July 12, 2020
Latest numbers show that on balance COVID19 incidence is rising rapidly in certain parts of the nation while declining to minimal counts in formerly hard hit areas. The death rate is not tracking as fast as the average age at infection has dropped by over 10 years from the previous months data. The death rate is also likely lower because of effective quarantining of at risk individuals in nursing homes and at home. Urban centers remain the areas with greatest mortality and infectious risk. As with the first newsletter on this topic, keep solace with the fact that there is a 99+% chance of survival for all of us.
1) Data is showing that my fears are coming true. Children are being abused more because of social isolation and lockdown events. Dr. Sidpra and colleagues analyzed a 30 day period from March of this year in the United Kingdom for abusive head trauma. "Ten children (six boys, four girls; mean age 192 days, range 17 to 401 days) with suspected AHT were seen during this time in comparison with a mean of 0.67 cases per month in the same period over the previous 3 years. This equates to a 1493% increase in cases of AHT."(Sidpra et. al. 2020) This is a huge deal as this type of abuse is the most violent and is perpetrated against infants by frustrated adults. This means that other forms of child abuse are also increasing in frequency at all ages. Poverty and social isolation from a pandemic lockdown provide for a bad combination of stress.
2) The data appears to support the notion that more at risk individuals are dying from COVID19 related events than previously attributed. A study by Dr. Woolf and colleagues noted that Between March 1 and April 25, over 505,000 deaths were reported in the US. This was 87,000 excess deaths compared to normal times. 65% were attributed to COVID19, while the remaining were not. There were 5 states with the most COVID-19 deaths believed to be caused by nonrespiratory underlying causes, including diabetes (96%), heart diseases (89%), Alzheimer disease (64%), and cerebrovascular diseases (35%). New York City experienced the greatest number of nonrespiratory deaths, notably from heart disease (398%) and diabetes (356%). (Woolf et. al. 2020) The study clearly shows that comorbid disease will be very difficult to tease out as the medical community grapples with understanding the true COVID death rate. The other way to look at this is that COVID just pushed otherwise ill individuals earlier down the mortality pathway. See the next piece.
3) 40% of COVID19 deaths are related to the cardiovascular system. "All these Covid-associated complications were a mystery. We see blood clotting, we see kidney damage, we see inflammation of the heart, we see stroke, we see encephalitis [swelling of the brain]," says William Li, MD, president of the Angiogenesis Foundation. "A whole myriad of seemingly unconnected phenomena that you do not normally see with SARS or H1N1 or, frankly, most infectious diseases." (Smith D. 2020) SARS2 was believed to be a primarily respiratory disease and that contention was false. This virus infects and does damage to the endothelial lining of our blood vessels leading to the non respiratory findings above.
"We found evidence of direct viral infection of the endothelial cell and diffuse endothelial inflammation. Although the virus uses ACE2 receptor expressed by pneumocytes in the epithelial alveolar lining to infect the host, thereby causing lung injury, the ACE2 receptor is also widely expressed on endothelial cells, which traverse multiple organs. Recruitment of immune cells, either by direct viral infection of the endothelium or immune-mediated, can result in widespread endothelial dysfunction associated with apoptosis." (Varga et. al. 2020)
Couple this information with last weeks discussion of furin proteases being used by SARS2 to fuse with human cells and that they are found throughout the vascular network and in high volumes in individuals with cardiovascular disease, CVD, or hypertension, HTN.
We now see that the SARS2 virus has the ability to infect the blood vessel endothelial cells. Then the immune system is recruited to deal with the virus leading to inflammation and ultimately blood clots making oxygen exchange impossible despite mechanical ventilation in severely sick individuals. This appears to be the second major missing piece of the death rate conundrum in the elderly and metabolically ill individuals.
Yet again, we find further evidence for the lifestyle induced comorbid risk associated with metabolic diseases like cholesterol associated CVD and/or HTN. This leads me to the article in #4.
4) Jeffrey Bland PhD has written a fascinating article entitled: COVID19 - A Pandemic Within a Pandemic. It is a must read for all of us as it lays bare the reality of future risk with COVID19 or the next non infectious or infectious trigger.
5) North Carolina data set out of Wake Forest University shows that as of early June the state has a 14% infection rate based on antibody testing. The death rate in North Carolina based on this study is 0.1% which is inline with common influenza. There is a lot of asymptomatic disease out there in the community which means that we may be progressing rapidly toward herd immunity in our state.
In a second study looking at antibody testing, a group out of Queens NYC found out that north of 60% of people in certain parts of the city were already antibody positive. This bodes very well for these areas as they are likely already at or near herd immunity and not going to suffer a second massive wave. This is reflected currently as the case numbers are not rising in these areas despite exposure risks existing (NYC is phase 3).
One possible issue may arise. As antibodies wane in previously mildly sick individuals, does the virus infect the rest of the at risk population via these mildly or asymptomatic reinfected individuals as well. These are unknowns. However, that much prior immunity in any population makes the death risk plummet based on previous historical infectious disease events. On balance, this data set appears to be a net positive in my mind as death will likely continue to decline over time regardless of an antibody therapy or a vaccine.
6) The good news continues to be that children are not experiencing significant disease in the overwhelming majority of cases from COVID. (CDC weekly update)
For new readers or for a refresher go to newsletters # 15 and 16.5 for prevention education. Link (1) (2)
Knowledge is power,
Dr. M
Sidpra Archives Disease of Childhood
Psychology Today
CDC Death Statistics
Woolf JAMA Network
Smith Medium
Varga The Lancet
Bland Medium
Ackermann NEJM
Harrison Wake Forest Article
NYTimes Queens Article
