Category: COVID-19

Two important news items came out yesterday (3/23/20) and today (3/24/20):

Time Magazine: President Trump Is Already Considering Defying Health Experts to Boost the Economy

New York Gov. Cuomo: ‘Troubling and astronomical’ coronavirus cases increase urgency for hospital beds

There are points to support both sides of this argument.

If we shut down the economy, the damage could be immense.  Note that China took drastic quarantine steps and is starting to emerge from the pandemic, but no one is sure if there will be a second wave of disease when people go back to work.  By March 6th, the Shanghai Stock Index had almost climbed back to its pre-crash high (but is currently testing new lows for the last year, undoubtedly in reaction to market panics around the world).

If we don’t shut down the economy, the health damage could be immense.  All one has to do is turn on the TV or listen to Governor Cuomo above to realize this.

As in any critical decision, we do not have all of the data we need to know the outcomes.

The government will try to make a cost-benefit decision, and to do this they will have to put a dollar value on human life.  Some lives will be judged more valuable than others.  In hospital triage situations, a person’s remaining life expectancy is a factor in the life-saving decision.

When the government is assuming the role of God, one hopes that we have the “best” people (however one defines that) in the country calling the shots…

But please don’t forget Abraham Lincoln’s words.  Our country is a “government of the people, by the people, and for the people.”  If there ever was a time to make your opinion known to your elected representatives, this is it!

My recommendation – If a decision is going to be made to allow an unknown, possibly large, number of people to die so that others can continue to work, this needs to be a collective decision involving top people across the government, including, at least, the leaders of Congress.  A significant fraction of the country does not trust the President, particularly his tendency to think he is the smartest person in the room and a “strong leader.”

It is in his personal interest not to make this decision without broad buy-in.  If he is wrong and the number of deaths is much higher than he expects, he will go down as the worst President in U.S. history.  Of course, if he decides single-handedly and is correct, he will confirm his genius status.  Does the country want to take this high-stakes gamble by a single individual??

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Last night Chris Cuomo gave the following “Closing Argument” on CNN. Cuomo argued in effect that the “Greatest Generation” made tremendous sacrifices during WWII to keep this country and the world free. Will we now ask them to sacrifice themselves yet again? No! He states we are all in this together.

You can also comment by calling the White House directly at 202-456-1111.

The topic of this article is still a hypothesis, and I am updating it as important news comes in.  However it will take some time to confirm or refute it.  People on these medications should take prudent social distancing measures in the interim.  There is no current consensus to change your medications however, and stopping blood pressure medication can be dangerous.  Some medical authorities are already disputing this hypothesis as noted below, but others call for more research.

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Last significant update of the main text on Monday, 3/16 at 11:55 AM Pacific Daylight Time.  Please see the Comments section following the main article for additional ongoing details.

A possibly very important article appeared in the Lancet medical journal recently:

https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30116-8/fulltext

In brief, the article states that people treated with specific classes of blood pressure medications (meds that are also used on some people with diabetes) have increased amounts of the ACE2 protein that the novel coronavirus binds to when it attacks lung cells.

The article states “We therefore hypothesise that diabetes and hypertension treatment with ACE2-stimulating drugs increases the risk of developing severe and fatal COVID-19.”

Note, of course, the word “hypothesise” (sic – hypothesize, unless this is UK spelling – the corresponding author is from Switzerland).  This hypothesis is not proven, but seems very plausible.

This hypothesis is similar to a question that I raised on local social media a few days ago in regards to ACE inhibitors (ACEI), especially lisinopril which causes “lisinopril cough,” at

https://nextdoor.com/post/139950824

[Sorry, but the link above will only work for people in my nearby neighborhood location (San Mateo, CA) with Nextdoor accounts.]

A local doctor, Dr. Raymond Hong who is an allergist, saw this post and commented that he believed that only Angiotensin Receptor Blocker (ARB) drugs increased the number of ACE2 receptor proteins that the novel coronavirus attacks, not ACE inhibitors.  He also thought that this was a very interesting hypothesis that needed additional research.

He cautioned (I added bolding in his quote for emphasis):

“Although this sounds concerning, in no way am I advocating stopping or switching angiotensin receptor blockers (or ace inhibitors) or discussing this with your doctor quite yet. But I agree we should definitely be looking at the patients with severe COVID-19 disease to see what medical conditions they have, and if they have hypertension, what medications they are on. Any positive findings might help spur more caution and studies. There may be multiple factors involved and I just thought I’d respond to your question in a responsible manner.”

Personally, I (Kristofferson) should note that changing medications will NOT cause the levels of these lung proteins that the virus attacks to decrease overnight.  If this hypothesis turns out to be correct (and unfortunately its resolution may take too long to help people currently at risk for COVID-19), my take is that people on these medications should take extra precautions to avoid exposing themselves to sick individuals.  This undoubtedly means hunkering down at home given the latest developments.

This hypothesis could also explain why young people might develop severe coronavirus cases – they might be at risk if they have elevated ACE2 levels as a result of using ACEI/ARB medications.

A new JAMANetwork review article (link added near the end of this article) states that it is possible that either genetics or the high rate of smoking among Chinese men may have increased their ACE2 levels and made them more susceptible to the disease, but, again, this is not yet proven:  “The ACE2 enzyme is expressed in type II alveolar cells, and some unconfirmed data suggest that Asian males have a large number of ACE2-expressing cells in the lung, which may partially explain the male predominance of COVID-19. However, other factors such as a higher prevalence of smoking among men in China may explain the difference in the sex distribution of the disease.”

Dr. Hong has just (3/13/2020 5:45 PM PDT) notified me of the following news:

I think it’s too early to make recommendations about switching. In fact because of social media posts similar to mine, there has been concern about patients stopping their blood pressure medications. The European Society of Cardiology published a position statement to not stop ace inhibitors or arbs as there is no evidence to support this. They stated there is evidence in animals that these medications might even be protective against serious lung complications from COVID-19. So they recommended against making any changes.

Here is the official statement that he notes above:

Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers

This ESC article clearly contradicts The Lancet article and states:

This speculation about the safety of ACE-i or ARB treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it. Indeed, there is evidence from studies in animals suggesting that these medications might be rather protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans.

The Council on Hypertension of the European Society of Cardiology wish to highlight the lack of any evidence supporting harmful effect of ACE-I and ARB in the context of the pandemic COVID-19 outbreak.

The Council on Hypertension strongly recommend that physicians and patients should continue treatment with their usual anti-hypertensive therapy because there is no clinical or scientific evidence to suggest that treatment with ACEi or ARBs should be discontinued because of the Covid-19 infection.

Important other expert opinions on this hypothesis can be found in the following link.  Some of these experts say that the jury is still out:

Expert reaction to questions about high blood pressure, diabetes, and ACE inhibitor drugs, and risk of COVID-19 infection

The following shows the tremendous complexity of this whole problem. Here is an interesting tweet from a doctor at Johns Hopkins. This doctor is working on novel therapeutics. He states in the tweet: “My recommended COVID19 treatment algorithm is starting patients who have more than mild symptoms or in high-risk category with: 1. Antiviral (chloroquine or hydroxychloroquine) 2. Losartan or other ARB (combat lung injury). Both proven w/ data, the latter acting on ACE2 pathway.'”  In the thread to his tweet he answers the concern about ARBs increasing ACE2 levels and claims the situation goes into reverse AFTER infection sets in as the viral infection causes ACE2 levels to drop.  Thus ARBs are helpful AFTER the fact: “it is beneficial for these drugs to increase ACE2. The lack of ACE2 leads to pulmonary edema.”  This looks like a case of initially damned if you do, but then damned AFTER if you don’t…

In conclusion, one should clearly not make any changes to your current medications while this debate plays out, but, in my personal opinion, we do not yet know what the final outcome will be, and the pandemic could be over before we do.  That is why I personally advise readers who take these medications to practice “social distancing” with particular diligence until the science is finally settled.

The following excellent JAMANetwork review article (which has section headings on the virus, epidemiology, clinical characteristics, case-fatality rates, screening and testing, clinical care and treatment, and prevention and infection control) just came to my attention via a tweet from Dr. Sanjay Gupta of CNN:

https://jamanetwork.com/journals/jama/fullarticle/2762510

Please scroll down to the Comments section below for further questions and information.

This blog normally focuses on education issues, but I am addressing the coronavirus pandemic here (and it is very likely a pandemic) because it is very probable that schools will be a primary mechanism of transmission if current quarantine efforts fail.  Kids just do not stay home from  school when ill, due in part to their desire not to fall behind, but also due to frantically busy parents shuffling them off so that the parents can go to work.

Sadly very often the media does not seem to have the expertise to ask the right questions.  I read a lot of news reports but have not seen answers to the following concerns.  Answers may exist, but, if so, they are not being distributed broadly.  CNN will have a special “town hall” the evening of March 5th on this topic, but my bet is that it will merely recycled the current oft-repeated news stories.  [Update – it turned out to be an EXCELLENT show.  Please see the Comments section following this article for details.  Regarding school closures, one participant noted that in poor areas closing the schools may also mean that some kids will miss their only good meal of the day.]

1. We hear that 80% of the cases are “mild” and yet young healthy people, like the ophthalmologist who was one of the first who reported the disease in China, became extremely ill and died.  This can be due to many factors.  Initially it was thought that the doctor was exposed to a patient from the Wuhan marketplace with a very high “viral load”.  However, there may be multiple strains of the virus circulating of varying mortality (I have been wondering about this for some time and CNBC just reported this news finally this AM).  The CNBC report stated that the initial virus may have caused more severe illness than the more recent mutation, but data is still preliminary. Evolutionary pressure favors viruses that do NOT kill their hosts because a virus needs its host to replicate.  There are also possible genetic variations in cell surface proteins that viruses may target, possibly making it cause more serious disease in some people than others.  We need people in the government and media with the appropriate scientific background to look into these questions and get better information out to the public.  No discussion that I have heard to date has addressed any of the above, but instead focuses merely on obvious items like hand washing and the pros and cons of wearing masks.
2. Reports abound of the virus mysteriously circulating in communities “undetected” and then cases suddenly appearing due to “community transmission.”  Clearly one wonders about the availability AND reliability of coronavirus test kits.  I read earlier that the initial kits distributed by the CDC were flawed and had to be replaced.  We have to resign ourselves to the fact that, in the middle of regular flu season, many cases of illness are NOT going to be tested.  Secondly, even if they are tested, what is the rate of false positives and false negatives for these tests?  The media immediately seems to report positives tests as gospel truth.  Without knowing the validity of the tests we do not know how much to trust this data. (False negative rate reported on 3/4/2020 to be <4% – see Comment section below). (3/5/20 – SF Chronicle article link in Comments below shows some patients getting variable results during repeated tests.)
3. We heard the other day that there are over 8000 people in California alone under self-quarantine and I have seen reports that the number is over 9000.  Initial quarantines occurred at Travis Air Force base and other bases in southern California.  I have seen almost no follow-up reporting about the outcomes of any of these quarantines.  I would imagine by now that many of the people have been released, but the media seems less excited about reporting such news.  I would hope that our state public health agency is monitoring this list and is providing updates somewhere as to whether the quarantine case load is increasing or decreasing.  The media needs to focus on reporting this information as well as the more sensational stories of people testing positive for the virus.

I will update this article with other concerns as more information becomes available; so please check back again and look at the Comments section below.