1 - COVID-19: how serious is it?
1. The R naught
2. The Complications
3. Comparison with the H1N1 Pandemic
2 - Incubation period and time of asymptomatic patients
3 - Testing
4 - Droplet size
1. Aerosol- size is <= 5 microns- can remain in the air for up to 3 hours.
2. Droplet- >5 microns- generally fall down after 6 feet- sometimes up to 13 feet.
3. Virus size is 90-100 nanometers and the sugical mask has holes of 300 nm- but the theory is the droplet gets stuck in the mask.
4. N95 masks can filter out particles down to 0.3 microns 95 percent of the time.
5 - Masking
1. Respirator versus mask
2. Royal Society DELVE Initiative Graph
3. Surgical mask versus homemade mask
- Surgical mask 96%
- Vacuum cleaner bag 94%
- Dish towel or tea towel 83%- single layer but 97% efficient with double layer but trouble breathing with leak.
- Blended tee-shirt 74%
- 100% cotton- 69%-70% efficient but less leaking and less trouble breathing; also antimicrobial pillowcases.
- Homemade masks are 50 times less efficient in stopping reception than N95 masks and 25% times less than surgical masks.
6 - Handling Groceries (posted March 28 on Doctor Emi Holistic Health Facebook Page)
DrJeffVW.com from March 28 (with updates on his site: March 31, April 1, April 5)
7 - Nutrition
1. Vitamin D- The evidence is called “circumstantial” because it is not in randomized controlled trial form despite the fact that longitudinal studies looking at hundreds of thousands of people point to reduced mortality from respiratory viruses.
1. Production of antimicrobial peptides in the respiratory epithelium, thus making infection with the virus and development of COVID-19 symptoms less likely.
2. Vitamin D might help to reduce the inflammatory response to infection with SARS-CoV-2. Deregulation of this response, especially of the renin–angiotensin system, is characteristic of COVID-19 and degree of overactivation is associated with poorer prognosis. Vitamin D is known to interact with a protein in this pathway—angiotensin-converting enzyme 2 (ACE2)—which is also exploited by SARS-CoV-2 as an entry receptor. While SARS-CoV-2 downregulates expression of ACE2, vitamin D promotes expression of this gene.
2. Intervention trials of Vitamin D have not always shown benefit except one glaring exception:
One important exception to this general trend is for upper respiratory tract infections: a 2017 meta-analysis of individual patient data from 11 321 participants in 25 randomised controlled trials showed that vitamin D supplementation protected against acute respiratory tract infections and that patients with very low (<25 nmol/L) serum 25-hydroxyvitamin D concentrations (a marker of vitamin D status) gained the most benefit.
4. Vitamin C
1. Meta analysis in 2019 showed IV Vitamin C could shorten the length of stay in the ICU.
2. Dr. Paul Marik
5. NAC- theoretical for COVID- some evidence in influenza
8 - Treatments
1. Hydroxychloroquine plus or minus macrolide- the concern is for a cardiac arrythmia called Torsades – prolonged QT
1. Helps to get zinc inside cells and zinc then stops replication of the virus.
2. Mandeep R Mehra, Sapan S Desai, Frank Ruschitzka, Amit N Patel The Lancet.com, May 22, 2020, “Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis."
This trial had no zinc:
3. Initial study done in France was small and poorly designed and only showed that people had nasal swabs go negative faster – no changes in morbidity or mortality- this trial has no zinc.
4. Hydroxychloroquine and Azithromycin plus and minus zinc- Retrospective trial from May 8th showed shorter hospital stays and less likelihood of intubation and ICU admission but did not help late in disease.
5. The Indian government is prophylactically dosing healthcare workers at 400 mg twice daily for 7 days and then 400 mg once a week for the next 7 weeks, and for family members of ill patients the same in the first week and then 400 mg for 3 weeks.
3. Convalescent Plasma
9 - Clinical Trials
1. High Dose IV Zinc
10 - Examples of Success
1. Mongolia- it pays to be smart rather than rich
2. Taiwan- Learning from SARS
11 - Vaccines
1. Comparison with the H1N1 Pandemic - Dawood F, Iuliano AD, Reed C, Meltzer MI, Shay, DK, Cheng PY, et al. Estimated global mortality associated with the first 12 months of 2009 pandemic influenza A H1N1 virus circulation: a modelling study. The Lancet. ARTICLES| VOLUME 12, ISSUE 9, P687-695, SEPTEMBER 01, 2012. Published:June 26, 2012. DOI:https://doi.org/10.1016/S1473-3099(12)70121-4
2. The R Naught - Sanche S, Lin YT, Xu C, Romero-Severson E, Hengartner N, and Ke R. High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2. EID Journal Volume 26, Number 7—July 2020. ISSN: 1080-6059. https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article2. COVID-19 Facts
1. R naught
Steven S, YT, Chonggang Xu, Romero-Severson E, Hengartner N, and Ke R. High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2. Emerg Infect Dis. 2020 Jul
. https://doi.org/10.3201/eid2607.200282 Volume 26, Number 7—July 2020. ISSN: 1080-6059 https://doi.org/10.3201/eid2607.200282
2. Case Fatality
MAY 4, 2020-Research team determines COVID-19 infection fatality rate by University of Bonn, MAY 4, 2020; https://medicalxpress.com/news/2020-05-team-covid-infection-fatality.html3. Masking and COVID-19 survival in air and on surfaces
1. Royal Society DELVE Initiative- Face Masks for the General Public- https://rs-delve.github.io/reports/2020/05/04/face-masks-for-the-general-public.html?
2. Davies A, Thompson KA, Giri K, Kafatos G, Walker J, Bennett A. Testing the efficacy of homemade masks: would they protect in an influenza pandemic? Disaster Med Public Health Prep. 2013;7 (4):413‐418. doi:10.1017/dmp.2013.43
3. Neeltje van Doremalen, Ph.D. et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 . New England Journal of Medicine Research letter published March 7/2020. N Engl J Med 2020; 382:1564-1567 DOI: 10.1056/NEJMc2004973
4. Radonovich LJ, Simberkoff MS, Bessesen MT, et al. N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial. JAMA. 2019;322(9):824–833. doi:10.1001/jama.2019.116454. Vitamin D
1. Mitchell F. Vitamin-D and COVID-19: do deficient risk a poorer outcome? The Lancet - Diabetes and Endocrinology, May 20, 2020: Published:May 20, 2020. DOI:https://doi.org/10.1016/S2213-8587(20)30183-2
2. Martineau AR, Jolliffe DA, Hooper RL, Greenberg L, Aloia JF, Bergman P, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data BMJ 2017; 356 :i6583 doi: https://doi.org/10.1136/bmj.i6583
3. Daneshkhah A, Agrawal V, Eshein A, Subramanian H, Roy HK, Backman V. The Possible Role of Vitamin D in Suppressing Cytokine Storm and Associated Mortality in COVID-19 Patients. doi: https://doi.org/10.1101/2020.04.08.200585785. Zinc
With Chloroquine and Hydroxychloroquine
Shittu MO, Afolami OI. Improving the efficacy of Chloroquine and Hydroxychloroquine against SARS-CoV-2 may require Zinc additives - A better synergy for future COVID-19 clinical trials. Infez Med. 2020;28(2):192‐197. PMID: 323355606. Vitamin C
1. Hemilä H, Chalker E. Vitamin C Can Shorten the Length of Stay in the ICU: A Meta-Analysis. Nutrients. 2019;11(4):708. Published 2019 Mar 27. doi:10.3390/nu11040708
2. Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229‐1238. doi:10.1016/j.chest.2016.11.036. DOI: 10.1016/j.chest.2016.11.036
3. Fujii T, Luethi N, Young PJ, et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA. 2020;323(5):423–431. doi:10.1001/jama.2019.221767. Quercetin
1. De Flora S, Grassi C, Carati L. Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment. Eur Respir J. 1997;10(7):1535‐1541. doi:10.1183/09031936.97.10071535
2. Clinical Trial of Quercetin. Effect of Quercetin on Prophylaxis and Treatment of COVID-19. https://clinicaltrials.gov/ct2/show/NCT043777898. NAC
De Flora S, Grassi C, Carati L. Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment. Eur Respir J. 1997;10(7):1535‐1541. doi:10.1183/09031936.97.100715359. Hydroxychloroquine Plus Azithromycin
1. Mehra MR, Desai SS, Ruschitzka F, Patel AN. Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis. The Lancet.com. Published:May 22, 2020. DOI:https://doi.org/10.1016/S0140-6736(20)31180-6
2. Gautret P, Lagier JC, Parola P, et al. Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: A pilot observational study. Travel Med Infect Dis. 2020;34:101663. doi:10.1016/j.tmaid.2020.101663
3. Philip Carlucci, Tania Ahuja, Christopher M Petrilli, Harish Rajagopalan, Simon Jones, Joseph Rahimian. Hydroxychloroquine and azithromycin plus zinc vs hydroxychloroquine and azithromycin alone: outcomes in hospitalized COVID-19 patients. medRxiv 2020.05.02.20080036; doi: https://doi.org/10.1101/2020.05.02.20080036
4. Meo SA, Klonoff DC, Akram J. Efficacy of chloroquine and hydroxychloroquine in the treatment of COVID-19. Eur Rev Med Pharmacol Sci 2020; 24 (8): 4539-4547. DOI: 10.26355/eurrev_202004_2103810. Success Stories
1. Mongolia - Indi Samarajiva, “COVID Underdogs: Mongolia, The best COVID-19 response in the world, https://medium.com/@indica/covid-underdogs-mongolia-3b0c162427c2
2. Taiwan - https://vimeo.com/399268213 American College of Occupational and Environmental Medicine : March 20, 2020: COVID-19 Protecting Health Care Workers-Lessons From Taiwan and ItalyThe Doctor Emi Team