New Studies, Transmission, Spread, & Prevention (lecture 10)
Welcome to another MedCram update. So first things first, we have 427 deaths and 20,600 confirmed cases. And again, we look at this ratio here not saying that this is a death rate or a fatality rate; it’s just a ratio of confirmed deaths divided by confirmed cases.
But as we predicted, the total recovered has gone up, and I refer you once again to the dashboard at the Johns Hopkins University site for the coronavirus. So there are a lot of things to go over today. First of all, there was a paper that was trying to calculate the RO, (R Naught) or the basic reproduction number. This is basically: if the virus is in somebody, how many people does that virus get passed on to? And I will put a link to this paper. The description shows about 2.24 – 3.58 is the number, which is a respectable number. Measles is, of course, one of the worst; it’s about 14 or 15.
Next big thing: three new cases in California, and currently California has about six out of the 11 cases in the United States, and that’s not surprising given that California is probably the biggest destination from Asia to the United States.
Second death outside of China was in a relatively young gentleman although apparently this guy had underlying illness. Other big thing in the news: patient in Washington state was released to home isolation, and the key here is home isolation. So they don’t say much about him. However, the thing that I would like to know is whether or not he’s virus-free. Why did he go home on home isolation, and in fact he was still infectious and he’s just not sick enough to be in the hospital; that’s an interesting question to note, but we’ll have to see.
I’ve got a lot of comments asking about stuff from China, like mail or packages. We just talked about yesterday how on a door handle they were able to pick up the RNA of the coronavirus and PCR, and I’ve seen at least two or three articles now with experts, virologists looking at the coronavirus and saying that mail from China is fine.
Now we bring up bats. So there seems to be some disagreement among scientists. When this originally came out, there was a study that showed that the coronavirus was very similar and probably most similar to that found in snakes. There seems to be some additional data that it could be from bats, and the news there are more evacuations coming, and the US government is going to be taking those to Air Force bases since that seemed to work out well for March Air Reserve Base in southern California.
A Travis Air Force Base seems to be one of the ones that’s targeted. They need to have big enough places where they can have single rooms to isolate, and as we mentioned yesterday in our video there were two people on a German flight to Germany with German Nationals that tested positive for the coronavirus.
Finally in weird news. Pakistan is bucking the trend. They’re going to resume flights with XXX, which leave a lot of people scratching their heads because they believe that Pakistan is in no way able to deal with a coronavirus outbreak there. They do note in some of the articles that I read that there is a pretty strong relationship between xxx and Pakistan. Of recent note, xxx has loaned them billions of dollars for infrastructure. Right now, there are no cases in Pakistan.
And what about the fact that this is a year that the Olympics are occurring, the Summer Olympics in Tokyo? So the question is where are we going to be when the summer comes around, and I will put some links in the description of epidemiologists, hoping that the summer is a slow-down because generally these viruses don’t do very well in the summertime.
But, remember this is a completely novel virus to the human body, and the Diamond Princess cruise ship is in complete quarantine just off the coast of Japan, and that’s because there was one person in late January that tested positive for the coronavirus, and currently there are seven people on board that are ill. Of course, that’s not too surprising if you’ve been on a cruise ship, you’ll know that you’re bound to get somebody that’s ill. The testing is not going to be completed on these people until Tuesday night.
Okay. The next thing I want to talk about is they check this patient out in Washington state and found that he definitely tested positive in his stool for the RNA for this coronavirus. Well, this reminded people of what happened back in 2002 with SARS. And as you make recall, and you will also link to a paper that describes this that there was a whole outbreak, I mean hundreds of people were exposed to one man having the SARS virus.
And where’s this going to happen? And that’s the next thing we got to talk about is public restrooms, public bathrooms. There’s some good evidence even the Chinese are agreeing that this is a potential issue as to how this thing can be spread. Just the flushing of the toilet itself that can also aerosolize things, just by flushing. So the question is, what do you do? Well, I’ve got no studies, can’t tell you for a fact that this works, but here are some steps I think you may want to consider.
Number one is avoid public bathrooms if possible. Number two, wash hands, and what I would say here is, use paper towels if possible to touch anything in public bathrooms. So walking into the bathroom, usually, it’s a push you can use your foot. Obviously. You want to have a barrier between you and the toilet seat. When you’re done, if you can, you probably want to close the toilet cover. So if you flush, it doesn’t aerosolize, of course, that’s going to be for you not to spread it to someone else. But of course, you can’t prevent people from doing that.
Washing your hands for at least 20 seconds. Okay, some people say sing Happy Birthday in your mine twice to get the 20 seconds. I would also carry hand sanitizer. You would not believe how many times you touch your face, you scratch your nose, you put your finger in your mouth. These are all entryways.
Another big thing. If you have children, teach them all of these things. So the second thing I wanted to get to really quickly was this Lancet article where they include a now 99, which is the most to date, people with pneumonia, with the coronavirus, and the average age here was 55 years old, 67% men, 50% chronic disease, 83% had fever, 82% had cough, 31 percent had shortness of breath. Interestingly, only 2% had diarrhea, 17% had ARDS, and 11% died as opposed to the original paper, which said 15%.
Now we’re going little bit more granular because we have more. Now, this brings us to another interesting thing, which was the prediction score for those that were going to die followed something called an MuLBSTA score for viral pneumonia. I’ll include that in the description below. It’s a very nice article. And what did it look for? Well, there are actually a number of things that you could look for in these patients.
To help tell you is this one that’s going to die, or just someone that’s not going to die. Number one was multilobar infiltrates. Number two was lymphocytes less than 0.8; number three was bacterial co-infection; number four acute smoker, number five quite smoker, number six was someone who had hypertension which I’ll abbreviate HTN. Number seven was age greater than 60 years of age.
So from multilobar infiltrates, they got five points, and you want to have the least amount of points possible. For low lymphocytes, they got four points. For bacterial co-infection, four points; acute smoker, three points. If you a quit smoker, two points; hypertension was two points, in age greater than 60 was two points.
So, I’ll give you some examples here. If you had zero points, your chances of dying from viral pneumonia was 0.47%. If you had six points, it was 2.9% if you had 12 points, it was 15% and if it was 20 points. And, of course, this can go up to as high as 20 points, but it was basically greater than 69%. And this was a very nice prediction method to determine in a viral pneumonia if someone would die, and it followed it pretty closely even for other viruses.
So the one that I see a lot of in the comments is this coronavirus and HIV. This probably started out because of a paper that was uploaded to bioRxiv not too long ago that found, by looking at the RNA, that there were four regions in the novel coronavirus that look like they had come from HIV. And this was a paper that was not peer-reviewed. It was uploaded to a particular part of the site where those papers can go before they get reviewed by other scientists. There was a disclaimer in that area that specifically said that, but the conspiracy theories abound. And I have to admit I saw it as well, and I was concerned about it because of what the implications could mean.
These HIV stretches were coding for gp120, which is involved potentially in the binding site of CD4 cells. So what they actually found out? Two of those areas are actually found in bat coronavirus. Okay, so that’s normally there. And of the other two one is found in HIV, but it’s only six amino acids long, and I don’t think that based on the number of matches that they have to go through the fact that you would find something that matches 6 amino acids would be awash, statistically speaking. Nevertheless, this paper was removed Sunday by the authors, saying that he was going to re-look at this.
But people will say, well, why are we using HIV meds then in this current outbreak? Why are they trying it? And why are people getting better on the HIV meds? Well, this is not a new theory back when SARS broke out in 2002. They also used HIV medications. Well, why? Well, because coronavirus is an RNA virus, and HIV is also an RNA virus, and so some of the machinery and getting RNA viruses into species that have DNA primarily. They are going to be very similar, and they may help, and of course, we already have it. We know that it’s relatively safe.
And so there are these questions about people being readmitted to the hospital, people who have recovered, yet they get sick again, only to have to end up on this. Well, I haven’t seen any cases out there of this particularly. If you see any, I would love to hear from you, please put actual case reports in there.
There was the gentleman in the Philippines who did die, but you’ve got to realize that a lot of these people who have viral infections will get secondary bacterial infections. And in fact, I see this all the time personally in my practice is people will come into the hospital with severe bacterial pneumonia. But if you check their history, they’ve had a viral infection prior to that. They’ve got better from the virus, moves in; it denudes the respiratory epithelium, and then the bacteria moves in as an opportunistic infection. So these people being readmitted to the hospital could be opportunistic infections of bacteria.
Well, you say, well, what about the fact that a lot of these people have decreased white blood cells? I mean, couldn’t this be the virus tearing up the CD4 cells, T-helper cells? Well, if you look back at that article that I was talking about with the viral pneumonia, you’ll see that part of the way they differentiate is that many times, regardless of the viral pneumonia, there’s going to be a lymphocyte count is low. In fact, that was one of the criteria that we used in figuring out whether or not the patient’s actually have higher risk of dying.
Remember that was the MuLBSTA score, and these people that are being discharged from the hospital as part of their criteria, at least in China, is that their viral loads are undetectable. They cannot detect the virus on PCR.
So the point of this is be careful. There’s a lot of theories out there that may be based on less than scientific data, and I guess I’ll take this opportunity to thank everyone for all of the nice comments. I’m glad that this is helpful. Thanks for joining us, and remember what we said about hand-washing. Pray for this to turn around and we will see you next time.