COVID-19: Illness, Prevention, Severity Reduction April 27, 2020

This is an update to the post that we placed on our website on April 7.  This update includes the prior recommendations on how to prevent or reduce the severity of the infection, and new information on testing.  Any changes since the last post are highlighted in bold font.   

Q:  Is COVID-19 a more serious illness than the usual yearly influenza?

A:  The virus that causes COVID-19 is SARS-CoV-2.  It is like the coronavirus that during the 2002-2003 SARS epidemic infected 8000 people worldwide, with a 10% mortality rate; this virus has continued to infect small numbers of people with a lower mortality rate since that time.  Another corona virus, MERS-CoV, caused illness beginning in 2012; the mortality rate from this has been higher, with around one-third of patients dying, but the spread has been limited  The mortality rate of COVID-19 is unclear, due to limitations in testing of individuals in the population (particularly those with low or no symptoms), but appears to be between 2.5 and 5%, based on nearly 900,00 cases overall.

Q:  What symptoms raise suspicion of the COVID-19?

A:  It is increasingly recognized that there are cases with minimal symptoms, including loss of sense of smell and taste, and that there is a period during which a person can have little to no symptoms, but have reduced oxygen in the blood and/or capability of transmitting the disease.   Generally COVID-19 presents with mild illness for a few days that is followed by more severe symptoms that includes fever, myalgias, and lower respiratory symptoms (cough and shortness of breath); a few people have diarrhea only.  At this later stage, patients may become very ill and require hospital care.  Mortality results typically from ARDS – respiratory distress and damage caused both by the virus and by the immune response to it.

Q:  How is the disease transmitted and how can transmission be reduced?

  • A:  Based on the transmission method that is typical of other coronaviruses, it appears that transmission occurs mostly based on large droplets from the lower respiratory tract, rather than via small droplets that are airborne, which is the usual mode of transmission with the flu.  As such, if a mask is used, a standard mask (rather than the special N95 mask) is likely to be sufficient to interrupt transmission outside the hospital.  Because the droplets survive for a week on surfaces, and are capable of being picked up by manual contact and then cause infection if transmitted by touching the mucous membranes of the face.  For this reason, de-infecting surfaces, hand-washing, and avoiding touching the face is recommended.  Furthermore, the amount of person-to-person spread of the illness is also important.  When on average a patient with the disease spreads it to more than one other person, the disease spreads rapidly in the population, so restricting contact (“social distancing”) may slow or reduce transmission and as a result reduce the likelihood of overwhelming hospital treatment capacity or the number of deaths that the pandemic is responsible for.

Q:  What should I do to reduce the likelihood of getting the illness, or to reduce its severity if I get it?

  • Sanitation and barrier methods are important to minimize the risk of contracting the illness. Follow the national prevention guidelines: disinfect surfaces that might have been exposed to the virus, wash hands, avoid touching the mucous membranes if there might have been exposure, and stay home if you are ill, exposed to a documented case, older, or have a serious underlying condition (affecting heart, lungs, or immune system).  If you are in the presence of someone with possible illness, wear a standard mask or a bandana.  There is some evidence that hand washing with soap is as effective, or more effective, than alcohol-based disinfectants.  A challenge here is obtaining disinfectants or masks.  You can make your own disinfectant with a mixture of 2/3 rubbing alcohol and 1/3 aloe gel (see https://www.cbsnews.com/news/hand-sanitizer-coronavirus-make-your-own/ ), or use any commercial product (multi-surface cleaner or sanitizer) that is at least 60% alcohol (see https://www.wtae.com/article/here-s-a-list-of-disinfectants-you-can-use-against-coronavirus/31250157 ).  You may also consider hypochlorous acid as a disinfectant (see https://naturesfriendus.com/collections/new/products/puromedi-spray-sanitizer?gclid=EAIaIQobChMIo9X51srU6AIVU-DICh2LiQBuEAAYAyAAEgLRV_D_BwE ).
  • Social distancing, including staying at home, is another key method of minimizing infection risk.
  • Because the illness typically begins with a 4-7 day period of fever and upper airway symptoms, it may be possible to minimize its severity by intervening during that time or prior to that time. Although there is currently no clear evidence of effectiveness, the following interventions may be considered:
    • Antioxidants such as Vitamin C 1000 mg twice daily prior to illness, or 1000 mg hourly to the point of diarrhea early in the course of illness
    • Avmacol, which increases the availability of glutathione, a powerful antioxidant, daily prior to illness, or three times daily early in the course of illness
    • Quercetin (e.g.250-500 mg twice daily) prior to or during the course of illness, has been recommended based on limited information showing that it may prevent the SARS virus from entering cells
    • Zinc 30 mg daily prior to illness or twice daily early in the course of illness
    • Inhalation of nebulized hydrogen peroxide 3% solution several times daily prior to illness, or hourly early in the course of illness; a video demonstrating this technique is at https://archive.earthclinic.com/remedies/hydrogen_peroxide_inhalation.html
    • Melatonin 3-5 mg once or twice daily prior to or early in the course of illness
    • Vitamin D3 5000 units to reach 25 OHD levels of 50 or above
    • Avoidance of electromagnetic fields (EMFs), such as are generated by wi-fi, cell phones, and other devices as much as possible prior to illness and more aggressive early in the course of illness
    • Use of ozone water or other methods of administration of it; this involves purchase of an ozone generator (see, e.g. https://www.simplyo3.com/collections/generators/products/stratus?_ga=2.87899931.2018403127.1586138178-2043708408.1586138178); a liter of ozone water daily prior to illness and three times daily early in the course of illness
    • Use of hydrogen water, such as Quicksilver H2 Elite, once daily prior to illness and three times daily early in the course of illness
    • Use of a broad spectrum herbal treatment approach, including one by Stephen Buhner whom many know as a prolific American herbalist with perhaps the broadest experience with use of herbs in treating Lyme disease; summary of Buhner’s recommendations can be found at https://highgardentea.com/herbal-treatment-for-coronavirus/

Q:  Is testing available to help me determine if I have had the virus, whether I currently have it, and whether I am immune to it?

A:  There are now generally available two types of testing:

  • Viral antigen testing using specimens obtained from the nose/throat or coughed up sputum. This test determines whether a person has fragments of viral RNA in the upper airway.  These fragments may be associated with the ability to affect others, although they may also be left over from infection that has recently cleared; the clearance process is typically complete about twenty-one days following the onset of infection, but may be persistent in some.  Labs vary in the amount of reactivity that is required for a positive test.
  • Antibody/serology testing using blood, in which the presence of reaction by the person’s immune system (IgM, IgG or IgA) to one or more viral proteins is determined. Labs vary in the proteins that are used and in their cutoffs for immune reactivity, such that the sensitivity (ability to detect disease if present) and specificity (ability to exclude those without the disease) vary.  Even a test with high sensitivity and specificity may not predict disease well when the amount of disease in a population is low, however (see, e.g. https://www.evaluate.com/vantage/articles/analysis/spotlight/covid-19-antibody-tests-face-very-specific-problem. A test that is 90% sensitive and specific will only accurately predict disease about one third of the time if the prevalence of disease is 5%.  For this this reason, it’s important to use highly accurate testing (at around the 99% level).  Furthermore, it is unknown whether people with antibodies based on prior infection are protected from reinfection, although it’s likely that they most often are, at least for a period of a year or so.  So it’s important not entirely rely on the results of a positive antibody test to determine whether you’ve had prior infection or are protected going forward. 

 Q:  Should I get tested?

A:  You may consider testing in either of the following contexts: 

  • If you are ill with symptoms that are suggestive of the flu (fever, achiness, cough/shortness of breath), call us and we’ll give you guidance on whether and how to be seen; current COVID testing is still in short supply but is being done in some urgent care and emergency rooms and there are drive though testing centers now open in Columbia, Glen Burnie, Waldorf, and Belair; physician authorization and scheduling of the appointment is required, and is based on high likelihood of positive testing based on symptoms.
  • If you are not symptomatic, and want to determine whether you’ve had infection or are susceptible to infection going forward, consider the discussion above about the limitations of such testing. Both LabCorp and Quest now offer antibody testing.  If you want to be tested, talk with your physician/PA about it.  If you have a positive test, you will then need to have a viral antigen test in order to better determine your status. 

Q:  Should I continue to be seen, either in person or virtually, for appointments?

A;  We continue to see patients.  We encourage you to do them virtually (insurers are generally covering this), but are also seeing patients in person when there is a need/preference for that.  We are calling patients prior to appointments to arrange this, or to confirm an in-office visit, or to reschedule for another time.  You may also confirm or make changes to your appointment by calling our office (410-648-2555).  Although most patients are now being seen by telemedicine, our schedules have been changing daily, so if you are interested in an earlier appointment than one that you currently have, or in having a 30 minute telemedicine appointment with your doctor/PA to discuss concerns in the context of COVID, call us (410-648-2555).

 

Osteoporosis and Low Bone Density

Bone is a dynamic structure, constantly being remodeled by cells that remove it (osteoclasts) and renew it (osteoblasts).  Once adulthood is reached, these two processes should stay in relative balance, but as hormonal status changes over time, the removal process predominates.  For some people, hormonal-mediated bone removal may be predated or augmented by other conditions.

Predominance of bone removal results in low bone density (sometimes referred to as osteopenia).  When bone density declines, the structure of bone is altered and it loses some of its strength and flexibility.  Severe bone loss is referred to as osteoporosis; osteoporotic bone has thinner outer cortex and trabecular supporting structure.

Low bone density and osteoporosis are associated with increased risk of fracture.  Other factors, however, are also important in predicting fracture risk:  age, smoking status, body size, alcohol use, etc.  The FORE Fracture Risk Calculator (https://americanbonehealth.org/bone-health/introducing-the-fore-fracture-risk-calculator/) can be used to calculate fracture risk.  Importantly, the radiographic assessment of bone density by DXA scanning, which is the most widely used method of predicting fracture risk, does not take into account all of the factors that are relevant to this prediction.  The quality of bone (how it is structured and what its mineral composition is), as well as its density, is also important.  Bone quality is not generally assessable through non-invasive testing.

It is common for patients to undergo DXA scanning, be told that their bone density is low, or that it is declining rapidly based on serial scans, and that as a result prescription medications are recommended to reverse the process of bone loss.  Although for some patients this may be appropriate – particularly when the risk of fracture is very high – for others it may not be for several reasons:

  • DXA scanning is subject to error, particularly if the patient is not properly positioned during the scan
  • Factors that are causing the imbalance of bone resorption and bone renewal have not been identified and addressed
  • Risks resulting from the use of the medications may be significant, particularly with bisphosphonates, which are associated with osteonecrosis of the jaw, and with spontaneous fractures owing to their effect on bone, which is to block the removal process such that bone formation predominates, which increases bone density but alters its quality (making it structurally more brittle).

When a DXA scan shows low bone density, it is appropriate to do lab testing to assess for conditions that are associated with bone loss (imbalance between removal and renewal).  Testing includes the general assessment that we use for most patients in integrative care (for hormonal status, nutrients, gut health/celiac status, and inflammation), as well as assessment of factors that are more specific to bone, including PTH, serum calcium, Vitamin D levels, 24 hour urine calcium, C Telopeptide (CTX) and osteocalcinin.  The latter three factors assess balance between bone removal and renewal, and are used in initial assessment of causes of low bone density and to monitor impact of treatment over the short run, with biannual DXA scanning and fracture risk prediction over the long run.

There are multiple causes of low bone density from imbalance between resorption and formation of bone:

  • Nutrient deficiency, either dietary or due to poor absorption from the gut
  • Hormonal imbalance: hypothyroidism or its overtreatment, hyperthyroidism, hyperparathyroidism, insufficient or excess insulin/diabetes, low growth hormone/IGF-1
  • Chronic inflammation and oxidative stress: infection or leaky gut-based
  • Heavy metal toxicity: cadmium, lead, mercury, aluminum, iron

The approach to treatment is as follows:

  • Healthy diet and weight-bearing exercise
  • Nutrient supplementation with magnesium, calcium, Vitamin K2, Vitamin D3, strontium, and trace minerals
  • Address issues identified through history and diagnostic testing: nutrient deficiencies, hormonal gut health, inflammation/oxidative stress, heavy metal toxicity

Helpful resources are:

 

IV Nutrient Infusions

Nutrients given by intravenous infusion have been used by many alternative and integrative medicine practitioners for decades.  The rationale for their use is that the blood levels of such nutrients when given orally is limited by the ability of the gut to absorb them, whereas with IV nutrients blood levels can be substantially increased.  This has been confirmed by clinical studies.

In considering use of IV nutrients, two questions must be asked:  are they effective in achieving their intended therapeutic purpose, and are they safe.  Ideally, the answers to these questions would be based on clinical research, but unfortunately the amount of such research is limited.

Four types of IV nutrients are in common use:  Vitamin C infusions, glutathione infusions, multinutrient (Meyers’) infusions, and phosphatidylcholine infusions.

Vitamin C infusions are the best studied.  Vitamin C has many effects:  it is an antioxidant that protects against damage caused by free radicals, boosts the immune system’s effect on wound healing and infections, and is toxic to some types of cancer cells.  There is some evidence that such infusions are beneficial in cancer patients in improving quality of life, and possibly that there are effects on tumors that reduce size and increase time to relapse.  It may also have benefit in patients with infection, shingles, and with chronic fatigue.  Used in patients without contraindicated medical conditions, IV Vitamin C is safe.

Like Vitamin C, glutathione is an antioxidant.  Most literature on its use is not based on clinical research, but instead based on case reports.  It may be effective in increasing the effectiveness of manual therapies in patients with musculoskeletal conditions, in reducing symptoms of parkinsonism, and in improving symptoms associated with autoimmune or other inflammatory response.  It appears to be safe.

Multinutrient infusions were popularized decades ago under the name Myers infusions, based on the work of a Baltimore physician named John Myers, and a modified version of this infusion has been used with thousands of patients across the country.  The infusion includes Vitamins C, B complex, B12, B5, B6, calcium, and magnesium.  It has been shown to have some benefit for patients with fibromyalgia, and based on case reports may result in improvement in fatigue, pain, and depression in patients with such issues.  Multinutrient infusions are safe.

Phospholipids are a key component of the membranes that surround all of our cells.  When such membranes are disrupted by toxicity or injury, particularly in nerve cells, illness results.  IV phospholipids are widely used in Europe, and based on experience, may be of benefit to patients with brain injury and inflammatory/degenerative conditions.  They are safe.