tricky – as mentioned earlier, allergies or a regular cold can give you the same symptoms as mild COVID. At this time, we CANNOT test all of these people. So, if you feel like you have a virus with a mild sore throat, stomach upset or a bit of a cough, STAY HOME and wait. If you get fevers, and your cough continues and you have trouble breathing, you need to go and get checked. Expect long delays and a very different process from a normal doctor visit. You may have to wait in your car, get checked in a tent, or be told to come back if you get worse. All of these reduce the transmission of virus to other people. Severely sick people with COVID cannot have visitors to prevent transmission.

As the world has struggled to adapt, we are making progress. There are now reliable tests available and they are getting easier to get and faster to report every week. There are now treatments that are being used and tested. All of the possible treatments are unproven and we are adjusting rules and standards of use to allow more use earlier. This is all part of reducing the “crisis” period.

Some of the more interesting treatments include: Remdesivir – an antiviral developed for Ebola – is under trial for hospitalized patients. It is an IV drug that is only available in the hospitals.   It is only available through trials or “compassionate use” procedures so most doctors cannot get it. Chloroquine or Hydroxychloroquine with Azithromycin. These are general prescription meds that are more available and are under trial for treatment and prevention OF COVID. There is test tube and early reports of these drugs reducing illness and decreasing how long hospitalized patients with COVID continue to produce virus. There are already supply shortages of these drugs. Lopinavir/ritonavir is a HIV treatment drug combination. It did not help in a small trial of critically ILL COVID patients but may help in less severe patients. Tocilizumab and Sarilumab are IL6 inhibitors – these drugs block IL6, an immune signaling molecule involved in inflammation. They have NO antiviral activity. In severely sick COVID patients the damage comes from both the inflammation (the body’s response) and the infection. They are under trials for severely ill COVID patients. Convalescent plasma treatments are also under trials in hospitalized and critically ill patients. This requires blood transfusion and handling protocols so is only available in hospitals.

In China, where COVID first became a large scale problem, the “crisis” phase appears to have subsided. It is encouraging that they have been able to close extra hospitals and are no longer short of ventilators. However, this took 4 months and does not mean that things couldn’t get worse again. As we make educated guesses about our COVID response and planning we should expect that it will take months, not weeks to get over our “crisis” period. We are not restricting people as much as China. Hopefully, our treatments and social distancing will buy us time. Our system is adapting and changing rapidly – there are reports of disinfecting N95 masks using hydrogen peroxide vapor – an established disinfection procedure available in many hospitals.

In conclusion, COVID is the worst health pandemic since the 1918 Spanish flu that killed millions. We are adapting but this is a true crisis. However, in spite of more rapid spread due to extensive modern travel, the world is adapting fast enough that we expect deaths in the 10,000 to 100,000 range, not the 20 million who died in 1918. For a sense of scale, the US has 90, 000 deaths from regular flu and pneumonia each year. This will damage, but not destroy our economy. Our government is working to reduce the deaths and manage this crisis. Be safe and smart, use your common sense and the best information to protect you, your family and your community.

Thomas Hoffmann, MD

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