Given the events of this week, I thought it might be a good time for a brief update. As always, lets try not to make it political and I invite other doctors, nurses, scientist, epidemiologist, or anyone else to add to this if they have direct knowledge on the topic. Everyone else is, of course, welcome to express their thoughts, view, experiences, opinions or ask questions.
First my credentials for those unfamiliar: I am board certified by the ABIM and ABMS in Internal Medicine, Pulmonary Medicine, Critical Care Medicine, and Hospice and Palliative Care Medicine. I am also board certified in Pediatrics by the American Board of Pediatrics. I work mostly as a Pulmonary and Critical Care doctor and I am or have been the medical director of two different hospitals intensive care units during the entire COVID 19 pandemic. I have personally cared for hundreds of infected coronavirus patients ranging in severity from mild hospital cases to severe ICU cases on life support, many of whom sadly did not survive. I offer this information as a matter of personal opinion and experience. It is in no way meant to be personal medical advice and if you think you are infected you should seek treatment from your local physician immediately.
Where things stand as of today:
World Wide Cases: 38,326,891
Global Deaths: 1,088,804
Global Mortality Rate KNOWN CASES: 2.84%
This represents a drop in mortality rate of roughly 1.4% since July 19, 2020
US Confirmed Cases: 7,883,392
US Deaths: 216,323
US Mortality Rate KNOWN CASES: 2.74%
This represents a drop in mortality rate of 1% since July 19, 2020
A reasonable estimate of the number of unknown cases is at least double the number of known cases, and possible much higher. The reasons for this is that a large number of people that are "exposed" to COVID19 and "catch" COVID 19 either never have symptoms or have very mild symptoms and do not get tested. If we use double the number of known cases (which is a very conservative estimate) then the mortality rates change:
Global Mortality Rate: 1.42%
US Mortality Rate: 1.32%
So why has the mortality rate gone down? The answer lies in several dynamics in this case:
A) Improved Treatments
B) Reduced Viral Virulence likely through natural selection
C) Group Immunity (intentionally avoiding the phrase "Heard Immunity" which is used incorrectly by the media)
D) Improved Testing
Lets explore this some more.
A) Current updated treatment approach in the United States as adopted by me (mostly consistent with everyone else, I tend to hit earlier with steroids and Zithromax):
1) Asymptomatic positive: Nothing
2) Mildly symptomatic positive with no respiratory symptoms: Supportive care (Tylenol, Hydrate, Chicken Soup, Rest)
3) Symptomatic with respiratory symptoms w/o hypoxemia: Supportive care plus Zithromax and Steroids (Dexamethasone or Prednisone)
4) Symptomatic with respiratory symptoms with hypoxemia and Chest Xray Changes: Admit to hospital, convalescent plasma (IgG antibody to COVID from donors), Remdesivir, High Dose Dexamethasone, and the Vitamins (Zinc, MVI, possible Vit D)
5) Severely Symptomatic with Respiratory Failure: Everything listed under 4 plus high flow oxygen first, then BiPAP if need. Self prone position as much as possible. Avoid intubation and positive pressure ventilation if at all possible. If intubated and ventilated, adopt ARDS treatment protocols and/or Airway Pressure Release Ventilation and prone 18 hours a day. Heavy sedation when on vent, often with addition of paralytic agent.
Patient with risk factors may be bumped up a number depending on presentation.
**Risk Factors can be divided into one of five categories in order of importance in my experience: Age, Morbid Obesity, Diabetes, COPD, other comorbidities.
A) Treatment: Key in treatment is early recognition of those with hypoxemia and xray chance and QUICK treatment with plasma, anti-viral (Remdesivir), and high dose steroids. In my experience and in the experience of my colleges and nationally, the EARLY TREATMENT with this combination really does seem to save lives. Prior to these therapies and back when COVID 19 first started, it was not unusual for me to have 10-12 ICU patients with COVID 19 on the ventilator. These days for the last 2 months I have averaged about 3 ventilated COVID 19 patients a week. That represents a TREMENDOUS improvement. Keeping the off the vent is key. If you don't go on the vent, you have a 99.9% survival rate. If you do go on the vent you have a 55-60% survival rate nationally. This mirrors my experience in my ICUs.
How does this combination therapy work? Why is it such a game changer?
When you get COVID 19 infection your body has a natural immune response to the infection. In a small percentage of people, the immune system is hyper-responsive and attacks not just the virus but also the human body, most frequently in COVID, the lungs. These leads to Acute Respiratory Distress Syndrome (ARDS) which causes the Respiratory Failure and shunt physiology in the lung. This leads to severe hypoxemia (low oxygen levels) and eventual scaring of the lung. At it's fullest expression, this leads to death due to suffocation.
So, the COVID IgG antibody (either from plasma from donors who have recovered from COVID) or the new monoclonal IgG COVID AB soon to be on the market (the one the president received) binds to the Coronavirus preventing it from infecting the airway cells and thus preventing infection and the subsequent immune responds. The IgG AB you have to COVID, the less virus is left unbound to infect your cells.
The anti-viral Remdesivir kills the most Coronavirus that does enter your body thereby reducing the number of virions left alive, something in medicine referred to as LOWERING YOUR VIRAL LOAD.
The high dose Dexamethasone reduces your immune response (which is what Plaquenil does as well in theory, but not as effectively as the steroids).
So in summation, after exposure and infection, if you are treated with this "cocktail," the IgG binds to much of the Coronavirus in your body rendering it non-infectious and eventually killing the virus. Most of the small percentage of virus that eludes the IgG will then be killed by the Remdesivir. If there is still enough virus left (live or dead) to cause a hyper-immune response in the susceptible population, the dexamethasone greatly reduces the immune response. This combination if extremely effective IF GIVEN EARLY. If given to late in the course (when they are already near 100% oxygen requirements or on the vent) if is seldom as effective and often to late.
B) Reduced virulence is the natural history of almost every viral plague or successful bacteria through history. The purpose of the virus is to reproduce it's genetic code, which is an RNA code in this case. Therefore, it serves no purpose for the virus to kill it's host which it is using to reproduce it's genetic code to then be released by millions of viral particles through the host. The host in this case being us. If a virus mutates in such a way that it becomes more virulent, and kills off it's host, then less of that virus is replicated and released. Those mutations therefore die out. The mutations that allow the virus to replicate with little to now damage to the host are replicated and released in much higher numbers and win out over time. This is why, historically, most new viral "plagues" wean over time and you see a generally predicable decline in mortality rate w/in the first few years. There is no reason to suspect that COVID19 will be any different than any other virus in this regard and we are, indeed, seeing lowering mortality rates. The key here is to realize the mortality rates are declining not just in the US (where we have all these amazing treatments at our fingertips as doctors) but also around the world including many countries with little to know healthcare.
If you want further proof of how super virulent viruses die out before they spread, well, ever wonder why all Ebola outbreaks are very time limited geographically limited? They kill off the host to fast and at too high a percentage to spread.
Continued..............................
First my credentials for those unfamiliar: I am board certified by the ABIM and ABMS in Internal Medicine, Pulmonary Medicine, Critical Care Medicine, and Hospice and Palliative Care Medicine. I am also board certified in Pediatrics by the American Board of Pediatrics. I work mostly as a Pulmonary and Critical Care doctor and I am or have been the medical director of two different hospitals intensive care units during the entire COVID 19 pandemic. I have personally cared for hundreds of infected coronavirus patients ranging in severity from mild hospital cases to severe ICU cases on life support, many of whom sadly did not survive. I offer this information as a matter of personal opinion and experience. It is in no way meant to be personal medical advice and if you think you are infected you should seek treatment from your local physician immediately.
Where things stand as of today:
World Wide Cases: 38,326,891
Global Deaths: 1,088,804
Global Mortality Rate KNOWN CASES: 2.84%
This represents a drop in mortality rate of roughly 1.4% since July 19, 2020
US Confirmed Cases: 7,883,392
US Deaths: 216,323
US Mortality Rate KNOWN CASES: 2.74%
This represents a drop in mortality rate of 1% since July 19, 2020
A reasonable estimate of the number of unknown cases is at least double the number of known cases, and possible much higher. The reasons for this is that a large number of people that are "exposed" to COVID19 and "catch" COVID 19 either never have symptoms or have very mild symptoms and do not get tested. If we use double the number of known cases (which is a very conservative estimate) then the mortality rates change:
Global Mortality Rate: 1.42%
US Mortality Rate: 1.32%
So why has the mortality rate gone down? The answer lies in several dynamics in this case:
A) Improved Treatments
B) Reduced Viral Virulence likely through natural selection
C) Group Immunity (intentionally avoiding the phrase "Heard Immunity" which is used incorrectly by the media)
D) Improved Testing
Lets explore this some more.
A) Current updated treatment approach in the United States as adopted by me (mostly consistent with everyone else, I tend to hit earlier with steroids and Zithromax):
1) Asymptomatic positive: Nothing
2) Mildly symptomatic positive with no respiratory symptoms: Supportive care (Tylenol, Hydrate, Chicken Soup, Rest)
3) Symptomatic with respiratory symptoms w/o hypoxemia: Supportive care plus Zithromax and Steroids (Dexamethasone or Prednisone)
4) Symptomatic with respiratory symptoms with hypoxemia and Chest Xray Changes: Admit to hospital, convalescent plasma (IgG antibody to COVID from donors), Remdesivir, High Dose Dexamethasone, and the Vitamins (Zinc, MVI, possible Vit D)
5) Severely Symptomatic with Respiratory Failure: Everything listed under 4 plus high flow oxygen first, then BiPAP if need. Self prone position as much as possible. Avoid intubation and positive pressure ventilation if at all possible. If intubated and ventilated, adopt ARDS treatment protocols and/or Airway Pressure Release Ventilation and prone 18 hours a day. Heavy sedation when on vent, often with addition of paralytic agent.
Patient with risk factors may be bumped up a number depending on presentation.
**Risk Factors can be divided into one of five categories in order of importance in my experience: Age, Morbid Obesity, Diabetes, COPD, other comorbidities.
A) Treatment: Key in treatment is early recognition of those with hypoxemia and xray chance and QUICK treatment with plasma, anti-viral (Remdesivir), and high dose steroids. In my experience and in the experience of my colleges and nationally, the EARLY TREATMENT with this combination really does seem to save lives. Prior to these therapies and back when COVID 19 first started, it was not unusual for me to have 10-12 ICU patients with COVID 19 on the ventilator. These days for the last 2 months I have averaged about 3 ventilated COVID 19 patients a week. That represents a TREMENDOUS improvement. Keeping the off the vent is key. If you don't go on the vent, you have a 99.9% survival rate. If you do go on the vent you have a 55-60% survival rate nationally. This mirrors my experience in my ICUs.
How does this combination therapy work? Why is it such a game changer?
When you get COVID 19 infection your body has a natural immune response to the infection. In a small percentage of people, the immune system is hyper-responsive and attacks not just the virus but also the human body, most frequently in COVID, the lungs. These leads to Acute Respiratory Distress Syndrome (ARDS) which causes the Respiratory Failure and shunt physiology in the lung. This leads to severe hypoxemia (low oxygen levels) and eventual scaring of the lung. At it's fullest expression, this leads to death due to suffocation.
So, the COVID IgG antibody (either from plasma from donors who have recovered from COVID) or the new monoclonal IgG COVID AB soon to be on the market (the one the president received) binds to the Coronavirus preventing it from infecting the airway cells and thus preventing infection and the subsequent immune responds. The IgG AB you have to COVID, the less virus is left unbound to infect your cells.
The anti-viral Remdesivir kills the most Coronavirus that does enter your body thereby reducing the number of virions left alive, something in medicine referred to as LOWERING YOUR VIRAL LOAD.
The high dose Dexamethasone reduces your immune response (which is what Plaquenil does as well in theory, but not as effectively as the steroids).
So in summation, after exposure and infection, if you are treated with this "cocktail," the IgG binds to much of the Coronavirus in your body rendering it non-infectious and eventually killing the virus. Most of the small percentage of virus that eludes the IgG will then be killed by the Remdesivir. If there is still enough virus left (live or dead) to cause a hyper-immune response in the susceptible population, the dexamethasone greatly reduces the immune response. This combination if extremely effective IF GIVEN EARLY. If given to late in the course (when they are already near 100% oxygen requirements or on the vent) if is seldom as effective and often to late.
B) Reduced virulence is the natural history of almost every viral plague or successful bacteria through history. The purpose of the virus is to reproduce it's genetic code, which is an RNA code in this case. Therefore, it serves no purpose for the virus to kill it's host which it is using to reproduce it's genetic code to then be released by millions of viral particles through the host. The host in this case being us. If a virus mutates in such a way that it becomes more virulent, and kills off it's host, then less of that virus is replicated and released. Those mutations therefore die out. The mutations that allow the virus to replicate with little to now damage to the host are replicated and released in much higher numbers and win out over time. This is why, historically, most new viral "plagues" wean over time and you see a generally predicable decline in mortality rate w/in the first few years. There is no reason to suspect that COVID19 will be any different than any other virus in this regard and we are, indeed, seeing lowering mortality rates. The key here is to realize the mortality rates are declining not just in the US (where we have all these amazing treatments at our fingertips as doctors) but also around the world including many countries with little to know healthcare.
If you want further proof of how super virulent viruses die out before they spread, well, ever wonder why all Ebola outbreaks are very time limited geographically limited? They kill off the host to fast and at too high a percentage to spread.
Continued..............................
