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COVID-19: Amid the Rising Caseload in the United States, the Country Braces Itself

I am an infectious diseases specialist and public health physician.  My career has been a series of opportunities to assist in the care of patients and collaborate with my colleagues.  I trained during the SARS outbreak and the anthrax scare, prepared for a possible ebola outbreak in the United States, and witnessed the innovation of scientists in discovering effective treatments for HIV and cures for Hepatitis C.

With the Coronavirus outbreak, it was almost other-worldly to see how significant the surge had impacted China.  I held onto a hope that cases would be appropriately protected from coming into the United States, and that the outbreak in other parts of the country would “fizzle out”.  The SARS-2-CoV was no SARS.  Although it is less severe, it is more easily transmitted.  We try to fit the virus into the categories of other zoonotic viruses, such as influenza virus, in which we were more experienced – and I did the same.  After all, who can be a novel coronavirus expert?

As I watch this pandemic unfolding in the United States, I realize that this is truly an unprecedented time.  Through the past few months, I have had the opportunity to be a resource for local KGW news, various newspapers such as Salem Reporter and the Sandy Post, and other sites such as the DO and Adventist Health website.  My general goal was to answer the questions with “facts not fear”.  Now that we are in the brink of a widespread epidemic in the United States, I have hope that we will persevere. But we can be sure that it isn’t just going to pass through without making an impact.

A virus is a force similar to a natural event. When a storm forms in the ocean, it ultimately will weaken after some time.  Though we can at least visualize a storm as it forms and moves. With a virus, a person who is ill becomes an appendage of the virus, its vessel that can deliver it to others unknowingly.  As our bodies are defined by natural forces, so too is a virus. Its presence is only as invisible as the capabilities of our technology to track its movement or the people that are spreading it.

When an infection emerges as an outbreak, there are no blueprints for how to address a mysterious disease as it spreads, while healthcare workers evaluate the initial patients in the clinics and hospitals – and inadvertently become infected and spread it; as epidemiologists and lab scientists collect data to analyze it and determine its cause; as other scientists discover an accurate test to use to diagnose it and get it approved; as industries manufacture it and distribute; while investigators work on vaccine and treatment options – all in live action.

Many people will succumb to this virus. Though many more will recover completely. Even as I realize that the impact of death from this virus will likely be less than the amount of deaths attributed YEARLY to influenza, I am not consoled completely.  Systems will be tested.  The societal support system will buckle.  The economy will be hit hard, as we have watched the stock market dive.  We will also continue to see decreases in growth, production, jobs, as we have watched events get canceled, flights and cruises get canceled or unfilled.    Those in the margins, such as the homeless, unemployed and chronically ill, will suffer a greater loss. People will die.

Society is like a living entity.  Its efforts have turned toward self-preservation and buffering the impact of this growing pandemic.  We shift toward producing masks and ensuring the our healthcare workers are protected.  We try to disrupt the chain reaction of this natural event through social distancing to “flatten the curve” as if removing the kindling away from a forest fire, lest one of us ignites and spreads the fire further.  At this time the collective consciousness is centered on one thing COVID-19.  It fuels our thoughts and fears, it fuels our actions, and it fuels our plans.

What will the future bring?  We are now living in an experience which is encapsulated by the course of this pandemic.  Moment by moment, we measure our actions, we speculate on the time left for it to pass, and we attempt to understand this epidemic any way we can.  The news outlets flood the public with exceptional cases – a women who is otherwise healthy in her 30’s developed respiratory distress because of COVID-19.  ER physicians on the frontline now in critical condition from the viral infection. These are true, unfortunate, and very sad to hear.  People will die.  Though most people will recover.

We all brace ourselves in the meantime. When will the caseload crest?  We await the next few weeks but realize that it will take longer than that.  The case load is steadily increasing throughout the world, with the United States now in the cross-hairs.  At the time of writing this, almost half of the 68,000 cases and counting in the US are from New York State (33,000).  The streets of the financial capital of the United States are barren.  We hear about the taxing effects it is having on the healthcare system there, but we also hear of the valiant efforts to organize assistance at this time of need.  Meanwhile the caseload in every state is gradually increasing, some of it outside of our vision – that which we have through testing.

 

We are now living in an experience which is encapsulated by the course of this pandemic.

 

Social Distancing

We speak of this concept of social distancing, which inherently makes sense to us.  In a viral infection, where hundreds of thousands to millions of particles are being expelled with each forceful cough, it becomes practically impossible to avoid getting infected without these measures.  Add to that the fact that the average person touches their face 25 times an hour.  Essentially, if you stay away from an infected person, then you don’t get the infection.

The concept of social distancing refers to the fact that a respiratory virus is incapable of surviving outside a host for more than a few days.  The history of social distancing goes back thousands of years, when people with physically stigmatizing illnesses like Hansen’s disease (leprosy) were isolated from the rest of societies in leper colonies.  More recently, in diseases such as tuberculosis and pandemic influenza (1918 influenza pandemic), it became increasingly understood that separating, essentially quarantining, those with infection could reduce the spread of illnesses.

The concept of social distancing is extended further out to social gatherings and is closer to a containment strategy.  Droplet-borne communicable illnesses like respiratory viruses spread mainly by coughing and sneezing.  These droplets usually have a radius of spread of about 6 feet.  If an infection were left to spread without any measure taken, up to three people can be infected on average by everyone infected person.  Those three people go on to infect nine people; those nine people go on to infect twenty-seven people and so forth.  This is known as basic reproductive number, or R naught (R subscript 0).

Exponential growth leads to a significant surge of cases.  Even if only a small amount of people have severe disease, there could still be enough influx of those severely ill from the infection to exhaust our health systems.  This very thing happened in Wuhan, China, with the original outbreak surge and then again in northern Italy.  Social distancing attempts to lower this reproductive number, thereby reducing, even if only a delay, of the growth, allowing for a slower development of cases.  Social distancing also protects those at highest risk for acquiring the illness (healthcare workers) and those at highest risk for severe disease (the elderly, those with chronic conditions and immunocompromised), by removing yet another person with mild disease who can go on to infect others, eventually getting to those higher risk populations.  What happened in Kirkland Lifecare Center was a disaster with 81 elderly infected and 34 deaths from COVID-19.

Social distancing requires sweeping recommendations that include the following:

  • No gatherings of up to 10 people or greater
  • No sit-down meals in restaurants
  • Cancellation of events, music, speaking and religious services
  • Increased vigilance if someone were to have cold symptoms (during the flu and respiratory virus season)
  • That they would avoid close contact with others, sneeze or cough into their arm sleeve not their hands and
  • Wash hands regularly
  • All should remember to wash hands, sneeze or cough in the arm sleeve or a tissue and wash hands after
  • Wash hands before preparing a meal or before coming into the house.
  • Cancel all international travel has also been suggested

There is no restriction on going outside, such as taking a walk in the park or going to the supermarket for provisions.  In fact, this might be helpful to provide a buffer from stress, anxiety or depression, as otherwise our lives have essentially been put on hold.  This is advised.

Outdoors, there would be little risk of acquiring any illness while in the park and social distancing of 6 feet can easily be addressed on a hike.  At a time of greater vigilance, it is with hopes that someone who is infected will also be mindful not to sneeze or cough without covering it.  Interesting greetings have come in the name of social distancing including the COVID-19 elbow bump and ankle hit.

Though, asking people to stop interacting with other and distance themselves is a difficult expectation. This means that those that already made plans like a spring break trip would have to cancel.  Unfortunately, social distancing didn’t hold many college students back from traveling and reveling in groups.

Though, what if social distancing didn’t need to be applied? What if testing capabilities would be accurate, available, and rapid enough to test people as they gather. Would a country need to jeopardize its economy and shut down its business sector? There are a few examples from this outbreaks where the countries didn’t have to enforce mass containment strategies. If you think about it, we are shutting down our entire society for something, instead of targeted quarantine to those that are infected.

The Benefits of Scaling Up Testing

Stopping a virus requires testing.  If a virus is able to be seen, it can be controlled.  We can start with the fact that the number of confirmed cases is likely a small fraction of the actual cases.  Yes, this means that the virus is not as fatal as we feared initially. A country like South Korea is the closest example of the importance of testing in identifying those who are infected with COVID-19, akin to “viral night vision goggles.”  South Korea, coming from the experience of a MERS outbreak in 2015, organized a massive campaign of testing of over 270,000 tests, most of it in drive-through fashion.  All of this was done without locking down the country.

However, a real time PCR test is not going to be positive in all patients with disease, so clinical suspicion should still guide recommendations.  The PCR has a variable sensitivity, depending on the source of the sample.  From an article recently published on Wuhan data of 1070 samples from 205 patients with COVID-19, 19% of whom had severe illness, a sample from the lower respiratory tract had the highest positive rate (14/15, 93% sensitivity).  Next in sensitivity was sputum (72 of 104; 72%), nasal swabs (5 of 8; 63%), fibrobronchoscope brush biopsy (6 of 13; 46%), pharyngeal swabs (126 of 398; 32%), feces (44 of 153; 29%), and blood (3 of 307; 1%).

If a patient is presenting with symptoms, a COVID-19 PCR can be ordered to confirm someone who may be infected.  If it is positive or the clinical suspicion is high, that person can be told to quarantine themselves for 14 days.  This could be used as targeted containment.  They do not spread the disease to other people, and, consequently, those at highest risk for death are protected by breaking this link.  Now that home tests are becoming available, a person who believes that they are infected can get an order from a physician through a telemedicine consult and use this test to determine their status and respond accordingly.  The virus is a catalyst to a chain reaction that requires humans to spread.  Testing removes a way to continue the reaction, arresting the process.

A second way to test someone is with serologic testing.  For some diseases, this can be used to make a diagnosis, but has largely been supplanted by more sensitive and specific (and more costly) methods like PCR.  Though there are some important differences.  For instance, take someone who had a recent viral syndrome that was mild and s/he didn’t get tested. The PCR tests for the presence of viral, bacterial or fungal or parasitic nucleic acid fragments.  In the case of someone with a resolved infection, they will have a negative PCR.  A serologic test measures the presence of antibodies that are made by our bodies after they come into contact with a pathogen.  If someone had COVID-19 and resolved, their PCR may be negative, but their serologies (immunoglobulin e.g.  IgM, IgG antibodies) will remain positive. Therefore, it can be a way to detect immunity. A positive antibody could be used to remove any restrictions on someone who either had confirmed disease or who was relatively asymptomatic with minor disease.

The United States has significantly ramped up testing from the beginning of March (less than 10,000 tests) to 103,945 tests up to March 19th, 2020.  South Korea did 10,000 tests a day and still leads the pack.  As we gain a greater understanding of this epidemic and look back like Monday Morning quarterbacks, one of our conclusions will be that testing can shape the epidemic and the mortality rate.  As we look at Germany’s COVID-19 outbreak and see the significantly lower case fatality rate compared to other countries (CFR 0.29), it is no coincidence that they are second on the list for total tests performed.  Testing visualizes the virus and bolsters social distancing strategies.

covid-19-tests-country (1)

 

In this last week of March, we are beginning to see the impact of this virus.  The caseloads of virus, the amount of hospitalizations and the amount of deaths are expanding.  We have gained much insight while we prepare ourselves for what will unfold.  Some of it is still in our control, such as the testing and social distancing practices.  Some of it has already been shaped by the preceding weeks, and we just don’t know about it yet.

One of the most underwhelming things of controlling an outbreak is that it will act like a “dud,” when measures work. We can’t rely on positive feedback after reducing the impact of an outbreak. The natural force dissipates with less cases and less deaths.  Invariably it gets looked at as unnecessarily sounding an alarm or as overly drastic measures.

We hope that the measures that have been imposed will effectively flatten the curve cases. We hope that scaling up our tests to anyone symptomatic – in the near future – will improve our ability to stop or mitigate the harm caused by this automaton – this natural event.  By what is occurring in New York City already, we fear that we may have already been too late. Most people will recover completely, but there will be deaths.

Future directions

Imagine that we develop a global epidemic surveillance and tracking system that can be immediately activated to mount a response to any outbreak. Scientists can determine the viral genome within a day of sounding an alarm of an outbreak. All countries can respond with assistance in various fields. A streamline way for making tests can ensure a test is developed and mass produced in the matter of days. These tests can be immediately employed to determine cases, which can then be effectively quarantined or treated. The outbreak dissipates as we gain the upper hand in controlling this force.

In many ways, we have the technology already. Sometimes, people can get in the way of best intentions. There are structures already in place which inhibit rapid upscaling. There is money and time needed to shift attention toward one effort. There are egos and communication gaps. Maybe after this outbreak, we can begin to realize that more effort and global collaboration up front would protect the entire world’s societal fabric, its economy and more importantly its people. When an outbreak occurs in one part of the world, it is as if a local infection occurs on our body. We have to believe that any outbreak could expand. We must act proactively to prevent that from occurring, even if the only assurance is knowing that it could have been worse – and has been before.

 

Thank your for reading this article.   Please share it if you found it helpful. Stay tuned for articles to come on viral and host interactions that cause disease, ways in which we can bolster our immune system to protect us from severe disease, and ways to keep balanced in this time of social distancing.

 

 

Below are some of the recent coronavirus-related media appearances that Dr. Cirino has had on television news, online news, and podcasts for infectious diseases issues:

 

Title with Link:  Can you get Coronavirus from packages sent in the mail

Source:  Finder

Author:  Cheryl Wagemann

Type of Assistance:  Written Format for HARO

Date:  March 23, 2020

 

Title with Link:  COVID-19 updates: The U.S. socially isolates as pandemic spreads

Source:  The DO

Author:  Andy Brown

Type of Assistance:  Telephone interview for internet article

Date: March 18, 2020

 

Title with Link:  Salem-area health officials say local coronavirus cases likely a matter of when, not if

Source:  Salem Reporter

Author:  Rachel Alexander and Saphara Harrell

Type of Assistance:  In-person Interview for news article

Date:  March 3, 2020

 

Title with Link:  Gresham medical, school, senior center officials address COVID-19 concerns

Author: Christopher Keizur and Teresa Carson

Source:  Sandy Post

Type of Assistance:  Interview

Date:  March 2, 2020

 

Title with Link:  What should I do if I’m sick? Are children more at risk? Doctor answers your coronavirus questions

Reporter:  Brenda Braxton

Source: KGW News

Type of Assistance:  Question and Answer Session

Date: March 2, 2020

 

Title with Link:  What are coronavirus symptoms? How are they different from the flu? Your questions answered

Reporter:  Morgan Romero

Source:  KGW News

Type of Assistance:  Interview excerpts

Date: February 26, 2020

 

Title with Link:  Adventist Doctor explains dangers of coronavirus

Reporter: Ashley Khorslien

Source:  KGW News

Type of Assistance:  In studio Interview

Date:  February 18, 2020

 

Title with Link:  Coronavirus:  News vs. Reality

Source:  Adventist Health Website

Type of Assistance:  Contributed Writing, excerpts

Date:  February 2, 2020

 

 

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Fear in the Age of Coronavirus: Reasons why COVID-19 is hitting our self-preservation nerve

We sat and watched the Chinese government implement its draconian measures on the Wuhan, Hubei province and the rest of the country.  We saw leaks of photos and videos capturing these harrowing times.  Healthcare workers strained to meet the needs of the surge of patients admitted to hospitals that were constructed to meet the emergent need.  Somehow, most of us thought that it wasn’t coming to our cities.

Little by little, the cases trickled in to other countries, first the countries neighboring China, then sporadic cases in Europe, Canada, Australia and the United States, all with ties of travel from the epicenter of the outbreak.  Suddenly, there was a huge spike in cases in Italy, Iran and South Korea.  Images and stories being transmitted from the heaviest hit zones in Italy were not encouraging and showed a system in major strain.  Cases started getting confirmed in the United States, with more than 13,700 cases reported as of March 19th.  A surge in cases seems imminent.

Beginning on March 12th, the United States began to issue recommendations for social distancing under consultation with the CDC.  This was under intense scrutiny of the US government and the CDC’s reactive approach, including the lack of testing availability and the strict guideline for whom was considered at risk for COVID-19.  Suddenly, schools were canceled until the end of April, all meetings and events were canceled, the remaining seasons of NBA and NHL and March madness were canceled, popular destinations, such as Disneyland, were closed, and families were asked to stay home.  Even employers asked workers to convert to home-based work, conduct teleconferencing, or, for the unlucky ones, to not work at all.  Just over the last few days, many restaurants have shifted over to take-out only.

The supermarkets were raided for essential materials and groceries.  Toilet paper (for unclear reasons!) and alcohol hand sanitizers were the first to go.  Longer lines, first at the cash register, then in front of stores on opening hours, are sending a signal of people in crisis mode.  The dramatic drop of the stock market over the last month, a total of more than 9,000 points, leaves little doubt that we are entering uncharted territory.  Since when can a virus infect the market!  All of this was caused by a black swan event, all from something that isn’t visible.

Captain of the Men of Death:  The Makings of a Global Disaster

We are relatively desensitized to the horrors of zombie apocalypse themes in movies and literature.  Though, when it comes to the unseen enemy that is a viral infection, our sympathetic nervous system responds sharply.  The fight, flight or freeze instinct overtakes our decisions.  What is different in the case of a viral outbreak, however, is that we do not see a lion or bear coming for us – or a zombie for that matter.  And we can’t fight it head on in one instance or even run away from it.   The scary thing is that when we are actively in this mode, our stress hormones trigger physical changes that lead to tunnel vision and not logical conclusions or judgements.

The information is freely available on social media, the news media, youtube videos, and all around the internet.  We have access to personal photos, putting a name to the face of death.  It is a response to these signals that makes someone go out and buy provisions for three to six months, buy every roll of toilet paper that remains on a shelf in their local COSTCO or order n-95 masks to put on and protect themselves from an unseen enemy – even though it makes them feel even more panicked!  Multiple people are doing the same, because sensing other people’s survival responses is programmed in our brain.  We owe our amygdala for processing fear signals and designating a reponse and our anterior cingulate cortex for sensing a collective fear.  There is one thing that is more infectious that COVID-19 right now and it’s fear.

This COVID-19 outbreak satisfies several ingredients of a destabilizing event, which propagate fear even before it makes its way into the community.  The fear incites actions for self-preservation and cripples the fabric of society.

  1.  The virus is an unknown, unseen enemy

For me, there was no greater fear in my childhood than the fear of the dark.  As a child, I held my breath as I quickly ran to turn the light switches on.  Instantly, I was ready to take a breath and defend myself with an immediate boost in courage.  At some point, this matured into a “fear of the unknown.”   I think it stands to reason that COVID-19 is as unknown and unseen as they come.

A coronavirus is about 100 nanometers in size – just to give you some perspective, you would need to put 10,000 viruses grouped together for it to be visible to most people (1mm).  Yet, when someone is infected, they can spread it easily when they cough, sneeze laugh or talk.  They may cough in their hands and greet you, or touch something that you touch – which gets into your mouth, nose or eyes.  Since a cough may contain as many as 3,000 respiratory droplets measuring 10 to 100 microns, we could be blasted with hundreds of thousands of viruses if we are a passerby.  On average, a typical person may touch their face more than 20 times an hour, with about 50% of the time being mucosal surfaces.  Most people don’t even realize they are doing it.  Unless your spouse gets ill and passes it to you, most of us really don’t even know when and where we catch an infection.

COVID-19 (SARS-2-CoV) emerged likely from an animal reservoir, a bat, or perhaps an intermediate reservoir, such as a pangolin.   The genomic sequence appears similar to the bat lineage coronavirus.  It is not exactly the same, because it changed when it jumped species.  This is a spillover event, where a completely novel coronavirus was capable of infecting humans and causing human to human transmission.  We cannot look back at this specific virus SARS-2-CoV to gain an understanding.  We can only look back to the research on SARS and begin to apply some of the research questions on this distinct coronavirus.  We have no vaccine. We have no treatment.    We have only uncertainty.

On a hopeful note, the only current method of visualizing this threat is testing.  Imagine throwing powder on the Invisible Man.  For a moment, the predator can be seen, its movement can be controlled, and people can be protected.  This is the power of testing.  The test has to be abundant, inexpensive and sensitive to allow for maximal benefit.  Restricting testing to only those with severe disease has a very limited role in curtailing an outbreak.  Testing  those with symptoms is like turning on a light and making the invisible – visible, allowing fine-tuning of containment and quarantine strategies in order to protect those at high-risk of infection (healthcare workers) and those at high-risk of complications (elderly, those with chronic diseases, those immunocompromised).

2.   This virus is deadly but not too deadly.

As of March 20th, there have been more than 245, 000 confirmed cases of COVID-19 worldwide (and likely many more untested).  10, 046 people lost their lives because of this virus.  When we hear of these deaths, the easiest way we can understand it is by thinking of our own mortality.  We do not dare to fathom this number of deaths, as 10,046 separate individuals plucked away from their lives, leaving a hole in the fabric of their family systems.  Each of us asks “Will I survive this disease, if I get it?”

We have diseases such as the yearly pandemic influenza that don’t seem to trigger national fear.  Most people who get infected will feel sick for a few days and improve without complications Not to mention, we have a vaccine for it that works about 40-60%, usually in causing a milder disease or in protecting from infection.  We don’t always think of influenza as that serious, and certainly not as serious as COVID-19, right?

Each year, the Global Influenza Mortality project (GLaMOR) estimates that from 294,000 to 518,000 people die of influenza-associated respiratory deaths worldwide.   More than two-thirds of the deaths are in those older than 67 years old.  We don’t tune in to the influenza outbreak daily news by youtube personalities like Dr. Campbell and go through the body counts, failures and recommendations for each country.  We don’t get the sensationalized reports.  Our sympathetic nervous system doesn’t alarm.  Some people don’t even get the vaccine.

We have diseases that are very deadly, like Ebola, which trigger fear but not a fight or flight response from afar.  These infections may not even spread outside of the countries in which the outbreaks began.  They are harder to transmit, tend to kill off people faster than they can be transmitted, and are usually easier to contain.    In the global village that is the world, ebola cases did get diagnosed in other countries, including Italy, Spain, the UK and the USA.  These were mostly imported cases, meaning from a person who left the outbreak site and arrived into another country with the disease.  In the wake of the 2014-2016 Ebola outbreak in West Africa, it was estimated that 28,652 were infected and 11,325 died because of this infection, a case fatality rate (CFR) of approximately 40%.  We feel for the losses, even feel fear, but still our sympathetic nervous system didn’t alarm to an action.

COVID-19 seems to trigger an amygdala reaction.  After all, it is at a “sweet-spot” for a virus: no one is immune to this infection; it causes a certain amount of more serious cases;  it spreads as easily as the flu;  and it can be lethal.  Photos taken from the outbreak site Wuhan show police donned in the highest level of personal protective equipment (PPE) with masks, bodysuits and respirators, impervious to the respiratory droplets carrying COVID-19.  We hear of the deaths being reported daily and the amount of cases being reported, like a malignancy out of control.

We hear of it on the news as a “deadly virus,” but is it really that lethal? We have learned from South Korea that with more available testing there was a lower CFR and in China there was a greater surge of cases and a higher CFR, which exhausted their health system.  We attempt to try to explain these differences.   Is this because the virus changed from L for to an S form, and that the L form was more aggressive – after looking only at 103 genomes of SARS-CoV-2!!?

Did the testing cause less deaths or just reveal that the virus was less deadly?  Perhaps both. The case fatality rate was 2-4.0 % in Wuhan at the start of the outbreak, where testing was just becoming available.  Only the most severe cases were tested; many milder cases were not tested.  It was 0.25-0.6% in South Korea, where everyone who had symptoms was tested. The South Korea government spearheaded a massive campaign, a “war on COVID-19”, that prioritized screening and identification of cases.  The testing probably also had a role in taragetting quarantine measures to protect the higher risk populations.

The crude CFR is likely closer to the lower end (0.25%), which is similar to a few of the more severe seasonal flu outbreaks that we have had.  All of the research coming out of Wuhan, showing age-adjusted CFR and range of presentations (82% mild, 15% severe and 3% critical) was tainted by the testing delays and not accounting for all of the cases.  One support of this is that outside of Wuhan, the case fatality rate jumped down to 0.8% from 4% – and even these areas were undertested; and even if the WHO thinks otherwise.  It is still impactful, but would these lower rates generate fear?

The tendency is to take these numbers and plug yourself into the equation.  What is my risk that I could die and that I would leave my husband or wife and children without a parent?  Let’s play Russian Roulette:  If I gave you a gun with a barrell that could fit 400 bullets and I placed one bullet in it, rolled the barrell, closed it, and then gave it to you to pull, would you be really scared that you would shoot yourself? 

That is likely the crude CFR.  If we adjust it to age and other health conditions if present, the CFR now is lower than that rate for most people and for some people it is higher and still support that the majority of people are going to be fine through this.  Does that invoke the same fear?  Most likely not.  Though fear probably doesn’t come as much from the case fatality rates as it does from the mass media storm (as it did with Ebola).

3.  The virus cannot be walled out.  It flourishes on social interactions and is stopped by distancing.

A virus has no brain and has no motive or conscience. It just is.  Yet, it can change the world.    This lifeless force uses cellular mechanisms to generate copies.  These copies infect adjacent cells and generate more copies.  A person develops a disease and has coughs, sneezes and lots of drainage.  The person essentially becomes a vessel – a conductor – delivering the viruses to others.  The viruses gain nothing from this, but the bridge for which they may make more copies and infect more cells.

If one infected person spreads viruses to three other people, and these three people spread to nine more, and these nine people spread to twenty-seven more, a little while longer and the a large amount of the population has been infected.  If it is a cold, people just keep on keeping on, infecting people and not affecting them.  Most people won’t call in for work if they have a minor cold, even if they probably should to protect others from getting their cold.

With COVID-19, there was enough uncertaintly and severity that health systems became strained, and other systems spiraled out of control.  We watched builders team up in Wuhan to rapidly build sixteen (!) hospitals to accomodate those sick from COVID-19.  We saw the government take strong measures of containment and social distancing, shutting down modes of transportation and enforcing curfews and other measures all for an unseen enemy.

Isolation can be a strong risk factor for anxiety and depression.  The rapid changes that are being requested for all of us can take a toll on those already at risk for mental health concerns.   The America Psychological Association has an informative page detailing about this concern, including suggestions to cope:  limiting news consumption to reliable sources, creating a daily routine, staying virtually connected, maintaining a health lifestyle, and using other strategies such as mindfulness and relaxation exercises.

A paradox:  You can’t put a wall around a city to protect it from a virus.  It comes in as a Trojan horse.  A society has to literally stop the spread by stopping what people do best – interacting with others.  Sure, most people aren’t going to die from COVID-19.  It isn’t so much about that one person who will likely recover, it is about the fact that this person can be a vessel to transmit an infection to that one elderly person – or maybe a nursing home filled with chronically ill elderly people (Kirkland Life Care Center, 81 infected, 34 deaths!).    In order to preserve the fabric of our society, we have to become unglued from each other.    As Phillip Picardi succinctly put it, “now our only way out is to come together – by staying apart.

4.  The virus is coming to a city near you.

We have watched or listened to hours of news reports, some even more than that.  The caseloads continued to increase, with new countries added.  All of the sudden, there was a surge of cases in Washington, then New York, then Los Angeles area.  Just under a few weeks later, there have been COVID-19 cases in every state and more than 14,000 cases at my last check on March 20, 2020.   It seems like there is no stopping it – it is coming to a city near you.

It provokes fear to think that something that originated across the world can find itself to you.  Sure it isn’t exactly the same thing that it was when it started. Sure this happens every year with the flu, but we aren’t scared to act then.

 

Summary

The COVID-19 outbreak is an unprecedented period in our history.  There are multiple reasons why fear can affect the way we respond to our preparation for this.  Measures that have been taken to stop further transmission can fuel separation, isolation and boredom, increasing the risk of mental health disorders and demoralization.

My suggestions toward managing this fear and anxiety include 1) getting plenty of sleep, 2) setting up a routine 3) getting some outdoor time  4) using this time to explore your interests, including crafts, hobbies, music and writing, enjoying the art of home cooked meals, and 5) tapping into technologies such as video calls, social media groups and other outlets.

Remember that this is a group effort.  We are physically preventing the virus from spreading to others and potentially putting someone in harm’s way.

 

After all it really is all of humanity that is under threat during a pandemic  -Margaret Chan

 

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Patient Information: Protecting Yourself from Viral Infection (Including COVID-19)

During an uncertain time as we realize the impact of the COVID-19 outbreak on the local communities, here are a few questions and answers regarding the virus and ways in which we can reduce spread:

 

Why is it called novel “coronavirus”?

Coronavirus is named for its appearance of the virus’s outer membrane on electron microscopy, which resemble a crown.  These zoonotic (animal derived) viruses were first discovered in the 1960’s and likely makes up approximately 15% of all colds.

The designation of “novel” comes from the fact that the virus is genetically distinct and emerged from animals and was capable of infecting humans, and then made the jump to human to human infection.  Scientists call the phenomenon of a virus being able to infect another animal as a “spillover.”

There are four major strains of coronavirus that cause common colds during the respiratory virus season.  COVID-19 is different from these in that it possesses different features on the viral outer layer that is foreign to our immune system.

Our bodies come across viruses frequently and our bodies have innate (meaning built-in) and adaptive (developed) mechanisms to protect us from them.  With COVID-19, the virus has not circulated in humans before, so the protections that normally dampen the response to infections are not present.

Therefore, there is an imbalance of managing this, resulting in increased viral stealth and an increased inflammatory response.  The body knows something is wrong but it cannot temper the response.  A mixture of these interactions contribute to varying severities of infection that could lead to a threat on life.

 

How is a virus spread?

Like most respiratory viruses, COVID-19 is spread in respiratory droplets.  Just to illustrate the magnitude of spread, take one simple cough.  One cough can spread thousands of droplets into the air at up to 50 miles an hour for 6 feet.  The size of the droplets measures from 10 microns to 100 microns. Just to give you an example of size of 10 microns, it would 100 droplets of this size together to make it visible (e.g. 1mm).  If the virus is 100 nanometers (or 0.1 micron) a droplet can have from 100 to 1000 viruses riding within it.  A single cough then is capable of shedding millions of copies of a virus.

How far the droplets can be spread depend on their size and wind currents – the majority of which fall within six feet, the space that doctors advise for social distancing.  There is no compelling evidence that the virus is easily transmitted in the air, or airborne.  Likely, as with all viruses, there is a continuum.  Small droplets known as droplet nuclei can travel on air currents for longer distances or float in the air.  Although people likely have a personal cloud of droplets around them, it is unlikely that this virus can be transmitted easily beyond 6 feet.

Studies have demonstrated that COVID-19 can remain viable, or “infectious” for 2-3 days and perhaps several days on surfaces.  This is not likely to constitute the main mechanism of spread and is also not unlike other respiratory virus characteristics.

The important thing to communicate is that the virus operates by natural laws and although new to our immune system, as we gain greater information of its mechanisms and employ rapid testing to mitigate risk and target containment, the chain reaction that is this outbreak can be blunted and interrupted.

 

How can I prevent the spread or protect myself from a virus?

General measures are still helpful to try to reduce the risk of getting this virus. Respiratory viruses notoriously difficult to protect against. The CDC estimates that between 10 million and 50 million people get the flu yearly. Nevertheless, an increased vigilance in these practices may still provide some protection:

  • Good hand-washing with soap and water for 15-20 seconds or the use of alcohol-based sanitizers
  • Social distancing and avoiding anyone who is coughing or sneezing. If you are sick, ensure that you are practicing measures of social distancing, handwashing and sneezing/coughing into your arm sleeve and not shaking hands.
  • “Corona elbow-bump” or ankle hit, instead of shaking hands. These are now “in” and accepted ways of showing respect, acknowledgement and affection.
  • Avoid touching the face, nose, eyes or mouth, which could lead to ingestion of the virus particles.
  • Wipe contact surfaces down before and after use, e.g. in the gym or in a common area or avoid touching your face or washing your hands after use.
  • Wash you hands before preparing food and before eating.

 

 

Can I get a viral infection after handling a package from someone who was infectious or that was delivered from a country where there is a high caseload?

COVID-19 is predominantly spread by respiratory droplets, where millions of viruses can be spread in one cough.  As other respiratory viruses, it can be transmitted by shaking someone’s hand who is infected and had coughed, sneezed or touched his/her face, touching a contaminated surface or an inanimate object (fomite) that have infected respiratory droplets.

It is unlikely that the virus can survive on absorptive surfaces such as cardboard for very long or in packages for longer than several hours, so it would be unlikely that the virus could be spread effectively in this fashion.  Some studies of coronaviruses (including those that cause the common cold) as well as other the coronaviruses SARS and MERS have shown that viruses are capable of remaining infectious for 2-3 days, and in some cases several days.  Fortunately, they are easy to wipe off with alcohol-based solutions, dilute bleach and other cleaning solutions.

If a delivery person is dropping off a package and is infected, there is a conceivable risk of transmitting viruses, if he/she coughs or sneezes on the package.  This is an exceedingly low risk to the general public.  Handwashing throughout the day is always recommended during the cold virus/flu season, in addition to avoiding touching the face, eyes or nose when out in public.

 

What are the signs of symptoms of viruses, including COVID-19?

Respiratory viruses infect mucosal surfaces in the respiratory tract, usually from nose to bronchial airways and sometimes even the lower respiratory tract. The more severe presentations are seen where a virus causes damage to the respiratory tissue, a process known as viral pneumonitis or viral pneumonia. Many viruses can cause this type of infection, including influenza, adenovirus, respiratory syncytial virus and COVID-19.

The common cold mostly causes cough, nasal congestion or runny nose and possibly a sore throat. It is not uncommon to have some tiredness and low to high temperatures for any of the respiratory viruses. Some people will have nausea and diarrhea.

The most common symptoms of COVID-19 include fever, cough and tiredness. If you have these symptoms, you would not be able to know if this was COVID-19 or another respiratory virus, without a specific test, a PCR on nasal secretions.

Most people will have only mild to moderate symptoms from COVID-19 that will improve after a few days of staying home, resting, keeping well hydrated and nourished. In those that are of advanced age and/or who have high blood pressure, heart disease, lung disease or diabetes, they may have a worse presentation that may require advanced care, including hospitalization. A smaller amount will die from the disease.

 

If I have a viral infection, when should I go to the emergency department or clinic?

The concern of severity of infection can get anyone worried about their health. We hear daily the amount of those that have died from COVID-19 and not influenza. The CDC estimates that as many as 30,000 people have died in the United States from influenza this season 2019-2020.

If you are experiencing cold symptoms that are minor, that is you feel tired and achy and are coughing a little, you can stay home and allow time to recover. If you are experienced a fast heart rate, recurrent fevers and increasing problems with breathing – “catching your breath”, “having difficulty breathing” or being “concerned about my breathing” are key words – then you should seek further care in your local emergency department.

We are currently not screening everyone with cold symptoms, reserving this for those who have severe enough illness to be hospitalized for now. With the amount of cases now reported in the community, there is likely local spread. Nevertheless, in people that are being tested, various viruses are likely to show up, like influenza A/B, respiratory syncytial virus (RSV) and metapneumovirus. With the upscaling of testing, it is likely that we may be able to test even those that have mild to moderate symptoms to better address the outbreak and target quarantine measures.

  • Unless your symptoms are as described above, it is recommended not to go to the local clinic or emergency department, where a respiratory virus could get transmitted to those that have chronic heath conditions and at risk to have more severe infection.

 

What should I do about my travel plans?

With the report of cases of more than 1400 cases in the United States (March 12, 2020), families are beginning to wonder if they should change their spring break or other trip plans.  The United States has enacted nationwide measures and various states have declared local emergencies to protect the public. Large events are being canceled as a means of interrupting viral transfer in the name of social distancing.

With this increased awareness, families are trying to balance between canceling plans to protect themselves or following through with the plans and possibly putting themselves at risk or contributing to further spread. The spread of disease in this outbreak is extremely volatile and could require in a sudden shift in plans as events are canceled.

The following are some considerations for your decision:

  • Did you purchase travel and/or flight insurance?
  • Is your ticket purchase (e.g. an amusement park) only for “same day” or can it be transferable for a later time? Review all of the policies for cancellation of the event, and contact the venue, park or hotel to discuss exceptions,etc.
  • How flexible are you to the possibility of sudden changes in your plans?

As for the risk of attending these events:  The risk of acquiring any respiratory virus is increased with proximity and likelihood of coming into someone who is infected, such as in social activities.  Common practices of social distancing and avoid contact of infected surfaces or inanimate objects (fomites) cannot be assured in an amusement park, for instance.  The same is true with access to hand washing.

Here are a few measures that families can take to prepare themselves for their trips:

  • Have hand sanitizer and handwipes available for use while traveling.
  • Instruct children to cough and sneeze into their sleeves and not their hands – and other practices to avoid touching the face, nose or eyes.
  • Check on outbreak information at the specific location or closest city to it before you embark. Disney just announced today that it’s closing the California park because of COVID-19.

 

Families can take certain precautions in advance of surprises.  COVID-19, as with other respiratory viruses can have a major effect on people of advanced age or with chronic conditions such as hypertension, heart disease, diabetes and lung disease or who are immunocompromised.  The majority of travelers require no further preparation than what they would do to protect themselves from viral infections during the cold season.

 

I hope this information is found to be useful.  Please share this with your friends and please feel free to comment.  This will be placed in the Health Information section as well as COVID-19 resources.  Thank you for reading this.

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Pandemic COVID-19: Applying Early Lessons Learned

The novelty of the novel COVID-19 outbreak has passed. Sure our imagination that drums up images of viral apocalypse and global chaotic destabilization are simmering. Although the fears are transforming into measured preparedness, there still remains an allure of uncertainty with how this outbreak will affect the rest of the world.    In the wake of this recent outbreak, the global public health community and the world in general is left with many important questions.  In real-time, the community has had to develop a blueprint to testing, containment and risk mitigation.  While the United States and countries in Europe are reporting higher case loads, some important lessons can be gleaned from the early part of the epidemic:

Emerging Lessons:

  1.  Containing the Transmission of a Respiratory Virus is like trying to hold water in your hands.

When the nCoV-19 (COVID-19) outbreak was declared in Wuhan, China in late December 2019, about three weeks of potential transmission for the index cases had occurred.  The first wave of cases were close contacts and healthcare workers.  The virus was transmitted to others through coughing, sneezing, talking, kissing, or from contaminated surfaces or objects.

Just one cough sends out thousands of respiratory droplets, varying from 10 to 100 microns in size, at a speed of 50 miles an hour to a distance of a meter or more.  If you sneeze when you have the cold, you are sending out 40,000 droplets of 0.5 to 12 microns at a speed of 100 m/s.  Imagine that if viruses, such as COVID-19, are 100 nanometers (0.1 micron), hundreds can surf on these droplets and easily become sprayed onto objects or surfaces at a closer distance, while droplet nuclei (<5 microns) may spread distances of a few meters or may even follow air currents still further. 

These infectious secretions can easily then enter the mouth, nose of eyes of a passersby or get ingested after touching the face from surface or fomite transfer.  Studies support the concept of a “personal cloud” of infectious particles supplied by coughing and sneezing and air currents around an infected person.  With so many viral particles, transmission of an infection to multiple people becomes easy.  

droplet modelThe Wells evaporation-falling curve of droplets  From Annex C. Respiratory droplets.

 

2.  Case Fatality Rates (CFR) are always overestimated in the beginning of outbreaks

An outbreak requires constant reassessment.  Imagine trying to isolate and contain an outbreak, while at the same time trying to identify the pathogen, confirm cases, protect those at risk, and consider treatment and vaccination options – all in real time.

Epidemiologists can draft a case definition early on, but if the outbreak is from a novel pathogen, cases are defined by syndromic presentation first until more specific tests become available.  The public health system and the general public have sensitive ears for case fatality rate, the amount of those dying from a specific infection over the amount of those infected.

Case fatality rates (CFR) depend on knowledge of all affected cases, which for respiratory virus is usually not possible.  The problem is that most patients that have mild infection may not get tested.  On the other hand, some serious cases may not go attributed to the infection.  As we are learning, even later into the outbreak, e.g. in the US, outbreak investigation and containment largely depends on the availability of tests kits.

In China, the Wuhan COVID-19 outbreak had an attributable CFR of 4%. These original rates are higher than what has mostly been seen in secondary outbreak countries, such as South Korea.  One-third of the caseload was determined by syndromic definition rather than specific testing.  Many more may have not been tested.  The more people that are tested including those mildly symptomatic or asymptomatic, the closer we get to understanding the true CFR.

Enter South Korea.  When COVID-19 was reported in South Korea, great strides were made to identify cases.  On Tuesday March 3rd, Moon Jae-in declared “war” on COVID-19.  This comes after an outbreak of MERS in South Korea where tests kits were not readily available, and 38 people died.  By March 4th, South Korea has already tested more than 140,000 people for COVID-19, even providing a “drive-through” testing option.  South Korea has detected 6,593 cases with 43 total deaths.

If you take into account a sensitivity of 95%, there may be 5% false negatives, this would equate to a CFR of  43 deaths/6,593 x 100% = 0.65%.   This represents the unadjusted CFR based on the positive tests.  However, there is a false negative rate of 5%, so taking into account all of those tested (158,456 – 6,593),  the adjustment could be as low as 0.2%.  Although there is a possibility that the numerator may not be correct, it is less likely to shift, as there isn’t another definition for “death” but it could not capture the attributable deaths from COVID-19.

The WHO declared that the case fatality rate of COVID worldwide has been 3.4%, which appears to be an gross overestimate.  However and importantly, even with the calculated CFR from  South Korea, the rate is likely to be twofold higher (or greater) than what is encountered with seasonal influenza yearly.  When determining risk, the Wuhan data closely correlated advanced age and those with chronic diseases with increased CFR.  So the adjusted case fatality rate is likely to be higher in these at-risk groups and lower in the general population.

covid-mortality-rates*This is coming from the China outbreak – Expect a similar mortality distribution though needs adjusted from other underlying risk factors

 

Think of a virus as a chain reaction.  Anytime a virus can spread easily and only cause some deaths, sometimes considered a “sweet spot” in disease transmission, it is likely to have a significant impact.  When a virus kills off its hosts too quickly or is transmitted by a different route (e.g. Ebola with infected blood and secretions), it is impactful in its severity, but it can’t get around to infecting too many people.  The CDC estimates that influenza causes about 10,000 to 60,000 deaths annually (CFR 0.1%) – in the Unites States alone.  Even if the CFR for COVID-19 similar to influenza, widespread disease could be impactful on our elderly and other at-risk groups and strains health care delivery.

 

3.  Outbreak Containment and Risk Mitigation Strategies Benefit Greatly from Accurate Case Definition 

Efforts to contain COVID-19 improve as the case definition becomes more specific.  The original CDC case definition was more rigid, since the outbreak was related to the specific outbreak city, Wuhan.  As is always the case, coming up with an accurate definition up front can be difficult in real-time.  The Chinese government imposed strict lockdown measures, which crippled the cities and was meant to interrupt further transmission.  It became apparent, that low grade transmission and milder cases continued both inside China and to other countries.

Chinese scientist defined the genome of the novel Coronavirus shortly after declaring the outbreak, allowing for the development of testing.  Once testing became available, it was as if an invisible menace could be seen.  In the South Korea outbreak, people were readily tested, so active recommendations for quarantine could be given.  Truly it is important to recognize the efforts of the South Korean government and medical community to contain and test the population.  This testing may have contributed to the lower case fatality rates, by identifying at-risk people and keeping them free of disease.

With the further spread of COVID-19, a country will be able to gain a greater control on the outbreak through greater testing.  This provides knowledge of active cases, so that voluntary quarantine can be put into affect.

4.  Protecting Healthcare workers, Care givers and High Risk Populations is a key strategy 

With the SARS outbreak in 2002, we were reminded that the ability to provide healthcare relies on its personnel.  During that epidemic, one-fifth of all cases were healthcare workers.  As the outbreak of COVID-19 continues, some people will require medical attention and report to the hospital – maybe not even knowing that they have the disease.

As the caseload increases in the United States, the at-risk definition will increase.  It may be necessary to wear personal protective equipment with anyone who exhibits a viral infection.  Healthcare workers will be a greater risk of acquiring the illness.  When healthcare workers are unable to attend to patients because they are sick, healthcare delivery is consequently impacted.

It is clear that there is a higher case fatality rate with the elderly and those with health condition.  When an infected person, whether it is a healthcare worker, patient or visitor comes into a population of those at risk, you see a perfect storm for severe disease and fatality.  Recently, the Life Care center in Kirkland, Washington had a spate of 13 deaths from COVID-19.  it is incumbent on long-term care facilities to develop strategies to prevent any further outbreaks of COVID-19 in such high-risk settings.

5.  With any viral spillover, there are always two outbreaks: Infectious Disease and the Infectious Fear. 

An outbreak is an unpredictable process.  It can sometimes burn out, even as we are still learning of the risk factors of its spread.  As for a respiratory virus outbreak, it is easily transmitted, often leading to relatively silent spread.  Containment strategies are often too late.  As information emerges from the virus, speculation can create narratives that lead to fear, panic and rapid decision-making.

Reports from the news are often related to deaths and how the viral infection is changing regular life and can be sensationalistic.  Online authors and presenters are shaping the news and narratives.  The images of the strict containment measures in China tempt us to think about self-preservation from an unknown invader.  These fears shape behaviors:  cancelling flights, stocking up on masks, cancelling conferences.  While it is not wrong that containment measures can help, defining cases can lead to more targeted containment without crippling the flow of a functioning society.

In the unknown of the COVID-19 outbreak, the stock market has seen great losses and is showing volatility.  Imposing mass quarantine and containment efforts can have real effects on the economy and productivity.  Canceling major conferences can lead to losses that can affect multiple sectors.  Even if you decide not to cancel your European trip, strict measures could be applied in the setting of an outbreak, that can limit or spoil your vacation plans.

Stories of vampires, werewolves and zombies go back hundreds, if not thousands of years.  The concept of some unknown force overpowering humans and causing them to morph into someone or something else hits the nerve of our self-preservation instinct.  In many ways, viruses are the true vampires.  They are lifeless forces other than the primitive instincts of self-preservation and self-generation.  A virus’s consciousness is generativity – producing copies to transmit to others.  It’s  result is a destructive untangling of the fiber of society. A virus is transmitted through social interactions and an interruptions in these behaviors although may be useful,  often results in a significant fallout. 

A Viral Outbreak Creates a Fissure in Human Collaborative Efforts, leaving a wake of social, economic and political fallout. Disruption of this force will require pro-active oversight and a multifactorial and adaptive approach.

 

Future direction:

This is an unprecedented outbreak in the degree of spread in modern times. With higher rates of international travel, technological advances of communication and distance consultations, we are poised to apply collaborative efforts in real-time. While this outbreak is not over, it is not too late to employ methods that will mitigate the impact. Below is a list of some brainstorming for future planning:

  1.  The use of already existing apps for description of symptoms to determine places for targeted testing.
  2.  The coordination of an international outbreak system either through already-arranged WHO or influenza surveillance sites.
  3.  Selecting specialized labs to launch testing as early as possible.
  4.  More rapid protocols for vaccine development in emergency situations that do not require the rigid testing phases as those that are currently imposed by the FDA and other entities.
  5. Better regulation and control of animal markets, restricting the sale and/or slaughtering of animals outside of approved centers (and not in city markets).

 

Summary

While COVID-19 is not a harmless virus, the manner of how it is transmitted and causes disease is predictable.  Those most impacted are the elderly, immunocompromised and those with chronic diseases.  Managing the COVID-19 outbreak will require a group effort to stay aware of individual symptoms and use standard precautions, to identify cases through rapid testing, to mitigate risk through targeted containment and to transform fears into preparation.

 

If you have found this reference useful, please pass it along to other readers.

Your Health Forum has recently added a COVID-19 resources section which includes a growing collection of posts on topics related to COVID-19, and newspaper and media coverage by Dr. Cirino, an infectious diseases specialist and COVID-19 commentator.

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COVID-19: Prelude to a Pandemic

COVID-19 has traveled far and wide from the original outbreak zone in Wuhan China.  Currently, the outbreak has spread to 68 countries (+ 1 cruise ship).  As of March 1st, 2020, there are a total of 89,081 cases with 3,057 deaths.  The rate of new cases in China has steadily dropped, likely due to containment efforts. Last week, the trajectory of the COVID-19 outbreak suddently changed, when local spread began to be reported in South Korea (4,212 cases), Italy (1,701 cases) and Iran (978 cases).  With higher caseloads in these countries, it is only a matter of time that the outbreak will become a global pandemic.
It is possible that transmission will smolder in some countries, while it is surges in other countries.  The surges will increase the likelihood of further spread.  Thereafter, it could be introduced and lead to outbreak spikes in other countries.  There is some suspicion that the disease may already have penetrated into sites, while rigid case definitions and persons under investigation were used.  What is also incredible is the degree of measures that countries are taking to protect themselves from localized spread or introduced infections.
A few local, unconnected COVID-19 cases have already been confirmed in the United States.  Currently, the US has 87 confirmed cases, with several recent cases identified in Washington State, including within a care facility, with two deaths reported.  A recent case of a high school student in Snohomish County was found to have virus with a geneitc link to the first US case, that of a man in his 30s who had traveled to Wuhan and returned to Washington state several weeks prior – potentially six weeks of local spread.  On Friday February 28th, a case was confirmed in Oregon.  On Sunday, a second case was confirmed, who was a contact of the other.  Neither of them fit the original definition of a person at risk.  A surge in cases, particularly those unconnected to the original outbreak, raises the high likelihood that occult community spread is already occurring.  
Key Points:
  • The case fatality rate is likely lower than original estimates and varies with at-risk groups, including age and underlying chronic disease
  • It is likely that occult transmission of COVID-19 has already occurred in a few areas (e.g. Washington State) in the United States
  • Masks are unlikely to be useful in preventing COVID-19 disease beyond the usual prevention measures, such as handwashing, hand sanitizers, social distancing and not touching hands to the mouth, eyes and nose.
  • Although person-to-person contact of COVID-19 is the usual mode of transmission, inanimate objects or surfaces could pose a risk.  The virus may survive on surfaces possibly for several days but are easily addressed with dilute bleach or alcohol solutions.
  • Rapid diagnostic tests, particularly at the point-of-care, are necessary and useful tools to mitigate risk and concentrate resources and containment efforts.
  • As a means of capturing all at-risk patients, the CDC recommends COVID-19 screening of any patient with severe respiratory disease and no other identifiable cause.
The Case fatality rate
The case fatality rate is one way of determining the severity of a disease.  It is specifically the total number of people who die from a disease over the number of those diagnosed with the disease.  This number is not always accurate because of assumptions on the reliability on the denominator.
Case fatality rate (%):       Number who die from disease
                                             ————————————————–                      X 100
                                              Number confirmed with disease
In epidemiology, a case definition often relies on syndrome lists, when tests to confirm diagnosis are not readily available.  Whereas death from a disease is usually more accurate, the number of people with a certain disease may be misrepresented.  Many people do not come to be assessed if they have mild disease.  Moreover, as with COVID-19, there was no readily available test in the beginning of the outbreak.  So, in an active epidemic, as more cases are determined with widespread, reliable diagnostic tests, the denominator becomes more accurate.  As is often the case, the case fatality rate tends to drift downward and closer to a reliable metric.
Based on the February 24th, 2020 JAMA article, of the 72,314 cases records, 44,672 were diagnosed with the viral nucleic acid test that was available (62%);  22% were suspected based on symptoms and exposures without testing; 15% were clinically diagnosed cases without testing; 1% were asymptomatic cases diagnosed with the nucleic acid testing.  This means that about 37% of the cases that go into the denominator were not confirmed with diagnostic testing.  Not to mention, how many more persons were not included, who didn’t seek care for likely milder disease and possibly, who died and the infection wasn’t considered.
Those with COVID-19 presented with mild (81% of cases), severe (14%) or critical disease (5%), of which almost 50% died.  The total case fatality rate (CFR) of confirmed cases was 2.3%.  Adjusting the CFR to age provides a more accurate picture of the impact of age.  From this, you can see that the infection is disproportionately more severe in the elderly.
AGE                                                                                                                 DEATH RATE (all cases)
80+ years old                                                                                                                14.8%
70-79 years old                                                                                                              8.0%
60-69 years old                                                                                                              3.6%
50-59 years old                                                                                                              1.3%
40-49 years old                                                                                                              0.4%
10-39 years old                                                                                                              0.2%
Less than 10 years old                                                                                                no fatalities
About 35% of those who died from COVID-19 in this study had a known chronic disease:  10.5% had cardiovascular disease, 7.3% had diabetes, 6.3% had respiratory illness, 6% had hypertension and 5.6% had cancer.
Outside of Wuhan, case fatality rate is lower (0.7%).  It is expected that with the secondary outbreak sites, we will have a better understanding of both numerator and denominator, as well as other demographic information to better inform us on the impact of this disease.
More on Masks:  Save them for Healthcare Workers
Behaviors have surfaced over the fears of COVID-19 “coming to a city near you,” some proactive and some not always thought out as well.  In one survey in Taiwan, 79.9% of the people questioned said that they were using masks to protect themselves from COVID-19.  The CDC currently does not recommend the use of facemasks or respiratorys (e.g. N-95) for the general public.  Masks or respirators likely do not provide any protection from general precautions such as handwashing or hand sanitizer use and avoiding touching your mouth, nose or eyes.
For the purpose of definition of “close contact spread”, this is when a person is in contact within 6 feet from an infected person for at least 1 hours of exposure.  The greatest at risk for infection with close contact spread are healthcare workers.  Like SARS and Ebola in the past, front-line healthcare workers face the biggest risk of becoming infected.  The sickening of healthcare workers would represent a strong blow toward our treatment capacity, and should be prevented.
At present good handwashing technique or the use of alcohol hand sanitizer and social distancing are probable the most helpful measures to protect the general population from infection.  If you are ill, please sneeze in your arm – not in your hands.
sneeze in hands
Surface Transmission of disease
Spread of COVID-19 is mainly spread from person to person, when respiratory droplets containing virus come into contact with a mucus surface, such as the mouth, eyes or nose.  They can also spread on fomites, inanimate objects such as keys, doorknobs, money or phones, or on contaminated surfaces.  According to the CDC messaging, “because of poor survivability of these coronaviruses on surfaces, there is likely very low risk of spread from products or packaging that are shipped over a period of days or weeks at ambient temperatures.”
What do we know about COVID-19 and survival on surfaces?
It is generally believed that viruses are relatively fragile and susceptible to desiccation (drying), if they are not within a host.  Smaller respiratory droplets evaporate and likely the virus particles on those droplets are not able to re-infect.  It is not clear whether COVID-19 virus particles on larger droplets would thrive longer.
A recent study in the Journal of Hospital Infection suggested that SARS, MERS and endemic (HCoV) coronaviruses could remain infectious on surfaces, including metal, glass or plastic, for up to nine days – at room temperature.  At a temperature of  30 degrees Celsius (86F) or greater, it is not as likely to survive that duration.  The CDC is presently studying this concern for COVID-19.  The researchers commented that surface disinfectants such as 0.1% sodium hypochlorite or 62-71% ethanol readily decontaminated surfaces with short contact times.
The Need for Readily Available Diagnostics
A speedy diagnosis has a lot of benefits.  While taking into account the timing to a positive test, symptomatic patients can be triaged into “confirmed” versus “possible” or “unlikely” groups, while other tests are employed (e.g. influenza and Respiratory virus panel PCR).  Those confirmed groups can be appropriately informed to stay home and avoid contact with others, bolstering containment strategies.
The ideal place for rapid diagnostic kits would be at the point-of-care, rather than at national or statewide public health departments.  Though the CDC has made test kits available to state public health departments recently, with confirmation of cases still managed centrally by the CDC.
The test for diagnosis of COVID-19 relies on nucleic acid (RNA in this case) and is referred to as a real-time reverse transcriptase-polymerase chain reaction (rRT-PCR).  A sample is taken from the nasopharynx (deep nose) or oropharynx (throat) and is run on a testing apparatus known as a theramal cycler.  Here is a hyperlink to the details of the procedure.  The test often has a high sensitivity (ability to detect a true positive) and high specificity (not detecting a true negative).
The use of a chest computed tomography (CT) can be another way to determine if someone has COVID-19.  A CT can demonstrate the effects of the lung tissue from the viral infection.  When using a positive RT-PCR result as a reference, the CT scan for detecting COVID-19 related pneumonia was 97% sensitive and could even show disease before the RT-PCR turned positive.
The Current Efforts 
In the last few days, several cases have been reported in the United States (e.g. California, and Oregon), with no clear epidemiologic connection to the original outbreak site.  Consequently, the CDC revised their criteria for a person under investigation (PUI), expanding the definition to include those with fever and cough and “no source of exposure identified.”  This leads to questions about the possibility of a smoldering epidemic already underway in some parts of the United States.
With a wider definition for PUI, it is expected that physicians will be able to test patients for COVID-19 who have more serious respiratory illnesses even without close epidemiologic connections.  They will be placed in standard, contact and airborne precautions and be isolated in special rooms that circulate the air out of the room (negative pressure), while they are being ruled out.
It is expected with a greater case burden, hospitals may be at the risk of exhausting their resources.  Presently, hospitals in the United States are coordinating efforts as entities and in conjunction with state and local health departments.  Particularly in light of the recent cases without connection to the initial outbreak area, hospitals are ramping up their vigilance in considering cases to be tested.  Signage, visual alerts and mask and alcohol sanitizer stations are placed at all entry points of the hospital.  Patients are being triaged in a way to avoid possibly infecting others in the waiting room or medical staff.
Patients who are ill with milder systems are being asked to stay home and not be seen in the clinic or in the emergency department, rather than put others at risk for infection.
The Stock Market has been infected by COVID-19
The uncertaintly of COVID-19 has led to a paralysis and sell-off in the stock market with a decline of 12% in one week.  Investors are being encouraged to wait out this volatility.  Its unclear how this strategy will be affected by the uncertainty of the COVID-19 outbreak.
Why take your chances with face-to-face meetings during the COVID-19 outbreak?  Zoom conferencing along with 3M, who make some of the surgical masks being horded, were a few of the companies that were buffered from these declines – a sign of how fears can promote company investments.  If Zoom conferencing becomes the standard for the office meeting during the COVID-19 outbreak, they will likely achieve further gains.  Anyways, at least you don’t have to shake hands with that guy who catches his cough or sneeze with his hands – or worse get sneezed on.
It is likely that there will be economic and sociopolitical reverberations as a fallout of this outbreak for some time.
Included is a March 2nd Question and Answer Series (35 minutes long) in which I participated with KGW.
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The Human Microbiome: Unlocking the Key to Health

What is the microbiome?

The word microbiome  describes the trillions of viruses, fungi, and bacteria that live on or within the human body in various habitats such as the skin, mouth, colon and vagina.  Each site has characteristics, including pH, water and oxygen content, temperature, and chemical metabolites, that favor certain bacteria over others.  Our normal flora can cause disease particularly if they are introduced into a different environment, such as from aspiration, surgery  or trauma.  Among these conditions represent the most common cases seen by an infectious diseases physician, such as pneumonia, surgical site infection, diverticular abscess, dental abscess, and urinary tract infections.  However, most of the times, our microbiome is either harmless, a state known as commensalism (+ for bacteria, 0 for host)  or even beneficial and important to human health, a relationship known as mutualism (+ for both).

Our bodies are actually a hybrid of human cells and bacterial cells.  In fact, we are more bacteria than human: 40 trillion bacterial cells compared to 30 trillion human cells, greater than 80% are red blood cells. Bacterial genes probably outnumber our human genes by 150 times.  Together our microbiome weighs between two and six pounds – about as much as an organ like the brain. 

Now that you have gotten a grasp of the scale of the microbiome, it is not a big leap to speculate that likely humans have evolved to accommodate this microbial relationship.  Microbes undoubtedly existed in the environment way before larger animals.  Our usual microbiome, although by no means static, is acquired from our first contacts with the environment, including the birth canal, the skin of the breast/hands of our mother, and later food.  The microbes in our gut may have been the key to the development of our gut immune system, which in an infant is at first impaired. since the gut is an entry point of the environment in the food ingested and is one of the immune system’s most active sites (70-80% of immune cells).  Stepping back a little, I will provide a broad summary of the gut microbiome.

green-bacteria

What is the gut microbiome?  How do gut bacteria affect the digestive tract?

The  “gut microbiome” describes those microorganisms that live mostly within the large intestine, or colon.  It is the environment that is the most populous of bacteria within our bodies.  Within the gut, there may be more than 1,000 different species of bacteria (even closer to 35,000! species).  The majority of bacteria thrive without oxygen, and are known as obligate anaerobes.  Scientists are only able to isolate 10-25% of the microbiota with culture techniques.  Instead they rely on more specific DNA testing (e.g. 16S ribosome).  Bacteria represent 55% of the dry mass of stool, an estimated 4×10 exp 11 bacteria per gram of stool.

Gut bacteria begin to affect the human from at least the moment of birth – if not before. Babies are exposed to bacteria as they pass through the birth canal – but there’s some evidence that the fetus may pick up bacteria while still in utero (in the womb).  Researchers can determine this by culturing from the amniotic fluid the meconium, or the first movement of feces (Walker et. al, 2017).  Even how an infant is delivered affects the first bacteria that they will acquire:  with normal vaginal delivery, common vaginal flora, such as Prevotella and Lactobacillus; with a c-section, skin flora mainly Staphylococcus. Within the infant gut, Bifidobacteria are among the first bacteria to be found. These bacteria, along with factors such as antibiotic exposure, hygiene, geography and nutrition, will influence the development of the gut microbiome and the immune system.

As a child grows, the gut microbiome expands to include numerous microbial species, the top being Firmicutes and Bacteroides (both accounting for 3/4 of gut flora), Bifidobacteria and E. coli.  Near adolescence, a child’s microbiome reaches a peak of diversity before it reduces to what is seen in a normal, healthy adult (Heiman M, Greenway F, 2016).  Greater gut diversity has been associated with health and wellness, and less diversity is associated with disease states. Diet is the principle driver of microbiome diversity (discussed below). 

The bacteria housed in the gut can fulfill several benefits in the human host.  Certain bacteria, such as Bacteroides activate the gut immunity, causing the intestinal mucosa to express a gut antibody (secretory IgA).  Other bacteria, such as Bifidobacteria and Lactobacillus, provide competitive inhibition, keeping harmful bacteria from adhering to the intestinal wall and potentially causing an infection.  These bacteria reduce the risk of microbial or toxin translocation, or “leaky gut syndrome” (I will refer to it as microbial translocation).  In microbial translocation, bacteria and/or toxins (e.g. lipopolysaccharide from E. coli) gain entry into deeper tissues or even the portal bloodstream (which drains into the liver) through weaknesses in the intestinal cell barrier.  Microbial translocation may contribute to disease manifestations, such as liver abscess, local processes like diverticulitis and appendicitis, irritable bowel syndrome (IBS) and even endocarditis (There is a certain pathogen Streptococcus bovis that is associated with colon cancer). Some chronic diseases increase the risk of microbial translocation, including Crohn’s disease, celiac disease, lupus, cirrhosis, HIV, and diabetes.

colon-biopsy

Slide showing colonic architecture.  This patient was found to have local tuberculosis infection of the colon.

 

Taking probiotics that contain Lactobacilli and Bifidobacteria may relieve the symptoms of IBS in some people, but for many a diet replete in plant fiber and with reduced simple sugars and processed foods is often useful.  Fiber provides a number of benefits, including regulation of stools and some benefit in preventing weight gain and reducing the risk of diabetes, cancer, and heart disease.  Some gut bacteria produce fatty-chain acids, which benefit gut health, by digesting fiber. 

What are some of the other effects of the gut microbiome?

An important function of the gut microbiome is the production of several vitamins, such as B vitamins (e.g. cobalamin (Vitamin b12) and Vitamin K, a clotting factor.  For this reason, people who are taking blood thinners like warfarin, may need to have their dose adjusted if they need to go on antibiotics (antibiotics kill bacteria – lead to less vitamin K and less clotting protection).

The gut microbiome can also affect the central nervous system and autonomic nervous system, sometimes referred to as the gut-brain axis. For example, some gut bacteria produce metabolites which are similar to neurotransmitters, chemicals that are used by our nervous system. One of these serotonin is produced almost entirely within the gut and exerts a positive effect on the mood.  Millions of nerves connect the gut to the brain, so the gut microbiome may also regulate the messages that those nerves send to the brain. Some researchers have found differences between the gut microbiomes of healthy people and those of people with psychological disorders. Such differences suggest that the gut microbiome may affect mental health. It is still unclear if diet and other lifestyle choices affected those differences.

The gut microbiome helps control how the body responds to an infection by communicating with the immune system, and those communications keep the immune system from attacking beneficial bacteria. As Vitamin A strengthens the immune system, the gut bacteria control the amount of active Vitamin A in the system to keep the immune system from becoming overactive. In 2018, researchers at Brown University found that inflammatory bowel disease was caused by disrupted communications between the gut microbiome and the immune system.

How does the gut microbiome affect the heart and circulatory system?
The gut microbiome may also affect the health of the heart. A 2015 study involving 1500 people found that gut bacteria affected cholesterol levels. More specifically, they affected the production of triglycerides and HDL, “good” cholesterol. The researchers also found that certain bacterial families were less common in people who were overweight or obese.

Some harmful bacteria can increase the risk of heart disease by producing a chemical called trimethylamine N-oxide (TMAO) that can cause blocked arteries and can thus lead to a stroke or heart attack. TMAO causes blocked arteries by increasing coagulation. Some bacteria produce TMAO by converting L-carnitine and choline, which are nutrients found in animal products like red meat, into TMAO.

Gut bacteria can also affect blood sugar levels. In 2015, researchers worked with 33 infants who were genetically predisposed to developing Type 1 diabetes. The scientists noted marked changes in the infants’ gut microbiomes right before they developed diabetes: The diversity of their gut microbiomes declined, and the number of harmful bacterial species increased.

Another 2015 study found that people who followed the exact same diets could have different blood sugar levels. The researchers speculated that the differences were due to variations within their gut microbiomes.

What is gut dysbiosis or bacterial overgrowth?
Gut dysbiosis, or bacterial overgrowth, represents an imbalance between beneficial and harmful bacteria, where selection pressures favor the growth of more harmful bacteria and less microbial diversity.  The multiple causes include behavior (alcohol, hygiene, etc), certain medications, some chronic disease, antibiotics, and significant stress.

Behavior.  Diet has a strong effect on microbiome.  In the infant, breast milk provides an advantage for the growth of Bifidobacterium, which is not as prevalent in infants fed formula.  In adults, an intake of higher fruit and vegetable fiber, even if done for a short period of time, results in greater diversity of gut bacteria.  A western diet, high in animal protein, sugar and starch and low in fibers leads to a predominance of Bacteroides. 

Unprotected sex, particularly anal-oral sex, can lead to gut dysbiosis simply by exposing the participants to harmful bacteria.  Other than sexually-transmitted diseases, transmission of Salmonella and Shigella has been associated with higher risk practices. 

Additionally, poor dental and oral hygiene causes an increase in numbers of certain bacteria to that grow in the mouth, such as Streptococci and Prevotella and with this can cause imbalance in the entire population.  

Medications.  The main medications involved that can lead to dysbiosis includes antibiotics, proton pump inhibitors, steroids and chemotherapy.  Antibiotics can selectively wipe out certain bacteria or have a more generalized action, depending on the spectrum of the effect.  The more broad-spectrum an antibiotic, the greater the risk for significant gut dysbiosis.  Antibiotics such as fluoroquinolones, clindamycin and cephalosporins are among the greatest risk factors for Clostridium difficile (C. diff), known for toxin-associated diarrhea and more severe colitis.  The resulting infection causes symptoms like abdominal pain, watery diarrhea, nausea, and fever.  Proton pump inhibitors, and to a lesser extent H2 blockers (zantac, pepcid, etc) reduce the acid that is produced by the parietal cells of the stomach.  Acid is an important defense to bacterial populations ingested in food or drink.  This type of medication has been associated with an increased risk of C. diff, traveler’s disease, and gut dysbiosis or bacterial overgrowth.  Prednisone and other anti-inflammatory modulate the immune system.  There is also an impairment of glucose synthesis, referred to as a diabetogenic effect.  This can lead to an increase in populations of yeast and other microbes.  Some chemotherapies affect white blood cell lines temporarily, the greatest immune being the gut, and can be a source of gut translocation and fever. 

Disease conditions.  Gut dysbiosis has co-associated with a variety of conditions including irritable bowel syndrome, diabetes, inflammatory bowel disease, obesity, Type 2 diabetes, rheumatoid arthritis, psoriasis and atopic eczema.  Whether a particular microbiome signature is found in a specific disease state (e.g. cancer) is the subject of research efforts.

Stress states.  Various states of stress increase the production of hormones such as epinephrine, norepinephrine and cortisol.  For instance, surgery leads to excess norepinephrine release, which has been associated with overgrowth of Pseudomonas aeruginosa in one study.  Psychological stressors, even short disruptions, could alter microbial populations as well, likely related to stress hormones.

 

Get to Know Your Gut Bacteria.  The following is a general overview of the most common bacteria in the colon.  Although, given the situation (mainly diet), the overgrowth any type of bacteria could cause host effects and increase inflammation.

Bifidobacterium and Lactobacillus help to protect the gut from harmful bacteria Plant-based foods which contain polyphenols, found in nuts, seeds, vegetables, teas, cocoa, wine and berries, feed these beneficial bacteria.  There may be a benefit in reducing inflammation in the cardiovascular system.  Bifidobacterium is also associated with butyrate production, which has a protective role in the gut and anti-inflammatory effect.

Bacteroides and Firmicutes are found in a healthy gut.  Consumption of a plant-based diet with no animal fat or protein has been associated with greater populations of these bacteria.  Plant starch can also lead to a greater population of Bacteroides, also tied to obesity prevention/treatment.

Prevotella, also may favor a setting of a high fiber, plant-based diet.

Ruminococcus is more associated with a diet higher in fruit and vegetables.  These bacteria are associated with breaking down complex plant carbohydrates and producing butyrates.

Bilophila and Faecalibacterium are found in increased populations in a high saturated fat diet and may be associated with increased inflammation.

garden-fresh-vegetables-variety

How can you improve your gut microbiome?

  • Healthy, Diverse diet:  For example, eating fruits and vegetables, replete with fiber, will increase the diversity of the gut microbiome.  Consuming less simple sugars and processed carbohydrates will also help to maintain gut bacterial diversity.  Eating fiber-rich foods like fruit, beans, whole grains, and legumes can stimulate the growth of Bifidobacteria. Whole grains are also a good source of beneficial carbohydrates that can help control weight and reduce the risk of cancer and diabetes. Prebiotics are a type of fiber that stimulate the growth of beneficial bacteria. Good sources of prebiotics include apples, artichokes, asparagus, bananas, and oats.Fermented foods like yogurt and sauerkraut contain beneficial bacteria like Lactobacilli and can decrease the number of harmful bacteria in the gut.

          By contrast, people should avoid diets that are high in simple sugars, such as with              processed foods, sweets and sweet drinks.  Even using artificial sweeteners like                  aspartame can stimulate the growth of harmful bacteria like Enterobacteriaceae                that can raise blood sugar levels.

  • Take antibiotics judiciously, when you really have no other choice.  Remember that probably 50% of antibiotics that are prescribed in the outpatient setting are unnecessary.  In my experience, this mostly occurs in the setting of a viral syndrome (upper respiratory tract infection), rhinosinusitis, or a miscellaneous skin condition.  The shift in microbe flora can lead to yeast infections and other dysbiosis, including a risk of C. diff.
  • Good sleep, regular exercise and good coping are likely also help.

Summary:  The gut microbiome should be considered an important “organ” in your body.  The greatest effects of our microbiome are in modulating the immune system and aiding in nutrition and digestion.  Studies have suggested a healthy, diverse state of microbiome is necessary for health and lack of complexity has been co-associated with disease states.  When you eat – you eat for your microbes too!

 

If you enjoyed this, pass it on to your friends and contacts.  Be sure to register your email for the latest posts and updates!

 

 

Heiman ML, Greenway FL.  A healthy gastrointestinal microbiome is dependent on dietary diversity.  Molecular Metabolism.  2016.  5(5): 317-320.
 
Jandhyala SM, et al.  Role of the normal gut microbiota.  World J Gastroenterol.  2015 Aug 7; 21(29): 8787-8803.
 

Ruiz-Ojeda FJ et al.  Effects of Sweeteners on the Gut Microbiota: A Review of Experimental Studies and Clinical Trials.  Adv Nutr.  2019 1;10(suppl1): S31-S48.

Tomova et al. The Effects of Vegetarian and Vegan Diets on Gut Microbiota.  Front Nutr. 2019; 6: 47

 
 
Web resources:

https://www.healthline.com/nutrition/gut-microbiome-and-healthhttps://www.ahajournals.org/doi/10.1161/CIRCRESAHA.115.306807
https://www.cell.com/cell-host-microbe/fulltext/S1931-3128(15)00021-9?_returnURL=https%3A%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS1931312815000219%3Fshowall%3Dtrue
https://www.cbsnews.com/news/nutrient-choline-eggs-meat-linked-to-blood-clotting-heart-disease/
https://www.sciencedaily.com/releases/2018/12/181218123123.htm
https://www.healthline.com/health/digestive-health/dysbiosis
https://www.verywellhealth.com/what-is-intestinal-dysbiosis-1945045
https://en.wikipedia.org/wiki/Dysbiosis
https://en.wikipedia.org/wiki/Proton-pump_inhibitor

 

 

 

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The Fractal Whisperer: Musings on health

What is “healthy” and would you know it if you saw it?

From nature, we gather our understanding of life and how our environment affects us.  We develop insights or “laws” – of gravity, entropy and heavenly bodies, through the observations we make in the world around us. 

At its essence, a law is a concept that is simplified, universal and expected.  If I dropped my cellphone as I was trying to put it into my pocket, I would expect that it would fall down not up.  The same goes with any sized object and from any height.  In health, for a law to exist, we would expect that it would be, at its core, an explanation that could be applied to any living organism with consistent results.  Even as we gain a greater understanding of molecular structure and other chemical signals that interface with health and disease, a law would be further enhanced through these discoveries, not broken.      

We are at a crossroads in our understanding of health, which I believe will take us to a time where more people will be able to realize better health and enjoy a long and productive life.  Can our understanding of “healthy” form a basis of how to construct health promotion and disease prevention efforts?  For example, wouldn’t it be better to determine a patient at risk for a stroke, than for s/he to have one and offer therapy afterwards.  Although many doctors already see patient with behavior challenges in their clinics – those who continue to smoke or do harm to themselves that do not want to change.  We already know that our current health system is “problem-focused” and limited in scope, since addressing disease is a palliative effort compared to preventing it and assisting in behavior change.  Still pharmaceutical companies spend millions of dollars on research and earn millions more on medications for depression, diabetes, heart failure and erectile dysfunction.

What is “healthy” and would you know it if you saw it?

The motif of nature and the four seasons and how it resonates in understanding our lives has been the subject of much writing and poetry.  We are born, as a seed germinates, then develop and ripen to our sweetest and most active forms before we begin to diminish, wither and die.  Nature is also a biologic mirror as well to the story and structures of our bodies…which takes me to a contemplative walk in the park to think of these questions.

Does nature provide lessons to us about our health?

When I am out in the park, I take a look at the oak trees and think about their components from most peripheral to most internal:  the leaves, the branches the trunk, the bark, and the roots.

The branch formations of the oak tree are vaguely familiar to our bronchiole system

In the spring, I look around and see the trees and their outstretched branches with blossoms in full bloom and small leaf buds starting to develop and grow into what will become full leaves in summer.  Each leaf shows veins that make patterns not unlike the branches of a tree itself.  The leaf identifies the tree and vice versa.  Using a magnifying glass, I see how complex the patterns areI realize that each leaf is fulfilling a role for the entire tree.    Is optimal growth and functioning a clue to what it is to be healthy as humans?

Our respiratory system reminds me of the trees and branches that I see outside on my hikes.  I read that if you were to take the segments of our lung airways and place them end-to-end, it would measure 1500 miles!  That is a lot of detail inside our chestThe characteristic of branching patterns that display self-similarity is the definition of a fractal.  This complexity seems inherent in what it means to be healthy.

It also interesting and not coincidental that our lungs represent the pathway of oxygen into the bloodstream, while the leaves are the surface, in which carbon enters the tree and oxygen exits.

How does outside interact with inside?  With a tree, there are two routes:  from the immediate outside – that which the leaves and branches comes directly across and from within the network of roots that connect the outside soil to the trunk, branches and leaves.

It is fascinating to see how a seed that may have been carried by the wind or a bird was able to germinate – in otherwise desert of volcanic rock where only lichens are seen.

The trunks of some trees that I see have either small knobby areas or oval-like structures which are known as a callus.  It occurs when something happened to the tree that disrupted the bark.  The tree heals like what would happen if we had an injury to our skin – our skin heals with a scar.  Does that tell me about what happens to our health?

My mother was diagnosed with diabetes when I was in medical school.  I learned that blood in her circulatory system became thicker and overburdened by too much sugar, as insulin secretion was diminished or was made less effective by adipose tissue.  Even the process of the decay in insulin production is tied to a similar disease process.  In this setting, the sugar could get through the entire system and cause changes from within the circulatory beds that can affect one’s vision, kidney function and sensation – their ability to feel what they are touching and more.  This could lead to skin ulcers on their feet and legs.  What initially starts in the circulatory system leads to damage to the other systems and affects the body as a whole.

So, health seems to relate to the natural design of our body and how it adjusts to the outside environment.  Like the root system in a tree, maybe our gastrointestinal system serves that purpose in our bodies, by breaking down the food we eat and absorbing the nutrients, proteins, sugars and fats in food.  Our liver is a filter system with a series of tubes that allow detoxification of the blood to be secreted as bile in the intestines.

How can we see the health of the trees and our body from the outside in?

When I look at nature and analyze the trees, I notice that some of the trees don’t look completely upright or as healthy as others.  What happened in the lives of those trees?  When I see how leaves change color in the fall, the color changes occur along the areas of the venations or are initially small areas where chlorophyll pigmentation has altered  

I notice people who are overweight and wonder what is happening in their bodies to cause them to gain weight. Is it just a question about what types of food one is eating that leads to this weight gain. Maybe it is like a plant that deals with a specific type of soil nutrient – it continues to work, even if the soil may not be right, until it can later improve. Only we are putting in the wrong food source.

Does the body work better when it is a specific weight?

A tree is capable of making its own food source through photosynthesis using the light of the sun, chlorophyll and water. As the food is created by the tree, it is directly used in growth. Any unused sugar is transported from the leaf through the phloem to be stored in the trunk or roots as a starch. It can then be converted back to sugar for growth during the next spring.

This process is not unlike what is planned in our bodies with the excess sugar. We take in food – sometimes in disequilibrium, which is utilized for maintenance and functioning of the body. Any excess sugar will be stored in the adipose tissue as triacylglycerols to be used for growth or in a state of starvation (such as in between meals).

The process of storage in adipose tissue continues providing there is a trigger – and it comes in the form of excess carbohydrates in the diet. In one way glucose is a energy source for the body; in another way, it is toxic to the blood in high levels. Insulin’s role then is to transport sugars out of the bloodstream to be used as energy – including energy storage. This leads to deposits in adipose tissues and weight gain. It is only with a shift in diet toward lower carbohydrates, that these stores can be utilized and weight loss can occur.

Excess adipose tissue hinders movement and body mechanics, alters pressures and challenges metabolism, thereby affecting normal processes. The adipose tissue makes it harder for the heart to beat and the lungs to aerate properly.

To some extent, the body adapts – but only up to a point. Complex organisms are able to adapt, the term homeostasis. When my father was diagnosed with high blood pressure, he was told that it might get better with weight loss. He fueled himself with a mostly plant-based diet and at one point lost weight. Even with as little as five to ten pounds, blood pressures improve. These changes seen in weight normalization are far greater than the activity of any pill.

How does our food intake affect our health?

I observe how leaves and other vegetables are so complex and whether that is the way our food should be – more complex in structure.

Romanescu Broccoli, a natural fractal

In Sicilian, things that are good are measured up to bread. “As good as bread!”

Look at the foods above: the top is Romanescu broccoli and the bottom is sliced bread. Compare the inherent complexity of spinach leaves, cauliflower and cabbage with that of processed foods, originally harvested from nature. The very act of processing food releases some of the most important constituents of food – the fiber – to create a food more akin to Euclidean geometry – the square piece of bread, the round cookie or biscuit. These foods are composed of simple and complex sugars.

It seems that these simple foods that we eat may be the wrong types of food for our complex bodies. The foods are held by loose bonds that break upon entering our mouth. There is no further digestive component needed, and the sugar is absorbed into the portal bloodstream through the jejunum. The liver meets it head on and attempts to detoxify the glucose. Insulin shifts the sugars to be stored as glycogen and fat in the liver, and once a critical threshold is met, complexed sugar spills out into the bloodstream as triglycerides. They trigger inflammation in the blood vessels contributing to atherosclerosis or otherwise get stored in adipose tissue. What was taken from the outside is processed in the body and enters into the bloodstream to affect our our entire body. The spikes in insulin and products of bacterial fermentation of sugar in the gut lead to important biological changes including creating pleasure and craving with foods higher in sugars, to the further detriment of the organism. It is only further compounded by liquid sugar found in sodas and juices.

How about getting older?

As we grow older, our structure changes – we shorten in stature because our bones demineralize and desiccate (dry up); our skin wrinkles and fingers and toes get colder; we can’t see or hear as well as our eyes and ears change.  My patients remind me that even our ability to taste decreases – and might lead some to choose sweeter foods.  Do these changes represent the tip of an iceberg about what is happening in our entire bodies?

When we look at the season of autumn – when the leaves start to dry up and change color.  A close look at a leaf with a magnifying glass reveals that these changes in color and appearance of the leave occur in small fragments congregating around the venations of the leaf prior to the confluent color change.  Similarly, the changes of the skin – a decrease in collagen production – that produces wrinkles occurs over time, as we move toward a phase of wilting.

Depending on how warm the climate is, the leaves on some trees stay viable toward the month of December, while the trees in colder climates are bare of leaves by then.  Are there ways to reduce the process of aging in our bodies?

It also reminded me of our experiment with Protozoa, single-celled organisms.  As a child, I remember a class experiment with Paramecia, where we put a dropper full of concentrated saline (salt) solution into the fluid where the Paramecia were swimming around.  Immediately, they swam away in the opposite direction from where the solution was coming.  Does our body have a way to protect itself from these changes?

The acid-base buffering system of our body is an example of how dynamic our bodies are.  If there were an ingestion of acid (like a poisoning of aspirin, causing metabolic acidosis), our body would be able to balance that effect without killing us – up until a point.  It wouldn’t be the same with the Paramecia – they would die with a little perturbationOur bodies are able to adapt to the environment and that dynamic ability is a picture of health.

Think about how our heart beats – is it like clockwork?  It actually isn’t.  The system adapts to changes in position, respiration and other stimuli to allow for the dynamic sinus arrhythmia.  Studies have found that when pulsations are less dynamic, there is an increased risk for mortality. 

Is the “climate” in our bodies something we can control – and can this extend the time of our healthy years?  It reminded me of my grandfather who a lot of people thought was younger than his age.  You and I have seen people in the gym, thriving, working out and keeping up with others decades younger – and the looks of disbelief when they reveal their age.  

Think about the natural cycle of nature – starting with the blossoms and leaf buds of the spring, proceeding to the fully developed leaves of the summer, then with the changes and eventual death of the leaves during the autumn and the slow state of the tree during the winter time.

Do we also become less complex as we go through this process of dying?

What is health and how can I tell it when I see it?

That brings us back to the first question.  I am observing what is happening in front of me, though it proceeds as it has for decades and centuries.  Trees stay alive even during the winter – the main structures that die are the leaves, only to grow back next spring. Even this process is happening in our bodies, as we shed hair, skin and cells in our gut – up until a point – some of which is programmed and some of which is modifiable.  We are interested in the modifiable. 

As I see it, health is a state that is far from staticit is the ability of an organism to withstand the environment, to harness it and to grow and maintain itself – to thrive.  We have organs in us similar to filter system or a root system which allow us to take in nutrients needed for growth and metabolic operations and use what is in the environment.  Just like the when you cut a tree you don’t see the soil inside it, so too does our blood work with what is absorbed after the liver detoxifies it – up until a point. 

Our bodies are a reflection of what is inside and how it relates to what is outside.  A diabetic may have numbness in their legs; a person with high blood pressure may have swelling in their legs; a person with a bad liver will develop jaundice.  As our bodies change, our structure changes and inherently our function changes.  We do have some control over this.  I am reminded of some of my patients, after they were diagnosed with diabetes, who started an exercise program and began to eat healthy food:  they were able to lose a significant amount of weight and reduce or stop insulin and other diabetic medications.

Ultimately what is in play is a shift from our more complex, functioning, dynamic lives to one where complexity diminishes, either slowly, from the blunting and structural changes in aging, or more rapidly, with the damage that occurs with disease.  The change in complexity to simplicity reaches a threshhold when we die – and even then our bodies further disintegrate into the various chemicals that were holding our lives in place.

Summary

1. Health requires the interplay of multiple complex structures that provide protection, buffering and dynamic adaptation to the host.

2. Disease can occur by way of external (injury or trauma) or internalized toxins (via the gastrointestinal system). Chronic metabolic disease occurs in the bloodstream and works its way through the entire body via the bloodstream.

3. Food should be complex, largely plant-based to balance short and longer term energy needs, while avoiding excess of simplified, processed foods that are easily broken down and enter the bloodstream.

4. Aging and disease represent forms where the complex structure begins to be blunted or simplified largely as a result of inflammation and scarring, such that a change in structure leads to a diminishment of function. These changes are in part modifiable.

5. The body external is a window to the body internal and We achieve dynamic stability as we approach being “healthy”.

Thanks for reading. If you enjoyed what you read, please share.

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A brief discussion of our daily (genetic) expression of self

I hope everyone takes some time out each and every day to appreciate and marvel at the wonderful miracle that is your life. Isn’t it fascinating that all of our cells have the DNA which define how the entire system works? It is only through various cell signals that these cells express DNA differently to become specialized into the tissues that make up our bodies.

I think as we gain a greater understanding of epigenetics, and even with what has already been understood, we begin to see genetics as “fluid” not static, i.e. capable of being optimized by the way that we live as humans in the environment, the way in which we manage our physical and psychological stressors, the food and drink that we consume, and how we treat our body (sleep, habits, social) from day to day. Already studies are finding trauma, poor sleep and diet have been tied to increased inflammation and changes in genetic expression. The central dogma is explained by DNA being transcribed to RNA and then translated to protein.  So when we speak of expression, it entails that both of these steps are optimized at the time of these actions.    

The empowering message of all of this is that we are not only a sum-total of the genetic legacy that we inherit but also how we live our lives. We are not fated by our parent’s “bad genes” but how we actively choose to live our lives and the behaviors we foster. As trauma is interwoven with our genetic expression, our lives are not as much about applying blame to the negative experiences that we have had but how we interact with them to create resilience and growth.

As we live this human experience, we blaze a path into the uncertainty that is our future.  Each decision that we make and do not make contribute to the quality of our live at this moment and ultimately factors into our healthspan – the period at which we can stay healthy and are capable of performing all of the activities that give meaning to our lives.  Ideally, if healthspan perfectly coincides with lifespan, we die in our sleep sometime in our nineties – the day before having enjoyed <insert meaningful daily activity>.

So the ball is really in our court, when we think about all our thoughts, behaviors and actions, are we making overall the healthiest choices?

For diet:

Are we consuming the food and drink that is easiest to digest for our body, that contains a surplus of nutrients and that is free of toxins?  Using a car analogy, what would happen if you gave your car the wrong fuel?

For stress and lifestyle:

Do we really need to take issue, have a breakdown, yell and name-call so that our needs can be met or that we can get our points across?  Obviously, this is a complex interaction and cannot be resolved simply by thinking yourself out of it. Or can it?  Are your needs being met?   Would adding just a little time in between received message and expressed response allow our mind to construct the message that has reduced internal bias, preparing our bodies to not be thrown into a flight-or-fight response?  For instance, the cortisol, epinephrine and norepinephrine released from stress or trauma, real or perceived, have been associated with pro-inflammatory states that may affect genetic expression.

For sleep:

We enjoy the time we have and living in the moment.  Sometimes this may lead us to continue to revel in it.  Do we need to rob ourselves of consistent sleeping habits to watch one more movie or to work the night shift?  This is similarly another challenging question in those whose livelihood depends on the extra money received by working nights.  But, is the financial compensation really worth affecting your health?

Final points to ponder:

1. How can we show gratitude to our bodies in the activities that we choose, the food we eat and through self-care?

2. How do we really spend our time each day? Do we just “wing it” and do the activities that we wish or do we plan a general path of our leisure time?  When we see a musician and think about how someone can be so skilled at an instrument, we often forget that their skill developed through time – short periods spanning years, rather than long periods spanning days.  Patience and discipline can be used toward “I always wanted to do that” goals.

3.  Think about your day being a mosaic of how you would like to direct your life.  In a way, it can then become a step on the path to the future you.

4.  Oh and as for cell phones – I have used the iPhone and have been surprised at how much active time I am spending on it daily.  Can you and I turn our phones off or put them in airplane mode for a larger part of the day?  Can we speak to the loved ones in our lives that our near to us, rather than the near-strangers in our lives that are far from us?

The last words come from from Satire X of the Roman poet Juvenal, credited for the contribution of the Latin phrase, “mens sana in corpore sano“, or “a healthy mind in a healthy body,” which is at the center of Your Health Forum:

You should pray for a healthy mind in a healthy body.
Ask for a stout heart that has no fear of death,
and deems length of days the least of Nature’s gifts
that can endure any kind of toil,
that knows neither wrath nor desire and thinks
the woes and hard labors of Hercules better than
the loves and banquets and downy cushions of Sardanapalus.
What I commend to you, you can give to yourself;
For assuredly, the only road to a life of peace is virtue. (t,r),

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Protecting Your Brain: Aging and Brain Health

September is Alzheimer’s disease awareness month. Many of you may know friends or family members who are in their seventies or older and are developing signs of mental slowing, or mild cognitive dysfunction or already have Alzheimer’s disease. I have seen the same changes in my parents as well. As Your Health Forum is all about prevention and risk reduction, this post will take a summary of dementia a step further and offer measures – all without a prescription – that can assist one who has mild cognitive dysfunction and protect others from ever developing it.

Introduction

An estimated 14% of the population over 70 has signs of cognitive decline characterized by a progressive decrease in memory, processing, recall and executive function. The endpoint of this decline is dementia, or major neurocognitive disorder, as preferred by the Diagnostic and Statistical Manual of mental disorders (DSM). If you are among the fortunate ones who live to be a nonagenarian (90), an age group that now compromises about 5% of the US population and is expected to increase, there is a one in three chance that you will develop some degree of dementia – a not so fortunate prospect.

Worldwide, it is estimated that approximately 47 million people are living with dementia, mainly in developing countries. In the background of an obesity epidemic which has had the greatest toll in these countries, prevalence rates of dementia are projected to rise in the ensuing decades.


From: The Lancet 2017 390, 2673-2734 DOI: (10.1016/S0140-6736(17)31363-6

Although cognitive decline occurs with aging, it does not just suddenly begin when you hit a certain decade or birthday. Cognitive decline probably begins around middle age. In a cohort study of British civil servants, researchers detected deficits in cognitive testing even in a 45 to 49 age group when compared to their testing a decade earlier (-3.6%). The gap widened in the 65 to 75 age group, with a decline of almost 10% of their testing a decade earlier.

Your risk of dementia is not random or left to the fates. What if dementia were like a train heading toward an inevitable cliff and within our control are the accelerator and the brakes? There are several proactive measures that can reduce the velocity of decline and even stimulate new brain growth as we age.

The post will outline the mechanism of decline in the brain’s processing, along with ways in which we may preserve our brain’s health. The overarching theme is when the body is healthy, the brain is healthy.

Mechanism of Cognitive Decline and Dementia

When most people think of dementia, Alzheimer’s dementia comes to mind (no pun intended), which comprises 60-80% of cases of dementia; vascular dementia is the second most common type. The pathology of Alzheimer’s dementia involves the build-up of protein substances in the brain, beta-amyloid in senile plaques and dysfunctional tau in neurofibrillary tangles (see image below). These progressively damage the brain’s neurocircuitry and leads to brain shrinkage, or atrophy. Studies have supported that the physiology of degeneration of other forms of dementia, although each with distinguishing attributes and causes, is not that diverse from Alzheimer’s dementia and likely overlap.

Taken from Alzheimer’s Disease Education and Referral Center (ADEAR) from National Institute on Aging

What is less clear is why this occurs? Traumatic experiences, both physical (including traumatic brain injury (TBI)) and psychological, and chronic disease states have been associated with an increased risk of developing dementia. Focus will be on chronic diseases.

Beta-amyloid and other inflammatory markers are elevated substantially in insulin resistance and obesity states. Although there is a negative relation of dementia risk and higher BMI in the elderly (it may be due to higher BMI correlating with muscle mass), mid-life obesity was associated with a higher risk as BMI increases. Being overweight or obese increases the risk of developing dementia by 2.3 and 3.6-fold, respectively. Significant obesity unleashes a maelstrom of inflammatory substances including triglycerides, that increases β-amyloid production and leads to progressive changes. Obesity and all of its associated conditions, including diabetes, high blood pressure and sleep apnea, contribute to dementia.

Signs and Symptoms and Work-up of Dementia:

A person with mild cognitive impairment may develop more serious dementia over a period of several years, though more rapid decline can occur. A concept known as cognitive reserve has been shown in individuals with higher education and occupational skills, and relates to a resilience that protects one from a more rapid decline even in the face of greater pathologic changes. It is postulated that it may be related to greater neural links, i.e. greater neuroplasticity, that compensate a person.

Symptoms of dementia include short and long term memory loss, word forming issues, speech and comprehension decline, misplacing objects, confusion, agitation and change in behavior. The severity of the symptoms progress over time. What a person might initially dismiss as a part of their personality, “I can be forgetful”, transforms into a convincing deficit. The news can be devastating when a person realizes that they are going through these changes. There is also a significant stigma associated with cognitive decline and dementia.

Dementia can be assessed in the clinical setting with several screening tools. Usually a family member who suspects that their loved one is developing dementia will accompany them to the clinic visit or alert the provider. A clinician will perform a Mini-mental status exam (MMSE – below) or other screening test, take a history and a examine the patient to assess for any obvious risk factors or physical findings. The patient’s medication list will be reviewed in detail for any concerns (See Polypharmacy post). The examination will look for cardiovascular associations (carotid bruits (turbulent sounds) from increased atherosclerosis).

The clinician may order screening bloodwork (e.g. CBC with Diff, Homocysteine, methylmalonic acid, Thyroid (TSH) and RPR (screen for neurosyphilis). A blood test of amyloid precursor protein (APP) levels looks like it may be promising to be as an adjunct in the work-up for dementia with a high sensitivity. An MRI with diffusion weighted images or A PET scan of the brain may also be ordered. All of these studies can assist in making the diagnosis of dementia and rule out other causes.

Dementia-Prevention Duty! – 10 Ways to take charge:

Fortunately, there are some things that can be done to help delay, and in some cases, prevent cognitive decline that is normally associated with aging. Though it requires an important change that becomes more difficult as dementia advances – one of behavior. A healthy lifestyle may afford significant improvements in memory, mental clarity, and even emotional balance. Not included is mention of medication options or supplements. As with many things in health, prevention and addressing cognitive impairment at its earliest stages has the most effect. Get your health as optimal as possible with these simple steps and make some lasting changes to improve your brain health:

1.Keep the body moving

For such a small organ that is the brain, weighing only 3 lbs, it commands approximately 20% of the total blood supply and oxygen demand of the entire body. Improvements in aerobic capacity of the body maximize the functioning of the brain. One randomized control trial of 120 older adults showed that aerobic activity can increase the hippocampus, an area known for spatial demensions, by 2% and trigger higher levels of Brain Derived Neurotrophic Factor (BDNF), responsible for building new neural connections. Aerobic exercise increases cardiac output, not only conditioning the vessels of the body but also the brain. Increased oxygen delivery to the brain cells allows for neurogenesis and the retention of memory and critical thinking.

In addition, weight-bearing exercises, particularly with lower extremity strength building, have been shown to improve the production of neurons and create new synapses in the brain. These studies support the neuroplasticity of the brain to improve connections associated with physical movement. This can be particularly effective in those who suffer from neurodegenerative diseases such as Parkinson’s disease and Multiple Sclerosis. These patient are at increased risk of cognitive decline, directly associated with progressive mobility limitations.

2. Ensure that all senses are functioning at their best (use devices if needed)

Hearing impairment is significantly and independently linked to a greater risk of developing dementia. One study in 2011 conducted by Lin et al. showed mild, moderate and severe hearing impairment were directly associated with a 2-fold, 3-fold and 5-fold risk of dementia over a 10 year period – a “dose-dependent” association.

The mechanisms behind this are likely multiple. The auditory cortex is located at the temporal area of the brain, in the same area where the speech centers. The cochlear nerve (in the middle ear) which encodes the sound and carries the signal to the auditory cortex. The auditory cortex also linked to the thought processing, other sensory perceptions, emotion generation and speech. Imagine not being able to hear something clearly because of hearing impairment — the material cannot be retained in memory.

A progressive decline in hearing is part of aging – but can be accelerated by the impact of tympanic damage from loud noises. Unfortunately, the rates of hearing aide use have been reported to be less than 25% of those that could benefit from them.

Sure, the eyes can develop a skill such as lip-reading, which enhances auditory peripheral encoding. But — another change that occurs with aging and accelerates in dementia is visual decline. Optimizing the senses can promote maximal ability to socially interact, synthesize data and maintain learning – all of these activities preserve neural circuits and mitigates dementia.

3. Keep calm and carry on.
Unhealthy stress and trauma, be it from real or perceived psychological or physical abuse, is intimately tied to increased activation of the stress response (hypothalamic-pituatary-adrenal (HPA) axis, leading to production of cortisol by the adrenal glands. Higher levels of cortisol have been associated with memory impairment and even lower brain volumes in middle-aged adults.

The brain benefits of stress reduction techniques, such as meditation, are numerous. Most of us are aware that meditation helps to quiet the mind, clear our thinking, and reduce stress, but there is actually a change in brain chemistry that results from this. Physiological changes include:

  • An increase in the production of glutathione, the “mother of all antioxidants” which has been shown to be decreased in mild cognitive impairment.
  • Preservation of telomere lengths and decline at slower rate within your DNA. Stress perceived or real has been associated with telomere shortening, and hence greater cellular aging.
  • A possible increase in the production of Brain Derived Neurotrophic Factor, which leads to new neural development and reduces the risk of dementia

Just a few minutes of quiet breathing per day is enough to get you started in the right track to improving and preserving cognitive ability, bolstering your cellular vitality, and improving overall health.

4. Eat like it matters
Would you put the cheapest fuel in a race car and expect top performance? Similarly, we should think this way about our bodies. However, with a third of the US population now obese, eating habits are hard to break. Convenience and comfort foods like high-carbohydrates and processed foods are linked to obesity, diabetes and atherosclerosis, hardening of the blood vessels that carry blood throughout the body – the circulation of the brain included. An increased risk (RR 1.16, without diabetes, 1.4 with) was seen in one study in patients with higher glucose levels even without diabetes. Eating a diet rich in fresh produce, whole grains, and quality proteins is ideal for optimal brain and body health, as well as promoting optimal weight. Eat like it matters, because it does.

5. Maintain social connections and healthy relationships
If you run on the introverted side (like me), it may be better for the sake of your mind to sway toward the social butterfly side. It may be related to the stimulation of conversation and neurotransmitters that shape and protect the brain. In one study, loneliness was associated with a double the risk of dementia in a four year longitudinal cohort study of 823 older persons. Brain derived neurotrophic factor (BDNF), responsible for building new neurons and neuroplasticity, increased with social interaction, as shown in an animal study. Additionally, the Harvard study showed a multitude of benefits of longevity from social connection in middle age and beyond. Those individuals that maintained rich social connections and loving relationships with family were less likely to develop dementia and other related diseases. Neurotransmitters such as dopamine, oxytocin “the love hormone”, and serotonin are likely at play. If there were any reason to maintain old friendships and develop new ones, brain health would be it. Maybe that is why one is silver and the other gold.

6. Get some sleep!
Even one night of compromised sleep can adversely affect brain chemistry. Quality sleep allows the brain to clear out toxins that naturally accumulate during the day. Researchers at Duke University studied the effects of gamblers in various states of sleep deprivation and found that those who had gotten enough sleep tended to make conservative decisions when playing. Sleep deprived players, however, made riskier decisions that ultimately resulted in the loss of both money and time that otherwise wouldn’t be spent in that atmosphere. Never underestimate the power of a good night’s sleep; it is your body’s best reset and protection against illness, disease, and aging. For more information of the importance of sleep, refer to a past submission.

7. Spend time outdoors in nature
Taking nature walks is not just good for your body; they are good for your brain as well. Taking a nature walk is not only an exercise but also a multi-sensory experience. A growing research base suggests that experiences that stimulate multiple senses often lead to improved neural circuitry, likely protecting against dementia. A reduction of stress and blood pressure are also seen – both factors related to dementia. Other benefits include improved sleep, a stronger natural immunity (natural killer cells), fewer disturbing and troublesome thoughts, and an overall sense of happiness. Even after dementia has develoed, initiatives to provide those with dementia nature hikes have shown improvements in connection and motivation.

8. Stay at a healthy weight
As stated before, research has consistently shown that those who experience weight gain or obesity in mid life are significantly more at risk for developing dementia and experiencing cognitive impairment. Conditions that are prevalent in obese individuals such as hypertension, cardiovascular disease, and diabetes all have their adverse impacts on the brain; keeping fit and healthy through the middle of your life might not always be easy, but it is essential to reduce the risk of cognitive decline.

9. Pick up an instrument or just sing along.

Music therapy for dementia can have a number of positive effects on the brain, which comes when multiple areas of the brain are recruited simultaneously. Music consists of words and rhythm, encouraging word-finding and synchronization. It evokes memory of past events associated with the music and time it was first heard as well as reduces stress. It is a social experience as well. Various reward neurotransmitters may be involved, including dopamine and serotonin. In evoking multiple brain neurocircuitry units, “neurons that fire together wire together” (Hebbian Theory). Elizabeth Stegemoeller wrote an excellent, detailed summary on neuroplasticity and the benefits of music therapy in dementia. Shout-out to Anne Tillinghast and The Backstrokes in Portland, a post-stroke and stroke awareness group with whom I have had the honor to play in their song circle. It is never too late to learn an instrument.

10. Refrain from recreational drug use
There is a lengthy body of evidence that links substance use with an increased risk of dementia. Any drug, no matter how mild it might seem (tobacco and cannabis), has the ability to interfere with the way neurons send, receive, and process signals coming from other areas of the body and within the brain. Consequently decision-making, judgement and coordination are impaired in the short term. Multiple drugs have been tied to possibly severe long-term neurocognitive dysfunction, including alcohol, cigarettes, marijuana and elicit drugs like meth and heroin. The practice of abstinence from any substance is likely a healthier decision than casual intake, but the “dose is the poison”.

Protect that brain!

Like the master switch to all of our systems, the brain is the most important resource that we have. Think of the brain as a network of sensors and effectors (i.e. receiving and sending signals). Where there is more stimulation to the body, i.e. exercise, there is greater signaling to the brain – and the brain fortifies. It is no surprise that the changes of aging, with superimposed chronic diseases, impact the brain as much as the rest of the body – (think of the blood supply needed for the brain). An optimal state of health can preserve the brain’s function throughout life. Even a health commitment at a later age can still reap rewards by reducing the velocity of cognitive dysfunction and is worth a try.

“mens sana in corpore sano”

“A sound mind in a sound body”

Thank you for reading the post and, if you have enjoyed this, please pass it along.

source: public domain

Media Coverage featuring Dr. Cirino, Founder Your Health Forum

As an infectious diseases physician and public health officer, Dr. Cirino has been asked for consultative advice regarding the COVID-19 epidemic.  Below are some media appearances that Dr. Cirino has had on news, online newspapers, and podcasts for this and other infectious diseases issues in the last few years:

 

Title with Link:  Christopher Cirino, DO: A 101 primer on COVID-19.  Santiam Local Podcast.  Interview with Michael Calcagno and Nicole Miller.  Date:  March 29, 2020.

 

Title with Link:  COVID-19: What is it?  Public Health Messages from Marion County Public Health Department.  6 separate videos which can be found below this video. Date:  March 25, 2020

  

Title with Link: Can you get Coronavirus from packages sent in the mail Source: Finder Author: Cheryl Wagemann Type of Assistance: Written Format for HARO Date: March 23, 2020

 

Title with Link: COVID-19 updates: The U.S. socially isolates as pandemic spreads. Source: The DO Author: Andy Brown Type of Assistance: Telephone interview for internet article Date: March 18, 2020

 

Title with Link: If you believe you had coronavirus, when should you visit the Emergency room? We asked an infectious diseases specialist. Reporter: Devon Haskins. Type of Assistance: Interview excerpt. Date: March 11, 2020.

 

Title with Link: Salem-area health officials say local coronavirus cases likely a matter of when, not if Source: Salem Reporter Author: Rachel Alexander and Saphara Harrell Type of Assistance: In-person Interview for news article Date: March 3, 2020

 

Title with Link: Gresham medical, school, senior center officials address COVID-19 concerns Author: Christopher Keizur and Teresa Carson Source: Sandy Post Type of Assistance: Interview Date: March 2, 2020

 

Title with Link: What should I do if I’m sick? Are children more at risk? Doctor answers your coronavirus questions Reporter: Brenda Braxton Source: KGW News Type of Assistance: Question and Answer Session Date: March 2, 2020

 

Title with Link: What are coronavirus symptoms? How are they different from the flu? Your questions answered Reporter: Morgan Romero Source: KGW News Type of Assistance: Interview excerpts Date: February 26, 2020

 

Title with Link: Adventist Doctor explains dangers of coronavirus Reporter: Ashley Khorslien Source: KGW News Type of Assistance: In studio Interview Date: February 18, 2020

Title with Link: Coronavirus: News vs. Reality Source: Adventist Health Website Type of Assistance: Contributed Writing, excerpts Date: February 2, 2020

 

Title with Link: Concerns about US Measles Outbreak Author: Christopher M. Cirino, DO MPH Source: The Doctors Company Type of Assistance: Contributed Writing Date: March 19, 2019

 

Title with Link: Portland Hospitals seeing an Uptick in Flu patients Source: Fox News 12, KPTV.com Type of Assistance: In-person News Interview Date: March 6, 2019

 

Title with Link: Salem Health Officials, Schools prepare as measles outbreak spreads to Portland Author: Rachel Alexander Source: Salem Reporter Type of Assistance: Interview Date: January 29, 2019

 

Title with Link: A Cup of Coffee: 7 Questions and Answers for the Measles Outbreak NW Author: Christopher M. Cirino, DO MPH Source: Northwest Osteopathic Medicine Foundation Type of Assistance: Contributed Writing Date: January 29, 2019

Pamplin Media Group – Gresham medical, school, senior center officials address COVID-19 concerns

Gresham medical, school, senior center officials address COVID-19 concerns, Local News, Gresham local News, Breaking News alerts for Gresham city.
— Read on pamplinmedia.com/sp/68-news/454348-370527-gresham-medical-school-senior-center-officials-address-covid-19-concerns

COVID-19 interview with Salem Reporter | News about Salem

News about Salem – In-depth, Accurate, Trusted
— Read on www.salemreporter.com/

COVID-19 Questions and Answers

Now that the COVID-19 outbreak is likely here to stay and will ultimately involve many more places than the 37 countries where cases have been reported, it is a good time to review some questions about the disease process and ways to prepare for the outbreak – coming to a city near you.  This is Part 3 of the COVID-19 posts.  Please refer to the other posts for more information of the virus and start of the epidemic and for epidemiology terms.  

As of Wednesday AM February 26, there were worldwide 81,194 cases worldwide, mostly in Hubei province,  1,595 cases in South Korea, 447 cases in Italy, and 57 (40 were from the Cruise ship) cases in the United States, to name a few.  Cases are being reported in Bahrain, Iran, Japan and will likely reach other countries soon.

On Being Asked Questions about COVID-19

Not many people are able to call themselves experts on COVID-19, because it is novel.  As a front-line doctor who serves as Hospital infectious diseases specialist and County Health Officer, I have taken upon myself to review the primary references and the epidemiology coverage.  My career as an infectious diseases specialist has allowed me to see and/or treat multiple viral diseases, even unusual ones like HHV-8 (Kaposi’s sarcoma), Dengue virus and Monkey pox virus, as well as EBV/CMV/HSV/VZV and HIV not to mention COVID-19’s “pretty cousin” that causes the common cold. It has truly been a fulfilling career filled with lifelong learning.

So, it is with this knowledge base that I was asked several of the following questions on KGW-8 for a COVID-19 question and answer blitzkrieg.  

What is unique about the virus?

For the most part, the virus is similar to influenza virus:  Cough, Fatigue, Myalgias, Influenza-like symptoms and Pneumonitis (see below).  The majority of people (80%) will have a mild disease;  about 18-20% will have severe disease and 2-3% will be critical.

The infection presents similarly to influenza.  There has been suggestion that the fact that it causes viral pneumonia (technically viral pneumonitis) is unique, but this is not true.  Influenza virus and Adenovirus are a few of the viruses that can present with potentially severe viral pneumonitis.  These infections can worsen over days, just as COVID-19 has been described to worsens and is likely not unique to COVID-19.  The fact that there is a higher mortality rate in COVID-19 than with influenza factors in the consequences of possibly a more vigorous pneumonitis – which leads to respiratory distress and other sequellae.

Should I buy a mask?  Which one?    NO, just healthcare workers

At present, there is no need to stock up on masks. Surgical masks and N-95, which are used in the hospital and specially fit-tested by hospital staff, are available at hardware stores for painting and other use. Fit-testing is a way to assess that the mask fits appropriately and will provide protection from infectious particles. It is performed by squeezing a bulb with e.g. saccharin and assessing if it can be tasted while wearing a mask. Having a beard or a nose ring may affect the seal.

The descriptions of N-95 mask were taken out of context. They are the better masks, with pores or fenestrations (or pores) that are 0.3 microns (300 nanometers in size) versus surgical masks which protect from droplets of 5 microns or greater. Studies on surgical masks show airflow is still present although reduced. The CDC currently recommends the N-95 for healthcare workers treating patients with COVID-19 infection.

At present, the CDC does not recommend anyone else not in that category get masks. Those with any viral infection should wear a mask to protect themselves from contaminating their hands, touching their face. The coronavirus is likely transmitted on small respiratory droplets rather than airborne on air currents, and is more similar to influenza than measles in that way. Measles has an R0 (“R-naught”) of 20, meaning that it is extremely contagious, because it can be transmitted by the airborne route. From what is gathered by predictions based on the COVID-19 outbreak, it has an estimated R0 of 3, above influenza (R0 1.3).

Respiratory droplets are spread in the air after someone talks, coughs or sneezes. The droplets generally fall by around 4-6 feet. Smaller particles can spread on air currents for hundreds of feet. COVID-19 does not appear to be transmitted this way. Therefore, it is unlikely that masks will ever be necessary for those that aren’t infected, since transmission is within a range of 6 feet. That doesn’t mean that the transmission characteristics will remain static.

Is there any reason to “stockpile” food?    Probably Not

We have seen with this outbreak that it doesn’t take a lot of uncertainly to destabilize our lives – look at the 2000+ point drop in the stock market. There may be a short fuse when the disease is identified in a US city, as it has shown to be in Italy, Iran and South Korea.  This means that there will be a rapid initial spike in cases, before we set containment measures.  The US is paving the way to have more readily available test kits for state health departments rather than only through the CDC. Researchers are working on vaccinations which may take the next several months to be tested, confirmed and prepared. At this time, there is no reason to have months of provisions. Most people’s refrigerator and pantry probably have enough for several days, if it were needed to extend a little further.  Images of empty shelves in Milan supermarkets do evoke the concerns that come up when a city faces mass panic and lock-down fears. My faith is that the infrastructure that is in place already with our seasonal influenza preparedness will likely be effective in reducing spread of this virus when it emerges in various cities in the US.  Maybe phone apps can be useful in pinpointing at-risk locations, where multiple people are presenting with flu-like illness, when COVID-19 does reach the US.  Other apps for food order and delivery may also become more vogue, as people wrestle with new challenges.  Though there may be a halt in multiple lines in the food industry, in the worst case scenario.  One to two weeks stocked food is likely going to be sufficient at the time of a spike  – probably amounting to the shopping for the week.  Water concerns are not expected.

Milan Supermarket:  Photographer not listedempty shelves

 

How long do virus particles survive on surfaces?  Probably only several hours

Most likely, the particles desiccate (dry) as water evaporates from the droplets that they are on. Virus particles are notoriously incapable of surviving outside of their host for long periods. It is usually felt that only a few hours outside the host is needed for the virus particles to no longer be “viable”. Some research has called that into question, raising concern that when giving the right carrier droplets /mucus, the coronavirus may live for longer period than 2 hours, even for several days (9 days possibly). My judgement would be that for the most part this would be extremely unlikely – and I would lean toward only several hours outside the host.

Another variation of this question is whether a package delivered from China could harbor COVID-19 and be able to transmit the infection to an enthusiastic box-opener.  The answer is NO.

Can the virus be transmitted in feces?

Coronaviruses cause infection most similar to the influenza virus. Although certain viruses can be shed in stool, like Norovirus, Rotavirus and Sapovirus, it is likely that COVID-19 is not able to be transmitted by fecal-oral route. Initial concerns were related to testing for the presence of RNA in the stool – though the presence of genetic material is not uncommon and doesn’t mean there was live virus. The major route of transmission is likely saliva, mucus and other respiratory secretions.

What Can I do to Prepare for this?

COVID-19 has shown to have a mortality rate of 0.9 %, which is likely two-fold to four-fold higher than seasonal influenza, which usually has an attributable mortality rate of 0.1 -0.3 %.  When you see these mortality rates for the population, it is important to understand that mortality rates is not the same for various ages, and is likely higher than 0.9% for those with chronic diseases, obesity and older age and lower than 0.9% for those immunologically healthy (fit, younger).  For the most part, vascular health correlates to a robust immune system.  Conditions such as diabetes mellitus, coronary artery disease, hypertension likely care a higher risk of mortality from COVID-19 infection.

  1.  Get plenty of sleep
  2.  Limit processed foods and eat plenty of vegetables.  If you are a diabetic, optimize your nutrition to optimize your immune system.
  3. Exercise daily
  4. Wash Hands Regularly
  5. Flu season = Fist bump season or Air hand-shake season.
  6. Get vaccinated for the Flu if you haven’t already.
  7. Think good thoughts; limiting stress has a positive correlation to immune health.

 

MeikeMicrobe_p09

 

 

 

 

Adventist Doctor explains dangers of coronavirus | kgw.com

I was featured on KGW news on questions on coronavirus.

Dr. Christopher Cirino breaks down health risks
— Read on www.kgw.com/mobile/video/life/adventist-doctor-explains-dangers-of-coronavirus/283-d4adc2e9-0351-4401-a880-52d57bf0055d

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