mistakes/missteps

Jun. 21, 2020

The use of 'face masks' to control or halt the spread of a virus has become a hot topic for debate in the past five months. Masks can indeed stop droplets and droplets are where the virus is most likely to be when someone infected coughs or sneezes, but out of curiosity, when is the last time someone purposefully got within 6 ft of someone else to cough or sneeze in that person's face as TV ads love to use as a demonstration? What seems to have been forgotten is that extensive randomized controlled trials (RCT) with meta-analysis of those studies have been done over many years. These studies have repeatedly shown that masks do not work to prevent respiratory influenza type illnesses transmitted by contact, droplets, and/or aerosol particles. The transmission path for a virus involves a particle less than 25 nanometers in size, too small a particle to be effectively filtered by a mask through which one can comfortably or effectively breath. Meanwhile the minimum infective dose (MID) for a virus is smaller than a single aerosol particle. For any of this to make sense, one needs to understand the size relationship of such tiny terms. 

    1 meter (about a yard ) = 1000 millimeters

    1 millimeter                 = 1000 micrometers

    1 micrometer (micron) = 1000 nanometers (nM)

an air molecule (oxygen, nitrogen, inert gases like argon ) = about 1 nM

a viral particle (Flu, Coronavirus) = 20-300 nM

bacteria ( staph., strep. etc )       =200-10,000 nM (.2-100 microns)

As a reference, if a one dollar bill was 1 nM, one could stretch them end to end 1/2 way to the moon ( about 200,000,000 meters) to equal about 10 meters. A Nanometer is VERY small.

If over-the-counter masks can filter out particles down to 100 microns 30% of the time, a quality surgical mask can filter down to 100 microns 95% of the time and an N95 mask can filter out 99% down to 300 microns (tighter mask needs bigger pores because of less bypass breathing), then one can hypothesize that some benefit exists to stop droplets and larger bacteria, but viruses? What happens when the filtration rate needed is measured in nanometers rather than micrometers (microns) ? If a single viral particle is 25 nM, (that's .025 microns) it would seem the single viral particles could certainly pass most barriers short of a full hazmat suit with rebreather. However, since the virus is usually (as far as we know) carried in a droplet, often one will see 1000-1,000,000 particles per droplet with the droplet large enough to be halted in most cases. what happens when the droplet evaporates? Can the viral particle then be shed elsewhere from the outside of the mask....or even from the inside if the wearer is a carrier ?  Do repeated coughs concentrate more virus within the mask and just how dangerous does that mask become and how easily is virus shed from insde and outside the mask ? Obviously there are a number of unanswered questions.

With this information, one can assume that masks can be helpful in filtering large particles including some bacteria and viruses that are carried by droplets. This might reduce but not likely prevent all viral particles in a given airspace from reaching a potential host to infect. The sheer numbers and particle size demonstrate that. If a given airspace contains billions of viral particles, many within millions of water droplets, yet only1-2 viral particles can transmit disease, the futility of mask wearing becomes more apparent. Age old physics and physiology tells us that particles will disperse evenly throughout a given space. When a virus is shed by a host, it's not a single viral particle, it's multiples of multiples. The MID (minimal infective dose) becomes the more important number. If it took a high number of viral particles to start the infection, then there would be some validity to mask usage. Unfortunately, the current Covid-19 virus of 2020  seems to have a low MID as a single particle can intiate a response....and there are 1000-1,000,000 particles in a droplet. In a 2009 study J.L.Jacobs reported in the American Journal of Infection Control that the wearing of masks by healthcare workers did not reduce flu symptoms among wearers, but those wearing the masks suffered significantly more headaches." This is another area needing more investigation. The important note in the study is that N95 mask wearers, above all others, should have shown a reduction as HCW (healthcare workers) should be more knowledgeable regarding proper use of any mask compared to the general public

What are the possible ill effects of wearing a mask? Some have suggested that decreased oxygen/carbon dioxide exchange could be a problem. We wore surgical masks in the operating room to prevent OUR germs form entering an open wound. Granted we were wearing surgical masks and ventilation along the sides was always an added adjunct, but if those masks had been N95s, one can only wonder if we might have experienced other side effects as referenced in the Jacobs study. The general public for the most part are not wearing N95 masks and most of those wearing masks do so improperly. A damp or wet mask can lead to the proliferation of bacteria deposited by the wearer. Although that person may be somewhat protected from their own natural oral microflora, new pathogens can be introduced by eating or drinking and if one were to rapidly replicate and be inhaled deep into the lung, a pneumonia could be the end result. The social aspect of mask wearing may be more of an issue with western cultures as facial recognition is important for social interaction. Humans are social animals and need the interaction from a psychological standpoint. Many feel the overall response to the covid virus is one of the things contributing to the social unrest and turmoil now being experienced in large urban populations locked down " for your safety". Masks also embolden people to act foolishly, recklessly, or even criminally. 

In conclusion, it's important to consider how future situations like a pandemic should be addressed. Responses should be regionalized with input form local doctors rather than nationalized by a government employed doctor using a large metroplex as the model. Living conditions and social interaction varies across this nation as it does across similar sized regions that make up entire countries in Europe. Further studies about the relationship of humidity and viral survival/transmission is needed as the viruses seem to do poorly in tropic environments while proliferating in drier places. Our air conditioned society with the attendant dehumidification may be contributing to the spread and one of the reasons people are better off outdoors than locked down in an apartment complex. UV light is beneficial as are vitamin supplements that boost the immune system or provide needed elements ( like B6, C, E and D3). Add to this the mineral supplement Zinc, and one has a very useful regimen that is readily available.  D.G. Rancourt from Ottawa University in Canada wrote " By making mask-wearing recommendations and policies for the general public, or by expressly condoning the practice, governments have both ignored the scientific evidence and done the opposite of following precautionary principle. In absence of knowledge, governments should not make policies that have a hypothetical potential to do harm. The government has an onus barrier before it instigates a broad social-engineering intervention, or allows corporations (or individuals) to exploit fear-based sentiments."

Personally, I feel a person should be free to decide for themselves whether or not they need to wear a mask unless they are actively showing symptoms, have been exposed in a closed room to a known carrier (of course they should be tested), frequently sneeze or have excess drainage due to allergies or even if they are simply angry by nature and shout a lot. People should be free and encouraged to pursue outdoor activities, especially younger, healthy individuals as the greatest future concern in the absence of a vaccine, will be lack of herd immunity among working class individuals. Freedom of choice to decide whether to use "outside the box" treatments including the use of the chloroquines as recommended by CDC and NIH in a 2005 paper regarding corona viruses, nebulized steroids, macrolide or tetracycline antibiotics,  plasma infusion and even stem cells and anti-parasitic drugs like Ivermectin. All of these agents have shown effectiveness against viruses with studies supporting their use singly or in combination.  Local doctors familiar with their patient population, living conditions, overall health and specifically their needs should be allowed to practice the art of medicine. We have inadvertly set the stage for a logistical nightmare of administering 1/4 BILLION vaccinations, as well as trying to find a way to package and deliver the vaccines in short order.  Are we sacrificing our freedoms including freedom of choice for the false sense of security of a mask mandate, business closures and social lockdowns ?

Studies: 

            Cowling, B. (2010) "Facemasks to prevent transmission of influenza virus, a systematic                                           review". Epidemiology and Infection

             bin-Reza (2012) " Use of masks to prevent transmission of influenza, a systematic                                                review of scientific evidence" ...review of 17 eligible studies

             Smith, J.D. (2016) "effectiveness of N95 vs. Surgical Masks"

             Offendda, V. (2017) Clinical infectious Diseases

             Randonovich, L.V. (2019) Journal of the American Medical Assoc.

***To date, no study exists that shows a benefit of a broad policy to wear masks in public. Time will tell what approach is correct. So far, leading health experts have been using the wrong approach using misleading computer models as their guide.

                                                                           

 

 

 

 

Apr. 9, 2020

The 21st century has introduced numerous changes to the world including many social and technological advances. It has increased overall awareness of complex topics, however, it has also contributed to an adversarial relationship in many of the arenas of daily life. The latest controversy concerns the proper management of the current pandemic brought on by a virus. At its onset, this particular virus was not even labeled 'a pandemic' by most experts and leaders of healthcare around the globe. Misleading and even false information was disseminated rapidly by social media and main stream media thanks to the world wide web. A very few individuals were able to guide opinions and even direct policy while other knowledgeable healthcare providers had little oportunity to provide input into decisions or even make suggestions that could improve the situation. Speak too soon or 'think outside the box' and often one would be subjected to widespread criticism or labeled a 'charlatan' who did not think of individual well-being. Social media could then amplify that with the end result being that many would not even speak up.

   In order to consider options to manage an epidemic, basic knowledge of the human immune system is necessary. Our immune system has multiple components and is first called into action at birth with what is referred to as our innate immune system, of which antibodies are generally non-specific to an invading antigen. The antigen, which stimulates an antibody response, can be any foreign matter (usually a protein ) from a bacteria laden splinter to a virus. Cell mediated or T-cell activity starts by age 2 with the thymus gland maturing lymphocytes to react on behalf of the human body. This system is at its height between age 2 and 45.  Adaptive or acquired immunity is provided as we grow older to provide more protection form invading organisms. This antibody (immunoglobulin or the 5 IG's ) production continues throughout life, although it slows as humans age. This incorporation of antibodies is referenced as the humoral response. Without going into greater detail, suffice it to say that other components of the immune response  involve not only B-cells and antibodies, but the cell mediated (immendiate) response with T-cells (killer T's). These are the two main factors involved in recognizing and destroying invadng viruses, bacteria and even developing cancer cells. Why are the most varieties of induced cancers seen in older individuals ? Partly because the immune system grows weaker as we grow older. The same rule holds true for why older individuals are more susceptible to any invading organism including bacteria (pneumonia) and viruses (like Covid-19) while younger people with rapidly developing or robust immune systems are more able to successfully defeat a virus quickly and often without outward symptoms.

   How could the current pandemic have been treated differently and what should be considered going forward ? Obviously, the misinformation about the initial outbreak, the vectors, the risks, and treatment options all could have been more timely as well as receiving better peer review if the proper data was supplied.  Social media clouded all of that along with the media's desire for 'breaking news'.  Knowing that acquired immunity developes in only two ways, healthcare managers are faced with the choice of a population attaining immunity by exposure or by vaccine or innoculation. The latter happens only after many months (years ) of research and trials to evaluate efficacy as well as safety. Community acquired immunity involves the risk of exposure, but exactly who is at risk ? Knowing that younger, healthy individuals are at the peak of antibody production and often are exposed to antigens (viruses and others) on a daily basis with mild reactions that are often little more than "I dont feel just right today" should have been part of the equation in formulating a response.  In fact, this is exactly the template being followed by the novel Coronavirus-19, even though it is being touted as three times more contagious and therefore more dangerous.  Contrary to the reaction seen in the younger and healthier population, the over 55 group and those with compromised medical histories are at much greater risk.  As we mentioned previously, the immune system is not as strong as we age. Who are the medically compromised ? Common sense will reveal that many older individuals also take a variety of medicines for everything from hypertension to cancer therapy.  Also in this group should be anyone with a history of smoking or vaping since it is well documented that these habits compromise lung function and this particular virus is very lung specific in most of its action.  Diabetes, GI problems and perhaps even chronic fatigue syndrome and fibromyalgia should also be considered as 'medically compromising' along with being considerably overweight or malnourished. Multi-generational families (as often seen in Asian and many european countries) should also be considered 'at risk'.  We now have two groups, one where subclinical or a predictable, benign course is 98% likely to occur, and one group with a potential of greater than 10% mortality as a result of comorbidity involving other disease processes or an overzealous inflammatory reaction or cytokine/bradykinin storm .  As late as the 1960's, local public health officials would go door to door, tagging a house under "quarantine" for other viruses like measels, yet the entire economy and social interaction for others was not curtailed.

  Another important aspect that is seldom discussed is the actual social interaction of various cultures. In the United States, individuals prefer to live separately from others, with most of rural Americans already separated from neighbors. Even in apartment building and condominiums, separate entrances are common allowing for separation. Only in the most urban areas do we see high rise, single entrance living spaces and even then, many are occupied singlely or as a couple. Contrast that with an Italy or Japan where three or four generations share the same house and often eat finger foods during meals.  Kissing each cheek and hugging have been standard greetings in other cultures for centuries. The latter social stucture lends itself to a higher per capita death rate which is exactly what has happened with the current situation. Common sense dictates that the older (over 55) or compromised population should be separated from the younger, healthier population, just from a survival standpoint.

   There remains the much larger question, however, of how to provide immunity to the majority of a population. In the distant past, it has been by exposure since vaccines were not available until the first attempt from scraping a cow-pox sore and innoculating a patient with the material. Washington did this to his troops at Valley Forge to prevent the spread of smallpox. Vaccines quickly became the answer for many communicable viral diseases, but not without the risk of the occassional violent anaphylactic response and death. Of interest is that the risk of death from a vaccine is purported to be less than 1/2 of 1%. At present, the current pandemic is producing a death rate much less than 1/2 of 1% of total population. If we were to develop a vaccine and adminster it to protect the population of the United States not previuosly exposed to the Covid-19 virus, it will require at least 1/4 BILLION doses to be given. Of that, we can expect a death rate of up to a million people, but they could be young and/or old, not just primarily old or infirmed. Mother nature has a way of saying, 'pay me now, or pay me later'.

    The question remains on how we should move forward. Do we wait for (and hope for) the development of a successful vaccine, knowing the potential risks of widespread use as well as the logistics and costs of adminstering millions of doses ? Or do we consider loosening the reins on the young, healthy population, allowing them to return to work while continuing to minmize exposure with proper hygiene and distancing practices within reason. The older and/or compromised groups (remember, many are in both groups) could remain in a form of isolation, mainly for their own good, if they so choose. Consider too that a large number of these individuals are already retired and not in the work force. Like was done during the gasoline crisis of the 70's (unfortuantely, too few recall that ) , alternating when one could get fuel could be applied by alternating hours (or days) for shopping, dining and other activities like attending a church or social gathering.  The end result would be a much higher percentage of the population developing acquired immunity thus fewer needing a vaccine in the future, while protecting the most vunerable. Hospitals would NOT be overwhelmed by subclinical cases of what would be no more than a minor flu among the young and healthy. Wards in the hospitals (like the TB wards of old) could be developed for any needing isolation or advanced care. We should also continue to study off label use of drugs that have been used succesfully in the past for similar widespread infective problems and realize that many countries have huge clinical experiences with these drugs (like hydroxychloroquine) and their expertise should be valued and welcomed. This would allow the economy to reopen without so many of the constraints now being used and even stricter lockdowns being discussed. When regular flu season does arrive in the fall of 2020, if we are not prepared with proper plans for long range management including early outpatient treatment protocols, there will be a sharp rise in positive testing with new, stricter mandates ordered by the government and our new policy maker, social media !