Coronavirus Update 20200730

It has been almost 3 months since our last update, but that is OK because things tend to move slowly where this disease is concerned. We are far from beating it, and there is a lot we don’t know, but at least a few things are coming into focus now, so it is a good time for another update. And it is worth noting that I am in the United States (South-eastern Michigan), so much of what I am seeing is specific to that country, but the medical work is broader.

There are three broad categories to deal with in this update: 1) Prevention; 2) Treatment; and 3) Immunization. So I will take them in that order, since they are in the order in which they can be used to help us. And I will add some resources at the end if you want to stay up-to-date on reliable information

Prevention

This is not rocket science. From the CDC site we get these common-sense recommendations:

Wash your hands often

  • Avoid touching your face, and most importantly, your eyes.
  • Avoid close contact, minimum 6 feet both indoors and outdoors.
  • Cover your mouth and nose with a cloth face cover when around others.
  • Cover coughs and sneezes. I hope everyone does this anyway. When I worked at a hospital we were told to sneeze into your elbow if you had on a long-sleeved shirt or jacket, since germs would not last long on the fabric.
  • Clean and disinfect. Soap is the best way to kill the virus, so washing for a 20 seconds with soap should do the trick.
  • Monitor Your Health Daily. And if you get any of the symptoms, quarantine yourself.

Now, none of these are radical, but it is just common sense that the best way to avoid problems is to not get sick in the first place. Unfortunately in the United States this has become extremely polarized, and people are expressing their political sentiments by refusing to wear masks and downplaying the dangers even as the deaths in the U.S. cross the 150,000 mark. But even if other people are stupid, you don’t have to be.

This is a serious illness. We know it attacks not just the respiratory system, but other organs, including the heart. In a study recently reported in JAMA Cardiology (JAMA is the Journal of the American Medical Association, and is highly prestigious), a cohort study examined 100 adults who had “recovered” from Covid-19 and matched them with another similar group that never got the disease, and performed MRI scans of the heart. In the “recovered” group they found 78 patients showed structural changes to their hearts, 76 had evidence of a biomarker signaling cardiac injury typically found after a heart attack, and 60 had signs of inflammation.

In addition, we know the virus causes clotting problems, increasing the risk of stroke. So if you think you’ll just get it and then get over it, you are being seriously stupid.

Testing

A key measure for prevention is testing, and the good news is that inexpensive quick saliva tests are being developed. But testing only helps if the results are acted on. The idea is that when you find someone who tests positive, you quarantine them, and then go through their list of contacts to do further testing, then quarantine any of those contacts that test positive, trace their contacts, and so on. This does work, and it is how the similar virus, SARS, was defeated. (Remember SARS?) SARS only killed 774 people worldwide solely because testing, tracing, and quarantining was effectively used worldwide. There is reason to doubt this would work well in the U.S. though since this has been so highly politicized and polarized, with some people refusing the simple act of wearing a mask. In addition, the U.S. is again running short of testing supplies, causing delays of anywhere from days to weeks in getting results back. That defeats the whole purpose of testing and tracing. This what yo get when you have no leadership.

Treatment

Since even vaccines are not 100% preventive, and we won’t have one until winter at best, the ability to treat the disease is very important. There are some hopeful signs here. But again, politicized stupidity is an obstacle in the U.S. with some politicians touting hydroxychloroquine as a cure, which it is not. Even the Trump-appointed FDA commissioner, Scott Gottlieb, has said this is one myth that needs to be put to death: “We can definitively say hydroxychloroquine doesn’t work”.

We do have some treatments that can help in some situations, but none of them are game changers. Remdesivir is an anti-viral that appears to reduce recovery time in some patients, and there is some preliminary evidence it may reduce the death rate. Dexamethasone was found in one study (by the NHS in England) to reduce the death rate in people who were on ventilators, i.e., the most severely ill patients. LAM-002A (apilimod) is another drug that has shown promise.

A multi-institutional study published in Nature (PDF), which screened more than 13,000 existing drugs against two strains of the live SARS-CoV-2 virus, found LAM-002A to be the most effective in combatting the virus, including in lung cells infected with the virus. 

https://news.yale.edu/2020/07/27/yale-lead-trial-potential-covid-19-treatment

The three drugs mentioned are all existing drugs that have already demonstrated safety, so all they need to do is demonstrate efficacy to be approved, and that can happen relatively quickly, which is why drug developers are screening all the existing drugs to find ones which work against Covid-19.

Cellular nanosponges are an interesting approach from scientists at the University of San Diego that essentially lock up the receptor molecules on the surface of the virus so that it cannot infect the cells and replicate. This has promise, but it is also very preliminary at this point, and as a new therapeutic would require all of the safety testing in addition to the efficacy testing.

Finally, we do know that blood plasma from recovered patients contains antibodies that can protect new patients, but at this point there is not a lot to go around. So this may help a few of the most seriously ill people, but is not likely to be a general therapeutic.

Immunization

The good news is that many different organizations are working on this, and we are even seeing some optimistic reports that we could have one approved by winter. The danger is that this pace of development means skimping on the testing, and if bad side effects occur that did not come out in testing, it could add to our terrible problem with people not getting vaccinated. If you never heard of Thalidomide, it was a drug marketed to, among others, pregnant women, and it turned out to cause birth defects in children. That largely missed the U.S. because the FDA Inspector involved, Frances Kelsey, refused to approve the drug because she had concerns about incomplete data and inadequate testing. This was a key moment in the culture of testing in our FDA, because she was correct to be concerned. Dangerous drugs can do more harm than good, and testing them is the only way to be certain, and that takes time.

And the vaccine may not be entirely painless. The whole idea of a vaccine is trigger a response in your body, and that response can involve things like headache, muscle soreness, and inflammation. Achieving the needed degree of vaccination for herd immunity is going to be a challenge:

“But in late May, 27 percent of Americans told an ABC News–Washington Post poll that they would either “probably not” or “definitely not” take a coronavirus vaccine if one became available. And that survey made no mention of potential side effects, let alone ones as significant as fever. Given the prevalence of both tinfoil-hat libertarianism and healing-crystal-necklace New Age-ism in the United States, it was always going to be a challenge to get enough Americans to take a vaccine to achieve herd immunity. Reports of a vaccine getting people sick (however mildly) would surely magnify that challenge.”

https://nymag.com/intelligencer/2020/07/heres-the-latest-good-and-bad-news-about-covid-19.html

Resources

If you want to keep up with the news on Coronavirus, here are some resources you might find helpful. These are not intended to be where your Doctor would be getting information, they are aimed at an intelligent lay audience, which I will assume is the audience I might have here.

  • CDC – This government site is the best place to get scientific evidence.
  • Curiosity Stream – This is a streaming channel devoted to documentaries and they have some useful ones on coronavirus.
  • Nature PodcastNature is the premier science journal and their weekly podcast contains a section called Coronapod which is devoted to current news on the coronavirus. It is worth mentioning that many of the reporters on this podcast have PhDs.
  • Healthcare Triage – This video podcast is hosted by Dr. Aaron Carroll. Dr. Carroll is a professor at the Indiana University School of Medicine. At Indiana University, he is also the Vice Chair for Health Policy and Outcomes Research and the Director of the Center for Health Policy and Professionalism Research. Healthcare Triage is a very useful series because he not only bases everything he says on research, he also discusses how strong the results are in terms of the hierarchy of study designs we discussed previously.
  • SciShow – This YouTube channel presents a variety of shows on different topics, but one of the topics covered regularly is Covid-19. While the on screen presenters are not scientists, the scripts are generally written by scientists, and are fact-checked. They are careful to give the date of recording at the beginning of each Covid-19 episode since things change so fast. Here is a playlist of their Covid-19 episodes
  • Science News – This is an excellent publication that comes out bi-weekly, and most of the authors of the articles are PhDs in the fields they cover.
  • Intelligencer Good and Bad News about Covid-19. This is a monthly series of articles that are very useful. Here is the July article.
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