Thursday, April 23, 2020

Coronavirus: mortality rates, questionable data, treatment. Part 3

Mortality rates and spread

We have had 5 weeks of quarantine.  I earlier pointed out that there is an average 4 week lag between exposure to SARS-CoV-2 and death (or recovery) for those with a significant Covid-19 illness.  So, if the quarantine was going to work as planned, we should now be able to see whether the number of cases and deaths have dropped significantly as a result.  Have they?

Let's look at some (mostly) official figures. For the US, daily mortality rose to about a peak of 2,000 per day on April 6.  Since then, mortality has held steady.  While it stopped rising, it has not fallen.  Based on mortality alone, the number of people to whom each infected person passes the infection, has dropped considerably (from estimates that varied between 2.3 and 5.7).  It may even be as low as 1.  But that is still not good enough to allow normal life to restart.  To get back to normal, we need new infections to get down enough so that we have the resources to do case finding and tracking for every single one.

Grossly, looking at total deaths divided by total diagnosed infections, US mortality is 6%.  The same rough calculation yields mortality in France of 14%, in Italy 13%, in Spain 10% , in Germany 4%, in Sweden 12%. 

There were over 32,000 new infections in the US diagnosed in the past 24 hours, the highest number yet.  While expanded testing accounts for some of the rise, we are nowhere near putting a lid on covid's spread.


NY state was hit hardest, so let's focus there. NY has had a total of 15,740 deaths. The number of people currently hospitalized is 15,021, down from a peak over 18,000, of whom 5,016 are in ICUs.  Recorded deaths have dropped from about 800 to about 500 per day in NY.  

But there are questions about the numbers.  CDC has instructed doctors who complete death certificates to stop using Covid-19 as the immediate cause of death, and to instead list it as the underlying cause of death.  According to Bob Hennelly at Salon,

...on April 15 New Jersey's Office of Vital Statistics and Registry, in accordance with the CDC's National Vital Statistics System, had ordered that deaths of confirmed or suspected COVID-19 patients should no longer be reported with that disease as the immediate cause of death... "Last week, because of changes on the national level, the primary cause of death can no longer be COVID-19. It can be a secondary cause or a consequence of the primary cause of death. But the primary cause of death must be something other than the virus itself."

Furthermore, Hennelly noted in an article written 2 weeks earlier, that NYC's Emergency Medical Services were being called for up to ten times more cardiac arrests per shift than in the same period a year ago.  These were likely not being counted as Covid deaths. His reporting suggested these deaths were disproportionately occurring in racial and ethnic minorities.

Gov. Cuomo reported a preliminary study of 3,000 New Yorkers, of whom 13.9% had antibodies to coronavirus.  But NY is the hardest-hit state, and even if this accurately extrapolates to NY's population of 19.4 million, that still leaves 86% of New Yorkers without antibodies and presumably vulnerable.

Vo, Italy 

preprint study from a small town in northern Italy was just released. In February, over 70% of its eligible population, over 2,000 people, received nasal swab tests 2 weeks apart.  About 43% of those who had a positive swab had no symptoms. Seventeen percent of those positive (but about 30% with symptoms) required hospitalization.

These data support earlier studies, which showed that most of those who become infected do develop disease. Less than half were asymptomatic.  

What is our Plan B?

While a general hope was that SARS-CoV-2 might slowly spread through the population and confer immunity without significant cost, that seems unlikely, based on these and other data. 
The vast majority of Americans remain unchallenged by Covid-19 and without immunity.  

Furthermore, the WHO warns that the presence of antibodies has not been shown to correlate with immunity.  While I suspect this reflects the questionable accuracy of the dozens of antibody tests currently on the market, or the fact that the specific antibodies being measured are not the best to show immunity, it could also mean that people do not develop strong immunity following SARS-CoV-2 infection. Sometimes this happens. For example, having one bout of Lyme disease does not prevent you from having another. 

The bottom line is that simply maintaining the current level of quarantine will not solve the Covid problem. It did end the exponential rise in the number of infections, and prevented (or at least postponed) a collapse of the medical system.  But it does not appear that the elapse of time will yield immunity without predictably high morbidity and mortality.

On the other hand, it is possible that neither our antibody nor our nasal swab PCR tests are adequately capturing infections and immunity, and things are actually way better than the numbers I cited above, show.  My friends tell me Sweden has claimed 1/3 of the population will be immune by May 1. Yet the numbers I see suggest only 0.2% of Swedes have tested positive, similar to the percentage in the USSweden's deaths are dropping, while ours are flat.  If Sweden has found a way out of this mess, I will be the first to follow their lead.

To me, the only workable Plan B involves finding preventive measures and effective treatments. Patients need cures.  The 88% mortality rate of those who were placed on ventilators in NY's largest hospital system is unacceptable.

In China, patients received a multitude of different treatments, simultaneously.  While that may create datasets that are hard for researchers to parse, since they are accustomed to determining the efficacy of one treatment at a time, more aggressive use of treatments might improve otherwise dismal mortality rates.  

The duty of a treating physician is exclusively to the patient, not to the fidelity of a pharma or grant-supported dataset or clinical trial.  It is time to throw the kitchen sink at our patients, and especially try vitamin and nutraceutical combinations that are unlikely to cause harm.  These are being used in some hospitals and recommended by some physicians already, for example, Vitamin D and glutathione, substances that the body requires and therefore are perfectly safe in therapeutic doses.  Or famotidine (pepcid) an OTC drug for heartburn. Here is another drug that may be useful.

Furthermore, treatment needs to be started early. When this virus hits hard, it happens fast and overwhelms us.  We need to lower the viral load before that happens. The common medications used for viral diseases: influenza, herpes simplex and varicella zoster infections (acyclovir, famciclovir, valacyclovir, oseltamvir) are all recommended to be started within 48 hours of the onset of symptoms.  Guidelines that recommend withholding safe medications, or waiting until patients are severely ill and hospitalized before using them, lack valid scientific and ethical justification for doing so. They should be consigned to the scrap heap.

Changes made by CDC to reporting guidelines for Covid-19 death certificates may corrupt mortality data. Out-of-hospital deaths may also do so.  Cities and states need their epidemiologists to scrutinize all deaths to make sure Covid deaths are correctly assigned. (Fox points out that Pennsylvania keeps changing the number of those who have died.) The data used by the federal government to make critical decisions about managing this pandemic must be accurate. It is not clear they are. 

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