Apr. 9, 2020

CV-19 media experts or practical experts

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 !