I am not an ID specialist and do not want to present myself like this in any way. I am a practicing Functional Medicine physician like Dr. Amy Fletcher, who has a husband at the front lines of this pandemic. I am receiving updated information locally and from a variety of national specialists working in the field. My goal is to use my knowledge to present the updated information in a precise and useful way, free of speculation, and full of helpful information. So, you can put into practice to address this growing epidemic with a sound mind. Nancy A. Palermo MD
The World Health Organization has declared COVID—19 a global pandemic, and the US government has declared it a national emergency.
Restrictions are in place with school closures, restaurant closures, and travel bans, and we are diagnosing new cases at exponential numbers. As of 3/22/2020, there have been 336,167 diagnoses worldwide, and of these 14,441 deaths and 96,958 of those previously diagnosed are now deemed recovered. Epidemiologists believe we have only just entered this pandemic, and in the end, 40-70% of the population will be affected. There is no question; this will be a tremendous threat to our health and our economy. We have dealt with worse in the past through wars and the depression, and there is every effort we will emerge with a new vaccine, medication. Treatment options, as well as widespread immunity. While all of this can currently be overwhelming, we want to provide information to help each of you reduce your risks and protect yourselves and your family members.
Before we get started, let’s take a deep breath and calm your mind so you can address this head-on.
It is fine to be afraid but not fine to be powerless and frozen in fear. In the words of Functional Medicine practitioner Chris Kresser, “this is not a sprint, but a marathon.” Overreacting in the short term will leave you drained and unable to keep up your resistance in the long run. Stress can only serve to weaken our immune system, so we need to prepare for long term protection.
What We Know About COVID-19…today
COVID-19, the viral disease caused by the SARS-CoV-2 virus, emerged from Wuhan, China. It is believed to have developed from animal to human infection and is postulated to have come from bats. The spread of coronaviruses from animals to humans is rare. However, this virus is very similar to the spread of SARs, which was from civet cats (Asia) and MERs (Middle East), which came from camels. The COVID-19 is a novel virus meaning the human population has not had previous immunity to it, and thus this makes us more susceptible. It also makes the
information we know about the virus appear confusing and limited. We are learning more every day with the country’s personal experiences as well as the reports coming in from its country of origin, China.
The virus appears to be spreading rapidly. On Mar 1, in the US, there were 76 cases, and as of today (Mar 22), there are 13,931 new cases for a total of 38,138 confirmed cases and 396 deaths in the US. This is a substantial increase. If we were to continue this trajectory, the estimated cases would be over 225,000 people infected in 2 weeks and 12 million in 4 weeks. This certainly supports the current reaction by states and the US administration. If we do not change this rate, the entire population could be affected. There is certainly support for drastic measures. If we can change the curve of transmission, we can get some control over the spread.
At the current rate of transmission, our hospital systems will be overwhelmed.
We have only 1 million hospital beds (with only 64,000 ICU beds). If there is not some control of this spread, the hospitals will not have the ability to care for the very sick. Overreacting currently makes complete sense.
COVID-19 is easily transmissible from person to person.
The transmission rate is unknown because of inadequate testing. Still, it is felt to be around 1.5-3.0 (Average number of people one sick person will infect). To put it in perspective, the flu is about 1.0, and the measles about 9.0. People are infectious and can transmit the virus from 2-14 days but appear to be the most infections in the first five days. The virus spreads from person to person through respiratory droplets. There is some evidence the virus can live on affected surfaces for up to 72 hours. However, this has been debatable and is not felt to be a common form of transmission as the virus has poor survivability on surfaces.
The typical symptoms are fever (98%), dry cough (60%), and malaise (70%) but rarely a sore throat or runny nose (<10% of confirmed cases).
Recent data has shown that up to 14% of individuals have gastrointestinal symptoms, including nausea, vomiting, and diarrhea.
Up to 80% of individuals affected have mild or no symptoms, and up to 96-99% recover without sequelae. The virus appears to affect the lungs and can lead to respiratory failure in severe cases because of the massive amount of inflammation that occurs due to a cytokine storm. (Cytokines are substances produced by the immune system to fight infections) This inflammation can then inhibit the surfactant production in the lungs, making it hard to keep the airways open. Death rates appear to be highest among those with chronic disease (diabetes, heart disease, cancer, pulmonary disease) the elderly and smokers and vapers. This is especially concerning because of the high rate of chronic disease in the US among all age groups. (In 2020 over 157 million individuals have at least one chronic condition, and 81 million have multiple chronic illnesses) There is some concern in the US of the increased number of severe cases in the age range of 20-40. To date, 20% of those who are affected in this age group have severe disease requiring hospitalization, and 12% of them need ICU care. This has not been the case in other countries and does raise the question of associated chronic disease, nicotine, and drug use and obesity, which is higher in the US, even in this age range.
Mortality rates of the Coronavirus are challenging to predict because of inadequate testing done to date.
Data coming out of China recently looks better and is about 1.5%. South Korea is probably our best predictor country as they developed a test early on that was 98% accurate. They performed over 10,000 tests a day and have shown about a 0.6% mortality rate, which is higher than the flu (0.1%). Mortality rates in China and Italy were higher, but testing was lacking. We must know the actual number of those infected to calculate a mortality rate. At this point in the US, that will be impossible because of the lack of widespread testing. The numbers from the Diamond Princess cruise ship are somewhat telling- 3500 people on board were tested with 706 positive and six deaths giving a 0.85% mortality rate. However, the data also suggested many of these individuals were in the higher risk groups.
The delayed response in the US has undoubtedly contributed to the growth.
Still, the scale of the testing seems to be improving. The goal at this point is to flatten the curve of growth, and therefore the mandatory restrictions and changes have been put into place. There is certainly some good news from China and South Korea concerning the reduction of cases because of their quarantine policies. The strict policies of a country like Taiwan, with only a total of 100 cases and one death, show how extreme control of the population can be successful in the spread of this virus. (To date Taiwan has only 169 cases and two deaths thanks to the early intervention) We need to consider this as well.
If nothing else slowing the spread by self-quarantine, government restrictions and social distancing will help to reduce the burden on our health care systems and the protection to those who are at the most significant risk.
The is no harm in an over-reaction.
In the words of epidemiologist Mari Armstrong-Hough: “You won’t know if what you did personally helped. That’s the nature of public health. When the best way to save lives it to prevent a disease rather than treat it, success often looks like an overreaction. ”
Treatment and Vaccines – Where are we now in the process?
Currently, there are no approved treatments or vaccines for the COVID-19. The treatment protocol involves early management and supportive care for those with infection, and in rare cases, ventilation for those in severe respiratory distress. Again, this is why prevention is being stressed.
We are at least 12 months out of the development of a widespread vaccine.
Some treatments have shown promise, including, Plaquenil (hydroxychloroquine), a medication used for autoimmune disease, Remdesivir, an antiviral drug developed for Ebola, Cytokine blocking drugs like tocilizumab and sarilumab, and Interferon B, a drug which reduces the inflammatory response. In China high dose IV Vitamin C also showed promise in those with severe forms of the disease. Many other therapies are also being considered, and there is no lack of attention currently being placed on finding effective treatments. In some institutions, physicians on the front line are not waiting for the data when treating the most severe cases. They cannot afford to wait for controlled studies when treating an individual on the brink of death. Early results have been promising.
What can I do to Protect Myself and My Family in the Meantime?
Most of us are not at high risk from Coronavirus. We should do everything in our power to avoid the infection to reduce the spread and to reduce giving the virus to others in the community who might be at a higher risk. Here are practices we can adopt now:
Change Your Daily Habits
- Practice Good Personal Hygiene: Wash your hands for at least 30 seconds with soap and water and use hand sanitizer when this is not possible. Do your best to avoid touching your nose and mouth.
- Stay Home: Avoid a place where you may be put at risk. Only go out if necessary and avoid crowds. If we can all stay home for just 14-21 days, we can have a significant impact on the growth of this pandemic.
- Social Distancing: Do not shake hands or give hugs. Try to keep a 6-foot radius from others. Do not travel and avoid restaurants, bars, and fitness centers. Work from home, if possible.
- Protect Individuals at the Greatest Risk: The CDC recommends that individuals over 60 stay home and avoid unnecessary contact. As much as your tendency may be to check on your older parents or grandparents, exposure in nursing homes and retirement communities could be disastrous. You should avoid friends and coworkers with underlying immune disorders like individuals with autoimmune disease, cancer, or transplant therapy as they are at a particularly high risk of having severe complications of the virus.
- Make sure to clean surfaces with an adequate anti-bacterial. The virus appears to be easily killed with anti-bacterial agents like alcohol, bleach, and hydrogen peroxide.
Support Your Immune System
- Eat a Whole Foods, Nutrient Dense Diet: Nothing we do can affect our immune system more than eating a nutrient-dense diet. Nutrient deficiencies make one more susceptible to infection and more likely to suffer complications. Phytonutrients and antioxidants provided in fruits and vegetables can be especially protective. There has never been a better time to load up. Use this time to try to get in at least
8-10 servings of colorful fruits and vegetables. Remember, every color adds a different phytonutrient and another therapeutic tool to ramp up your immunity. It is always preferred to get vitamins and nutrients through foods, not supplements.
- Remove processed foods, refined sugars, and hydrogenated oils. These fake foods can ramp up inflammation in the body and distract our immune system from fighting more important things. Multiple studies have linked these inflammatory foods to suppression of our immunity. The stress of this viral epidemic may have us looking for comfort and grabbing junk. Now is not the time to increase our inflammatory load.
- Add Powerful Antioxidants to Your Diet through the Allicin foods (garlic, onions, green onions) and herbs and spices like curcumin, ginger, rosemary, and oregano. Make sure you load up on garlic, onions, and lots of spices. These additions have been shown to offer antimicrobial properties, which may give additional benefit to the immune system.
- Drink Plenty of Fluids. It is crucial to your immune system to have adequate fluids. Drink plenty of water, teas, and broths to support the functions of your immune system. Avoid juices and sugary drinks as they raise inflammation in the body, which may be counterintuitive.
- Get Plenty of Sleep-Aim to get 7-8 hours of sleep. Limited sleep can have a profound impact on immunity and inflammation. If the stress of this viral mess has you excited, work hard to establish routines, and practice breathing and relaxation techniques to prioritize sleep. Avoid watching the news or reading about the epidemic before going to bed. The information will be available in the morning if you feel you need to keep updated.
- Get plenty of Exercise – Mild to moderate exercise can boost the immune system. Studies have shown that movement improves your immune system by increasing the activity of “natural killer cells”-immune cells that directly fight infections. Exercise can also enhance our gut microbiota, which in turn can strengthen our immunity in the gut. Seventy percent of our immune system resides in our gut, so this can be a significant boost to immunity. Exercise will also help with sleep, which is an added benefit. Even if you cannot go to your regular gym class, you can investigate online courses or even better- get outside and move. Overdosing on exercise may damage your health and immunity. It may add to the already growing amount of stress brought on by this viral pandemic.
- Reset Through Breathing, Meditation, and Yoga: There is no question the current state in this country has everyone on edge. Now is the time to address the stress. There is enough data suggesting stress can have a profound effect on our immune system and make us more susceptible to infections. Find ways to reset and release this stress through yoga. Consider a hot bath with Epsom salts and lavender. Now is a great time to introduce meditation if you are not already practicing. There are many apps you can explore, like Headspace or Calm, that can help to add you to meditation practice. Breathing is a simple calming technique. Practice 3-4-5 breathing twice a day (or more) to calm the mind and body. Breathe in deeply for a count of 3. Hold it for a count of 4 and breathe out entirely for a count of 5. Repeat this for 5 minutes.
- Optimize Your Gut Health- Eating a Whole Foods Plant-Based diet is key to boosting gut health. Since 70% of your immune system resides in your GI tract, optimal gut health is key to a healthy immune system. Consider taking a multispecies probiotic with at least 25 billion CFU. Make sure it contains Lactobacillus and Bifidus Hopefully, eating a whole foods diet will help you to reduce the use of antacids and PPIs as they can have a detrimental effect on gut health and immune health as well.
- Add Supplements to Optimize Your Immunity
In addition to taking a good multivitamin and essential fatty acids (Omega3-6-9) consider adding the following supplements to boost immunity during this trying time:
Vitamin D3 1000 IUs minimum
Studies have shown that low vitamin D levels can decrease your immunity. Recent research has uncovered receptors for Vitamin D on our white cells – the cells that provide our first line of defense. Lower levels of D are associated with lower recruitment of these fighters. Adequate Vitamin D intake has been shown to reduce colds and flu by 42%! If you are deficient, then adding supplementation would be beneficial for immune protection. If not, make sure you are taking the recommended 1000 mg daily. There is early evidence that excess D may be detrimental in individuals who have Coronavirus, so if you suspect illness, discontinue supplementation.
Vitamin A 600IUs of RDA in a multivitamin.
Vitamin A Is a powerful antioxidant and appears to be especially beneficial to the immune system. It has been shown to increase a bacteria Lactobacilli in the gut, which can bump up the production of interferon and immune chemicals to fight infection. Like Vitamin D, excess doses are not beneficial, and there is some suggestion that they may even be detrimental if the illness occurs.
Buffered Vitamin C
Vitamin C has longstanding support of the immune function. Consider taking an additional 500-1000 mg a day with food for prevention and 3000-4000 mg per day if you need an immune booster.
Zinc Citrate- 30 mg/day
Zinc plays an essential role in the growth and integrity of the immune system cells. Zinc deficiency has shown to place an individual at increased susceptibility to a variety of pathogens, including viruses.
NAC is used widely in several conditions but has been shown to be especially helpful in individuals with chronic respiratory conditions and respiratory viral illnesses. It is crucial in the detoxification process as it is converted into Glutathione, the body’s most potent antioxidant. Optimizing this powerful antioxidant has been shown to boost the immune system. Consider taking 900 mg twice a day if needed.
(None of these recommendations are intended to take the place of medical care if symptoms present. The best way to get vitamins and antioxidants is through a whole-food, plant-based diet. These are options recommended simply to optimize immunity and prevent illness)
In Closing, some positive notes
For the first time since the outbreak of the virus, China has reported no new confirmed or suspected cases in the past four days. They have flattened their curve. (Jan 22 to Mar 19) The most recent death rate estimates coming out of China have fallen to 1.4 %. (Again, the actual rate is probably lower since many affected were never tested) Data from the Diamond Princess cruise mentioned earlier showed a fatality rate of 0.002%.
When testing has been done as in the Diamond Princess and the NBA, the results suggest we may be underestimating global exposure and infection rates, suggesting there are many asymptomatic individuals. Herd immunity may be higher than predicted. This is how pandemics end.
Right now, there are over five vaccines in development. Some are already being put into clinical trials.
Researchers across the globe are working on drugs effective against the virus, and preliminary results have been promising. Some research centers are already putting these drugs to the test.
If we can hunker down during this period of Sheltering and Quarantining, we will have some options to tackle this overwhelming virus.
These will be trying times, but if we can maintain common sense and focus on optimizing our health and the health of the community, we will get through this pandemic. We must be mindful of our actions both personally and in the community to not only protect ourselves and our family but also to protect those in our community at the most significant risk.