In this update, we take a step back, and consider perspectives on the whole coronavirus experience, some perspectives not discussed often:

• Seasonality
• Cross Currents
• Ibuprofen
• East and West
• How to Beat a Virus

But first a regular feature of these updates:

Glossary

• Virus- a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
• Coronavirus- a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes
• SARS-CoV-2- the specific name of the new coronavirus
• COVID-2019- the name of the illness that the new coronavirus is causing
• Endemic- an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic- a sudden burst of an illness that comes and goes over a limited time
• Pandemic- an epidemic that bursts across the world not just one region
• Spreadability- how contagious is the disease, how many people will end up infected
• Severity- what harm does the disease cause, in terms of  how sick you get and how many it will kill

Now to our Perspectives.

SEASONALITY- The Equinox is Thursday

Many discuss the hope that this COVID-19 illness will be seasonal.  It is a very real and very great hope.  Should this particular illness turn out to be seasonal, and active only in the winter, the illness could start fading away soon.

Seasonality is one of the great unsolved mysteries of medicine.  It is not odd or uncommon, but mysterious because no one has any idea how it works.

Consider a classic seasonal virus, the influenza virus.  Every year it appears in the US around mid-December, infects nearly every block around the whole nation, typically infecting 40 -50 million people, then just as mysteriously, vanishes completely in April, like clockwork.  In fact, right now, the influenza virus has begun its annual decline towards vanishing.  It usually declines in March, and it is, right now.

How does a very tiny, very microscopic virus suddenly appear across continents, spread in weeks across vast spaces, sustain chains of infection for months, then suddenly vanish, every year?  The answer is no one knows.  It’s not the temperature, Florida can be as warm as most Northern states are in the spring when influenza leaves the North, during the thick of winter, and yet Florida still as the same months of influenza infection.  So it is not temperature, but it is seasonal.  Around the spring equinox, influenza virus somehow begins to cease and desist.  The equinox this year is this Thursday, March 19, and as noted, the influenza virus is on its way out.

But influenza virus is not the only one.  RSV is a winter virus.  Enterovirus which causes summer stomach flu and other illnesses is seasonal, peaking in summer.

However, some infections are not seasonal, happening easily all year round.  A good example is the common cold which can happen anytime of the year.  Another is strep, again one can get a strep throat in school or camp.

So now, which is COVID-19, seasonal or not?  This perspective is offered because much rides on this question, and rides on it just now.

Since seasonal illnesses that rise in the winter and fade in the spring actually do fade in the spring, if COVID-19 is a winter virus, we should see it begin to stop rising and start disappearing as spring emerges.  This is the importance of the equinox this Thursday, it marks the beginning of spring, so that in the next 1, 2, 3-6 weeks or so, if COVID-19 is a winter illness that clears in the spring, we should see the number of new cases diminish.

Let us all hope so, what a relief it would be.  And if it does not happen, if COVID-19 is not seasonal, then the epidemic will rage until either everyone easily infected has had it, or we come up with an intervention that stops its spread.

CROSS CURRENTS

If America should succeed in massively increasing the number of tests for COVID-19, then we will experience the impact of two major interventions, each designed to do the exact opposite, potentially creating a numbers cross current.

Here is what I mean.

The first new event is the increased testing noted.  This is expected to allow us to see far more people who are infected that in days we did not test.  If this is true, doing a million tests will lead to big jump in the numbers infected.  Think about if only 1% of 1 million tested are infected (the number in most countries is much higher), that would bump our numbers up by 10,000.  We are currently at 3, 318 as of March 16 at 3PM.   Going from about 3,300 to 13,300 suddenly is a big, big jump.

The second new event is the cancelling of all activities outside the home.  We have no idea if this will slow down the spread of infection.  In Asia, the strategy was never to simply go home.  It was to have everyone go home AND identify all infected and ISOLATE all infected OUTSIDE the home.  We simply do not know if staying home will slow the spread.  What if the virus spreads mainly in the home?

But let us assume for the moment that closing schools and everything else works, then that would mean there would be fewer cases.

Now for the cross currents.  Let’s say if nothing changed we would see about 300 new cases a day in the US this week.  Now add in school and everything else closing, that would be a force to lower the number of new case- one current, and downward.  Now add in the new testing, that will likely increase the new cases- the other current, and upward.

These two currents act in opposite directions.  So let’s say the number of new cases this week goes up 5,000, a very big number.  Maybe that is not up 10,000 because everyone is staying home, or maybe it is 5,000 because of new testing discovering old cases AND staying home failed.  We will never know.

IBUPROFEN

There is word out of France that ibuprofen use can make the illness COVID-19 worse because, as one professional in Toulouse, France claims, such drugs by blocking inflammation make complications more common in most febrile illnesses.

Ibuprofen is a known anti-inflammatory, it reduces swelling and soreness from inflammation.  And, we also know that inflammation is important in recovering from infection, it helps kill the virus and other germs.

But what is not mentioned in this worry from France is that we have studied the impact of ibuprofen on colds and viral fevers in kids.  And it turns out kids who take ibuprofen do not suffer more complications or any longer time being ill, compared to kids who do not.

So, unless and until someone actually observes what happens to children who have COVID-19 taking ibuprofen, it is not helpful to simply whisper rumors of possible harm.  Ibuprofen has a great track record of safe reduction of fever and aches in millions and millions of viral illnesses in children, why take at least this comfort without better proof?

EAST and WEST

A great and terrible experiment is underway.  No one has chosen to experiment, but a test of two strategies is underway anyway.

The two strategies offer the same hope and are reaching for the same goal: To stop the spread of COVID-19

One strategy has been adopted by the nations of East Asia, specifically China and its province Hong Kong, Singapore, Taiwan, South Korea.

The other strategy has been adopted by Europe and America.

Let’s take a look at the East and the West.

The East

In the nations listed above, the core strategy to stop the spread of the virus has been to identify and isolate.  That is, each nation has found a path to test enough people to identify a good proportion of those carrying the virus, and here is the core of the strategy- isolate that infected person from infecting anyone else.  The key tactic has been to place identified infected people in isolation facilities, outside the home.   Some of the countries have closed schools, some have imposed lockdowns, but some have not.  But all have identified and isolated.

Level of success:  In each of these nations, the spread of the virus has been dramatically reduced, or even halted.   One example.  We were in Hong Kong on February 2, they had 50 cases.  Today they have 162 cases and no more than 4 deaths, in a region of 7 million people!

Here is an excellent summary of the strategy across several regions in East Asia: https://www.nytimes.com/2020/03/13/opinion/coronavirus-best-response.html

The West

Across our United States and across Europe a different core strategy to stop the spread of the virus has been adopted, namely, quarantine at home.  In our country and in many others in the West, there has been an effort to put everyone in their home, to reduce the number of people we touch, contact, or get close to.  This strategy is the key strategy for everyone.  We tell healthy people to stay home.   If someone is tested and found positive, the policy of each of these nations is to ask them to stay home.  And so the key tactic in the West is to stay home.

Level of success:  Unsure.  To date, no nation in Europe or North America has achieved substantial decrease in the spread of the virus.   However, the strategy of breaking the chains of transmission by having everyone stay home has not been in place long enough to really test the idea.  The question will be, when will a nation have its population sufficiently staying at home to reliably say contact with others has been truly interrupted?  Once a nation achieves this we should see the number of new cases drop dramatically in that nation within a few days, maybe a week if this strategy actually works.

HOW TO BEAT A VIRUS

Perhaps one of the most dramatic experiences of this exploding epidemic from this new coronavirus is how helpless we all feel, how helpless we actually are.

There are reasons upon reasons not to be sure of how this new virus will act:

• It’s still new, just a few months old in humans
• We don’t even know if it’s seasonal (see above)
• We don’t know exactly how it spreads
• We don’t know exactly what it’s real mortality rate is
• We don’t know if children can even be contagious
• New viruses change over time

To make matters worse, no one has a cure, and we don’t really have a treatment, and we don’t know what will rid us of this plague for sure.  Here are some things that don’t work yet, or we don’t know if they will work:

• Staying at home, the European and American solution.  Might work, has not yet.
• Identifying cases and isolating them from everyone, the Asian solution.  Seems to have worked, but await return to normalcy to see if success holds.
• Masks, social distancing, washing hands- no proof if it works yet
• Alternative therapies, such as herbs, homeopathy, other traditions- There are not proven therapies in this category.
• There are no medications proven to help, yet
• There is no vaccine proven to help, yet

What is striking, really rather extraordinary, is that this is the situation with most viruses.  Think about the common cold, it’s been around for millennia.  Absolutely nothing has been tried that rids humanity of this malady.  No avoidance works, no medication works, no vaccines exist for it, it just happens when it wants to and there is literally nothing anyone can do about it.

The most striking fact about viral infections is on plain view across America, across Europe, across Asia:  no matter what technology and civilization can bring to bear, we are amazingly helpless in the face of a new virus spreading widely.  It is a painful reminder that only one strategy can reliably protect humanity from the damage a virus can wreak.

In fact, with the rare exception of AIDS and Hepatitis C, the only technique that has ever vanquished a virus from having its way in harming humanity has been…

…immunization.

The reality of immunization is that it THE unique strategy to rid humanity of the scourge of a virus.  

Immunizations are for viruses are what antibiotics are for bacteria, they each save humanity.

One could now see that today we are living through a plague much as our ancestors did routinely.  Imagine smallpox hitting a nation in 1345, it would threaten the lives of everyone.  People would scurry about desperately looking for something to keep it at bay.  Maybe smoke in the home, praying or sacrificing, anything at all.  But alas, all human efforts would fail in 1345, and 1445, and 1555, and really forever, until someone in India and then England thought of the idea of vaccination.

With vaccination, smallpox suddenly became a nothing threat.  It disappeared off the world stage, going extinct in the wild many years ago.  After thousands of years of hoping, only the vaccine delivered a world free of smallpox.

With regard to COVID-19, we are living how life was in 1345 with smallpox, fearful, unsure, knowing that someone we care for might come to real harm, with no real way to be sure we will all be safe.

So right know, imagine that one day a good vaccine for COVID-19 is released.  And ask yourself, would you rather it had never been invented?  Before answering, consider that use of this vaccine is proven to be safe, and will end the presence of COVID-19 on the planet.  Which of us would act to make sure no one got this vaccine?

This turns out to be the choice for all vaccines.  Those opposed to their use in general, not because of a specific concern for a reaction in a specific person, would have us not use the only strategy that can lift the harm a virus poses for humanity.

Having said that, there is no guarantee that we will invent a working, safe vaccine for this coronavirus.  Sometimes we succeed in creating such a wonder, such as is the case for measles, polio and many other viruses, and even some bacteria such as those that cause meningitis, tetanus and others.  But sometimes we do not, as in the case of AIDS.

So, let us hope that a vaccine that works and is safe, will be developed and soon.  The scenes in Italy, and around the world should put an end to the question of whether immunizations should exist or not.

BOTTOM LINES:

1. There remains much to do right now to protect ourselves and those we love from this virus, but for just right now we offer these perspectives.
2. Seasonality:  The equinox is Thursday, viruses that only spread in the winter are beginning to fade, we will know in the next 4-8 weeks if this coronavirus is seasonal.  Let us hope so.
3. Cross Currents:  The United States is unique amongst wealthy nations to have only introduced widespread testing many weeks after the virus began spreading widely.  And so this week we will have two currents operating at once:  Big jump in testing which will jump numbers of cases up simply because we will see them, big jump in social isolation which may or may not drop numbers of new cases.   The result:  it will be impossible to know if actual new cases are dropping or rising, at least until the number of people we test settles into a steady and large number.
4. Ibuprofen:  Rumors that it will make things worse are not true.
5. East and West:  East Asia asks those infected to leave the home until not contagious, America and Europe ask those infected to stay at home until not contagious.  East Asia countries have achieved dramatic drops in the numbers of new cases, essentially stopping its spread.  America and Europe have not.  If the West strategy continues to fail, when will we adopt the strategy proven to work?
6. The Only Tried and True Secret Weapon Against Viruses:  If we learn only one thing from COVID-19, it will be that it a profound and sad truth that it is very, very hard to treat a virus once you are infected.  The scenes across the world make this point every day.   And so it makes it all the more urgent that humanity come to accept an actually wonderful fact- we do have one tool that can be relied on to stop deadly viruses:  Immunization.

To your health,
Dr. Arthur Lavin