There has been alot of debate on whether hydroxychloroquine (HCQ) is effective in preventing or treating COVID-19. What got things started was a French study suggesting efficacy in lowering the viral load in patients with COVID-19 back in March 2020. We have learned alot since then and other studies have called into question both the efficacy and safety of HCQ in treating COVID-19.

The French study was a non-randomized study of 36 hospitalized people in which patients were recruited either into a treatment group or control (non-treatment) group. This was an observational study. Since then, there have been roughly 900 published studies in which the vast majority are observational studies. So whats the difference?

In an observational study, the effect of the drug being tested (in this case HCQ), is due to its true causal effect (lowering viral load or treating the infection) AND the characteristics of who was selected for treatment.

Whereas, in a randomized trial, because the selection is random, the effect is due solely to the true effect of the treatment. This is a much better type of study looking primarily at the effect of the drug treatment.

So if you are able to select the people in the treatment group, the researcher can tend to choose those that are younger, and who have fewer co-morbidities which is poised to do better than if the treatment was assigned randomly.

Observational studies are still good studies and should be used to design randomized studies. Randomized studies should then be used to guide therapy.

So the next time you are reading research about a new prevention or treatment for COVID-19, check to see if it is a randomized study. It will serve to be more reliable.

References:  Randomized clinical trials

https://www.nejm.org/doi/full/10.1056/NEJMoa2019014

https://www.globalhealthnow.org/2020-06/more-clues-potential-treatments

I was hesitant in posting this article because I didn’t want to give the wrong impression in stating that good hand washing and cleaning surfaces is not important. It is. This article explains how some companies emphasizing how they are disinfecting their areas may give us a false sense of security. This obsession of risk reduction rituals that make us feel safer but don’t actually do much to reduce the risk if transmission is called hygiene theatre.

In May, the CDC updated its guidelines to clarify that COVID-19 is spread primarily through the air, not by touching surfaces. According to Emanual Goldman, a microbiology professor at Rutgers New Jersey Medical School, “Surface transmission of COVID-19 is not justified at all by science”.

But wait…weren’t we told that the virus could remain on surfaces for hours and even days?!!! Yes! Backing up those many scary stories of how people were infected after touching their mail, packages and doorknobs were several Lancet studies in July that  were based on unrealistically strong concentrations of the virus. In other words, 100 people would have to sneeze on the same exact area of a table to mimic some of the experimental conditions. But now…we have more research.

The article below reviews other studies looking at how this coronavirus really spreads. There is new research and studies everyday. The one thing that has not changed is that this is an airborne virus, and that besides good hand washing, the importance of social distancing and wearing masks cannot be over-emphasized.

The problem with over cleaning and making us feel safe is that it justifies more social gathering places to open up, such as indoor seated restaurants, bars, gyms and now schools. I’m concerned people, especially students, will feel that as long as surfaces have been cleaned, wearing a mask is not as important.

A new study in South Korea, published Thursday in JAMA Internal Medicine, offers more definitive proof that people without symptoms carry just as much virus in their nose, throat and lungs as those with symptoms, and for almost as long. The South Korean team analyzed samples taken between March 6 and March 26 from 193 symptomatic and 110 asymptomatic people isolated at a community treatment center in Cheonan. Of the initially asymptomatic patients, 89 — roughly 30 percent of the total — appeared healthy throughout, while 21 developed symptoms. The participants were mostly young, with the average age of 25. A study last week found children, who were mildly infected also carried at least as much virus as adults. Yikes!

Asymptomatic People Carry coronavirus in High Amounts

Many  of us are either exercising too much or too little during this pandemic. Here is reason to get up out of your chair and get moving…

A molecule called Gpld1 (glycosylphosphatidylinositol (GPI)–specific phospholipase D1), seems to improve neurogenesis and cognition in mice. In a series of experiments in older mice, regular exercise, compared with sedentary behavior, improved neurogenesis, learning ability, and memory.

Blood extracted from older mice, midlife, or younger exercising mice that was injected intravenously into older sedentary mice produced improved neurogenesis, learning ability, and memory. Blood infusions from sedentary mice did not have this effect.

Mass spectrometry (a sophisticated tool used to measure the mass-to-charge ratio of 1 or more molecules) identified about 30 molecules that increased after exercise; one of the most prominent was Gpld1, a molecule produced by the liver. When scientists enhanced liver production of Gpld1, it led to improved neurogenesis and cognition.

Levels of Gpld1 are also higher in physically active humans than in sedentary humans. This is the equivalent to about 7100 steps per day. A molecule common to mice and humans has been linked to the benefits of exercise and the aging brain. Whether we see this being used in humans therapeutically is yet to be seen. But it suggest that specific molecules brought on by exercise can improve cognition.

Reference: Horowitz AM et al. Blood factors transfer beneficial effects of exercise on neurogenesis and cognition to the aged brain. Science 2020 Jul 10; 369:167.

You may not have signed up to be in an experiment…but we are all in one. This pandemic is the largest psychologic experiment in history to test human resilience under adversity. It will test all races, religions, genders, ages and socioeconomic settings. This virus spans all countries and has no borders. It effects everyone…everywhere!

As many as two thirds of people recover from difficult experiences without prolonged psychological effects, even if they have lived through extreme events like prisoner of war or violent crimes. But the other third suffer real psychological distress that can last for months or even years.

Even if most people prove resilient, the sheer numbers involved have experts warning of a mental illness “tsunami.” COVID-19 has disrupted so many peoples’ lives with the threat of disease, loneliness of isolation, loss of loved ones, repercussions of job loss and ongoing uncertainty about when the pandemic will end. Suicide deaths by health care professionals are a chilling reminder of the risks that are still present.

Epidemiologist Daisy Fancourt of University College London began a study in mid-March that grew to include more than 85,000 UK residents. They tracked depression, anxiety, stress and loneliness week by week. Six weeks in it was found that levels of depression were significantly higher than before the pandemic. In China, the first nationwide large-scale survey was taken where the crisis hit earliest and found that almost 35 percent reported psychological distress.

Generally, those with previous diagnosed mental health illness, those who live alone and younger people were reporting the highest level of depression and anxiety. Interestingly, there was a decrease in anxiety levels once the lockdown was declared. “Uncertainty tends to make things worse” according to Fancourt. Some people tend to find ways to carry on while others are frozen by not knowing what is to come.
Another study showed worrisome findings in older adults. Most adults older than 65 have better emotional well-being. This could be due to the fact that seniors have lived through more than younger people and had more time to develop skills for dealing with stress. Also many have retired and are less concerned about work. On the other hand, some seniors understand the higher likelihood of getting sick and of losing loved ones. Some are fearful of going out and fearful of anyone coming to their front door. They are also not as tech-savvy so it is difficult for them to get the information they need.

Successful coping in a crisis means continuing to function and engaging in day-to-day activities. Strategies that buffer the effects of stress include getting enough sleep, observing a routine, getting outside and enjoying nature, exercising, eating well and maintaining strong social connections. Spending time on projects and solving problems, even small ones that provides a sense of purpose are important. Factors that predict resilience are optimism, the ability to keep perspective, strong social support and flexible thinking. People who believe they can cope do, in fact, tend to cope better.

Also, in previous work by psychologist Anita DeLongis of the University of British Columbia who studies psychosocial responses to disease, those who are high in empathy are more likely to engage in appropriate health behaviors such as social distancing. They also have better mental health outcomes than people who are low on empathy. Her COVID-19 study will follow people’s behavior and attitudes for months to capture changes in empathy and coping over time. DeLongis says that empathy can be learned and encouraged with proper messaging, and depending how you respond will determine health behaviors and coping mechanisms.

Reference: Denworth, L. “The Biggest Psychological Experiment: What Can The Pandemic Teach Us About How People Respond to Adversity?”. Scientific American. July 2020, p 40-45.

Since we are all trying to make fewer visits to the grocery store, why not stretch those dollars and keep you fruits and veges as fresh as possible.

Here is a great article on just how to do that…

Keeping Produce Fresh Longer

Depression is a common condition involving 30 million office visits annually. There have been more cases of depression, anxiety and other mental health conditions especially in these uncertain times. Antidepressants are commonly prescribed for many people along with psychotherapy. When therapy goals are reached, many patients will need help tapering off their medications. Withdraw symptoms can occur in days or weeks from stopping antidepressants if it is done too quickly or not appropriately. Some of these symptoms include headache, nausea, diarrhea, electric shock sensations, insomnia or mood changes.

Expectations of the length of time it takes to completely stop medication use is important. It can take a minimum of 2 weeks to on average 2 months to taper. This is dependent on the length and dosage of medications and the half-life of the medication. Some people may also have other health conditions or medications that can affect drug metabolism which may take even longer.

It’s best to start the discussion to taper off antidepressants early…at least 2 months in advance.
Work with a practitioner who is experienced with medication withdraw to get the best results for you.

Different viruses can be most transmissible (able to spread) at different times. For instance, influenza (flu) is most transmissible at or just before the onset of symptoms. Whereas SARS is most transmissible at 7-10 days after symptom onset.
A team from Wuhan China created models based on data from two different studies of patients with COVID-19.

The researchers found that the highest viral loads on throat swabs collected were when symptoms started. The loads rapidly declined during the next 7 days. They concluded that about 44% of secondary cases among people in close contact (households) were infected in the 2 days prior to the onset of symptoms. Now this is based on modeling since no samples were collected in patients prior to onset of symptoms.

But if this is correct, then aggressive tracing of contacts will be even more critical than quarantining!

References: He X et L. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med 2020 April 15; [e-pub]. (https://doi.org/10.1038/s41591-020-0869-5)

This is a great article from a physician and anthropologist who has experience with fighting pandemics and developing a plan to transition people back to a virus-free future.

He calls it: Five Elements, five weapons: social distancing, testing, contact tracing, isolation and treatment.

Read more…

Transitioning To Safety

A new survey right in the heart of silicon valley looked for antibodies for COVID-19 in over 3000 residents of Santa Clara County. What was found was that the infection was more widespread and less deadly than we believed.

What does that mean?

Well, with limited testing available in the beginning of this pandemic, county’s were only testing those that were sick with moderate to severe symptoms. This doesn’t give us the true picture of the prevalence of the disease since over 80% of people had mild or no symptoms at all and were not tested. But now we have more testing available so we can test more people to get a sense of the numbers that really had COVID-19. This survey in Santa Clara Country tested immune system antibodies to the virus  which tells us if  people had been infected at some point even if they had no symptoms. The larger the number of people who had the infection but went unnoticed, the lower the death rate may be.

There are some biases in the survey which needs to be considered.

Even if this virus is less deadly than we once thought, we still need to be diligent in taking precautions to avoid spread of the virus and follow “shelter-in-place” orders until we hear otherwise. Overall there are more than 30,000 COVID-19 deaths in the U.S. so it’s hard to find good news in that. People are still getting infected and getting sick. We need to hang in there…

More testing will continue to be done and we just need to wait and see how deadly this virus really is.

Covid-19 Testing Shows More People Infected But Less Deadly Than Thought