My Prognostication of COVID-19 Plague
We have heard from many experts on TV their prognostication of COVID-19, and we have all, including me, expected some comprehensive knowledge that will guide us and calm us- but despite the hype they would give us the answers, we have been left with no answers.
So here is my prognostication:
First the source entries:
1. Most plagues historically have generally been awful for 2 years, then calmed down. This is regardless of anything being done.
2. Infectious agents result in sickness both based on their intrinsic lethality (both transmissibility and direct ability to damage/kill cells) and the host immune response (Again the two factors seen with GDD).
3. Susceptibility of the community. Age, poverty, extent of crowding.
4. Treatment and prevention.
5. Host immune reaction improvement (may be better killing, or simply ignoring the entity [bat {the flying mammal} technique]
So considering all the most important factors here goes:
Specific attention to pt 1, which is particularly central. How is this possible? It sometimes seems that this disappearance of plagues is a miracle (think of the plague columns throughout Europe) but how does it happen, regardless if it is a bacterium (Yersinia pestis, typhoid fever-causative agent strain of Salmonella, cholera) influenza (Flu 1918- H1N1 Influenza A), or parasite (malaria due to Plasmodium parasite).
Some plagues, especially the famous major plagues in Europe from 1300-1700, seem to largely disappear. Others, like Tuberculosis, sticks around, in smaller distribution across the population, and generally focused in the immunocompromised.
The miracle of plague resolution largely reflects herd immunity. One of the keys to all plagues is social distancing. This terminology widely used today with COVID-19 actually is something that humans historically realized, even without formal medical knowledge, keep away from other people, especially if they are sick. Interestingly some also heated themselves with fires, and heating does have effect with many infectious agents.... but not all.
Of all of them, ofcourse since they are both viruses and similar viruses, the best comparison for COVID-19 is Influenza, and hence the Flu of 1918, is the most comparable. It lasted for 2 years, with some seasonal variation (less severe in the summer). Seasonal variation may not reflect a temperature phenomenon as much as a social distancing effect: that in warm weather people get outside and there is more space, specifically more air volume space, and also wind to move viruses away. Influenza also has the ability to vary its genetic code, which COVID-19 apparently (key word apparently) does not. So the Flu of 1918 died down in 2 years- why? Primarily sufficient herd immunity, which means that enough of the population (around 60%) got the infection, developed antibody response, and were resistant to future infection. But this population protection also includes the culling of individuals with an immune system unable to develop an effective neutralizing antibody response; also those with a propensity to over-react (cytokine storm death), and leaving those alone without that propensity(which really is not what is meany by herd immunity, that you don't react to the virus). That Flu's propensity for young adults: means it had a particular ability to trigger a cytokine storm, which is worth repeating, this exaggerated damaging host response in individuals with health immune systems.
So what happens with pandemics is they drop down dramatically after 2 years.... but they stick around.
The population recovery reflects that a bulk of the herd is more effective at killing the virus and some also more effective at ignoring the presence of the virus - and probably both, and these immune responses may differ for various groups of the population- ignoring the infectious agent is probably critical in young healthy adults.
Particularities to population distribution and crowding is also critical. In 1918, crowing of healthy young adults, because of armies of healthy young males crowded together, provided a nidus for infection. In our present age the greatest areas of concentration are probably: 1. old people in retirement facilties: so in general the greatest risk population for infectious disease, in the worst setting: crowding, then other crowded settings: 2. prisons, 3. factories. Probably the unique crowding today, not seen previously in history, is the crowding of elderly in elderly facilities, so the death rate will likely be greater for this group than the historic norm.
The lethality of COVID-19 seems moderate. Left on its own the lethality appears 0.1%, so likely not much different than the 1918 Flu (maybe 0.5%). But this means left alone the virus should kill 350,000 Americans.
Sweden is trying the approach of pure social-distancing as management for COVID-19, which in many respects social distancing represents a similar but milder effect as herd immunity.. For the virus to survive it must transmit from 1 host to another, and they have to be in close proximity. So well controlled social distancing by a responsible motivated populace is a very reasonable approach. I suspect it takes the mortality from 0.1% to perhaps as low as 0.01%.
In the US experts like Tony Fauci, who describe 'flattening of the curve' as the reason for 'self-isolation/staying at home'. They seem to use this to mean that the total number of cases will not be less, but rather the time when people get infected become stretched out - with the benefit that there will not be an early huge bolus of people sick from the infection that overwhelms the health care system. So flattening the curve is not that reassuring a plan, as many of us will still get infected, just later than sooner. However where this may alter things in a positive fashion, to also include decreasing the number of cases, is that in the interval there may be development of a vaccine that prevents the disease occurs before the entirety of the flattened curve develops infection.
Ultimately for the haphazard approach now employed in the US, what has to happen, for atleast 2 years, include: social distancing, and those with a cough must use a mask, preferably for the next 6 months everyone should wear a mask in public, but this may be unreasonable to expect- what is essential is anyone with a cough should wear a mask and this strategy should be employed for atleast the next 2 years.
My opinion is, using Flu as the comparator, and accepting the information from experts that COVID does not change its genetic makeup, natural immunity lasts for atleast 2 years, which is long enough. A vaccine that is developed for use and is effective, likely will not be available till the middle of 2021, this should help a fair amount, but perhaps mainly for moving forward as it may have to be an annual vaccine. I do not think COVID-19 is disappearing so this will be valuable.
COVID-19 also has the remarkable feature of causing asymptomatic disease, that can still be infectious. It is not clear to me how many of these individuals are truly asymptomatic or pre-symptomatic, when it comes to someone feeling well and yet spreading disease. As with all plagues in the past, and I do not say this as indifferent to what this means: many people will get the virus. The nature of the virus is that it appears to have the greatest adverse effect on the compromised immune system individual (the senescent immune system, the immune system of people with chronic infection)- so it primarily is the direct effect of the virus to further diminish the immune system. Probably injury/death to children and the younger adults is uncommon- the effects of a strong immune system hyperactivity, and probably relatively specific to COVID-19 a vessel wall/ coagulopathy condition. So 0.1% of everyone may perish, but this may be 0.001% of children, 0.0001% of health young adults, 1 % of those with chronic diseases and 2 % of the elderly. I suspect the great majority of young healthy people, whose tragic stories we hear on tv, have a genetic variation that makes them susceptible. It may be in this group standard therapy should include anticoagulation, even if they don't have symptoms yet (that is no stroke yet, for example).
The wild cards of a vaccine include: how effective and long--lasting will it be. How quickly will it be widely available, and will the disadvantaged in the US or abroad ever get it.
One final historical perspective before the summary points. Probably throughout all history humans and pre-humans, have experienced pandemics from various infectious organisms. Some probably that have been very lethal (is the great flood in the Bible that spared Noah and his family [who possessed the correct immunity to manage], and very few animals as well, actually a description of a huge pandemic that killed 90% of the population at the time?); many probably like COVID-19 mainly killing the old and the sick; BUT some being helpful for evolution. The bacteria, on our skin and in our GI tract, absolutely essential for survival, were these originally a pandemic that stuck around and we learned to live together well? The origin of mitochondria is considered an endosymbiosis (learned to live together well) between the native host cell (eukaryotic) and an invading organism, with the two primary considerations being primitive forms of bacteria (I had thought one of the theories was a virus), were these also then a universal pandemic that occurred 1.35 billion years ago? So perhaps us and our many lines of predecessors experienced pandemics, some maybe universal, every 1-2 hundred years... for over a billion years?? So not all pandemics have been bad, some maybe essential to have made us what we are today. So the nasty viruses that still stay with us for ever: Herpes, Varicella, EB virus, I would not be surprised if a dozen more aren't hanging around, maybe even they could somehow be helping us? Giving us small electrical pulses to our immune system so that we can resist even more vicious viruses.
So using all those data inputs:
1. COVID-19 will be a huge problem for atleast 2 years (historic norm). It will not go away. It will stick around after that probably in the pockets of the underprivileged, and the new population of the privileged but who are opposed to vaccines.
2. The infection is of just moderate severity but will kill a fairly large number of individuals.
3. Unfortunately as with all plagues of the past, the ones who will most suffer are the elderly, the poor and the sick. Although coming to the fore in the news, the entity Pediatric Multi-System Inflammatory Syndrome is rare, and children will be relatively less effected than the historic norm, except where poverty and poor health co-exist. So in North America the death rate for children may be 0.01%; while in troubled areas like Yemen, many places in Africa, Bangladesh, the death rate may well approach 30%. The better circumstance in North America is a reflection of affluence, lack of crowding, and general health effect.
4. Social distancing. For now it is 100% important for everyone, whereas for the future some level of social distancing will remain important. There may never be a reason to shake anyone's hand in the future... It does make one wonder that perhaps 2,000 years ago and over a period of a few hundred years, the Japanese realized that touching people who one is not related to, or interested in being close with, has an adverse health effect - so no hand-shaking, etc, but bowing at some distance. Maybe our greeting in the future will always be a non-contact, such as a hand wave, like a royal wave, 6-8 feet away from some else.... Note that no one is allowed to touch the British queen: smart idea, also perhaps health related from observation of centuries from 800 -1700 AD.
5. Masks for now should be mandatory when in close quarters. Forever, someone with a cough must always wear a mask in public.
6. Treatment. Ventilators, supportive care (these probably decrease the death rate by 30%). Specific treatment with effective antivirals and injected neutralizing antibody will have the potential to improve the death rate (these could decrease the death rate by 50% - for those who can afford to get it). The deaths of the healthy normals and healthy children may also be decreased by selective treatment of the specific abnormalities of heightened immune reaction (specific immune suppression - probably of specific cytokines) and blood vessel treatment (anticoagulation - and modifications of this).
7. Testing. For virus, for portions of the virus (antigen testing), for antibodies (and types).
Keeping track of virus expansion locations, especially hotspots, to isolate and contact-trace, and the last to identify those likely the most resistant to be sick again from the virus.
8. Vaccine for prevention. This may not be available till June 2021 for wide spread use - optimistic projection. So no effect on the first 2 waves of infectious spread, but may catch the distal 25% of the flattened curve. The vaccine role may end up being to diminish future upticks in COVID infection waves, and I suspect the vaccine ultimately may need to be a general COVID vaccine, as COVID-19 almost certainly is not the last COVID we will see.
9. Niduses of increased spread will pop up, probably everywhere over the 2 year period of the current great presence of COVID-19. Rather than panic, we need to retrench to the principles of social distancing, reasonable hand-washing, royal wave, and masks if you have a cough. This for now and forever. These principles work for COV-19 now, but will also work for all future viral pandemics that we will undoubtably see... It may be that all healthy younger people will need to take in the future the 'Bat Pill' where all our immune systems are knocked down to the level of the bat when it comes to viral infections... Maybe the same 'Bat Pill' will be the pill that works for the same purpose for GDD.
10. A new life: healthy food, healthy environment (air, land, water) for humans and animals. Something positive. The haphazard approach of the US opening up the economy should probably follow the Swedish approach... what I write here is my modification of that, but it requires the populace to be sensible and rational: social distancing; masks as I describe above, especially always a mask in public if you have a cough; people with cough, fever, etc go into self-isolation for 2 weeks; be particularly careful with the elderly, chronically sick, and small children; reasonable distances in work spaces, prisons, elderly facilities; stop the horrific factory farming: animals must be given space, a healthy environment, and the broad use of antibiotics must stop as it makes it extremely dangerous for everyone because it creates antibiotic-resistent bacteria. Perhaps this is the approach that should be done now, except in the areas with still high rates of developing infection where more stay at home isolation is necessary for 1-2 months. I would prefer that we re-trench to this point if when the haphazard return of the economy results in increased infection rates, rather than another lock-down. We return to a committed rational Swedish approach.
11. Invigorated effort to improve conditions for the poor, the sick, and the disadvantaged. Another positive outcome of the pandemic.
Richard Semelka MD Consulting Stay tuned on the latest advancements: