COVID update March 2021

COVID has spread worldwide and is the largest public health crisis of the century.  There are more than 100 million cases and more than 2.5 million deaths.  This occurred in spite of modern medicine.  However, much has been learned.  We now have vaccines, have treatments, and more advances are coming. 

COVID is a disease where most people are asymptomatic or have a mild "like a cold" illness. You can spread the virus before you feel sick.  You can't tell from how you feel if you have COVID, are feeling your allergies or something else.  Uncommonly, some people become critically ill and die.  Overall, less than 1% of people with COVID become severely sick.  Many mild or asymptomatic people are never tested.  Being older, more obese, diabetic - especially if poorly controlled, or otherwise sick are risks for more sevre infection.  Major immune suppression - for example, organ transplant patients,  cancer patients or needing treatment with 20mg /day or more of prednisone or other strong immune suppressant drugs (like for organ transplant or chemo) also is a higher risk for COVID.  Luckily, these problems are present only for a small part of the population.  

COVID does not spread evenly.  Some people are more infectious than others.  People with COVID who are more obese and have poorly controlled diabetes are likely more infectious to the people around them.  There are also rare people with defects in there immune system with interferons.  Interferons are signalling proteins that affect the immune response to viruses.  It is likely that some of the "super spreaders" were people with this type of defect.  This is not something that can be regularly clinically tested - this is research level testing.

Comparing responses around the world shows what works to control the pread of the virus.  Mask use and social distancing, with extensive testing, contact tracing and quarentine provide good protection against viral spread.  There has been a massive shift to remote work and school which has allowed some economic recovery while limiting the spread of the virus.

The basic health of any individual is the major determinant of the risk for severe COVID.  This means that it is now even more important to eat in a healthy way, exercise moderately and protect your sleep.  Eliminate sugar and starch to reduce obesity and control diabetes.  Start regular stretching and begin gentle exercise.  I will write another update about how to change your habits to build better health soon.

Being treated for high blood pressure does not worsen your risk for COVID.  High blood pressure is a risk mostly when untreated or not controlled.  Even ACE inhibitor medications do not affect COVD risk as was initially feared.  Neither do pain medications like NSAIDS.  Proton pump inhibitors (PPIs) for acid reflux may increase your COVID risk.

People can take steps beyond masks, distance and handwashing to protect themselves.  Regular household cleaners like bleach will kill the virus.  Handwashing removes the virus.  Mouthwash that is dis-infective can likely reduce the chance of infection if you may have been exposed.  Swabbing the inside of the nose with iodien disinfectant can reduce infection.  Taking vitamin C, zinc, and vitamin D may be helpful.

There has been massive research into COVID.  Many existing medications have been checked to see if they will help fight the virus.  Plaquenl and others have turned out NOT to be effective treatments.  Plaquenil does help some people but not enough to be approved as a COVID treatment.  There are some medications that have evidence that they DO help. Other medications are under investigation now.  

Medications that have proven to be helpful include the manufactured antibody treatments that reduce the risk of severe illness for high-risk patients.  These include bamlanivimab and casiriivimab/indevimab.  These are given as a one time IV infusion.  These antibodies were carefully selected to be VERY effective.  They also prevent transmission of the virus.  Convalescent plasma is a collection of plasma with antibodies from people who have recovered from COVID.   These antibodies vary in strength and type.  This plasma has NOT proven to be a reliable treatment but does help some people.  

Most proven treatments for COVID are for severe illness - patients in the hospital.  Many of the treatments have mixed results- some trials showing good effect and some showing no help.  This is likely because of the differences in patients and situations.  For example, how old, obese or otherwise sick the patients are and how long it takes to get care and treatment will affect how well any treatment works.  Remdesivir helps.  It is a series of IV infusions.  Dexamathasone reduces death (mortality) by 30%! Baricitinib reduces need for ICU and mortality.  In patients on ventilators, Actemra can help.  Anti-coagulation can improved ventilation and prevent blood clots.  

Treatments under investigation with promising early data include:  Colchicine to reduce inflammation in mild to moderate COVID.  The anti-depressant fluvoxamine seems to reduce COVID viral loads and protect against severe disease.  This may also be true for some other SSRIs like prozac - fluoxetine.  The drug interferon, used to boost the immune response against the virus may be helpful.  

Vaccines are now available.  The US has 3 approved vaccines.  The Pfizer and Moderna vaccines are MRNA vaccines that need 2 shots for full protection.  They are very effective and generally safe but have a risk of allergic reaction to people with severe allergies -severe enough to have needed an Epi pen.  The Johnson Johnson vaccine only requires one shot and may not be as risky for people with severe allergies.  

The supply of vaccine is growing but there are literally billions of people who need vaccination.  Production is increasing every month but it will take time - likley much of 2021 to get general protection.  To have herd immunity (general protection) about 75-80% of the population needs to be immune - either from recent (3 months) infection or vaccination.  How long the vaccines will last is unclear.  So far the vaccines seem to be effective against virus variants.   Richer countries with more pharmaceutical and vaccine industry capactity will get more vaccine sooner that the rest of the world.  

Vaccines were not studied in pregnant or immune suppressed people.  There is no PROOF but we believe the vaccines will work.  This is also the situation with children.  The risk of the vaccine needs to be balanced against the risk of the infection for each person.  A healthy child is very low risk for COVID.  There is not enough vaccine available yet to immunize every person. Waiting to vaccinate healthy children is both reasonable and necessary at this time. A pregnant woman who is obese and diabetic has a higher risk of severe COVID disease.  The vaccine is UNPROVEN to be safe and effective but MOST LIKELY is both.  She and her doctor have to decide what to do.  

Immune suppressive medications are only used for dangerous conditions.  This makes it risky to reduce their use.  The increased risk of infection (not just from COVID) has to be estiamated against the risk of the immune condition.  Severe auto-immune disease like Rheumatoid Arthritis or Systemic Lupus can cripple or kill someone if not controlled.  In this situation, taking the UNPROVEN but LIKLEY EFFECTIVE vaccine is a smart choice.  

People on high doses of prednisone may not get full protection from a vaccine.  They will LIKELY get some protection and some protection is better than none.  People on prednisone (or other immune suppressing medicaitons) are at more risk of infection.  Mostly, the lower risk option is to get the vaccine.  

I am Dr Thomas Hoffmann.  Please work to protect yourself and your contacts, friends and family.  Wear a good mask - N95 is best, medical is better, at least multi-layer!.  minimze contact and social distance.  Get vaccinated when it your turn by health and job risk.  Get tested.  Get treatment.  This pandemic is the health crisis of the century.  I believe 2021 will be the year that the world gains control of the pandemic.  

Author
Thomas Hoffmann, MD

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I am Dr. Thomas Hoffmann.  I'm a Rheumatologist who treats auto-immune diseases like lupus or RA where the body's immune system overreacts and attacks joints or organs in the body.

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