By Dr. John R. Mishock
COVID-19 has devastated the US population by; those being infected, the secondary impacts of social distancing/quarantine, school and business closures, and unprecedented unemployment. The economy is tumbling into recession with US job losses reaching 25 million, with the potential to reach over 50 million. (US Dept. Labor) COVID-19 has created fear, anxiety, and in many cases panic. Mental health issues are on the rise. The use of anti-anxiety (34% increase), anti-depressant (20% increase), and anti-insomnia (15% increase) medications have increased significantly in the last month. (Express Scripts Pharmacy, WebMD, 2020)
In many cases, the internet and news media outlets propagate the panic by highlighting the worst cases scenario and outliers who are not the typical sample, based on scientific evidence. Keep in mind, the internet outlets and news media profits are based on viewership. This pandemic has viewers glued to their screens (TVs, tablets, and phones). No one should suffer or die unnecessarily as all life is precious. Any life lost is tragic. The action taken by the government such as; social distancing and business and school closure has flattened the curve reducing the impact on hospital systems. Now, moving forward it is important to progressively work to resume normalcy in our lives. In this article, I will review the best scientific research regarding COVID-19 with hopes of reducing the irrational fear and panic that has paralyzed some individuals and communities. In part II of this writing, I will encourage the reader to use COVID-19 as a springboard to take control of their individual health and lifestyle choices. These choices, based on the best available science, will improve the body’s immunity and prevent or minimize the chronic disease which allows opportunistic viruses, like COVID-19 to thrive. If you missed my last article, you should read “Coronavirus (COVID-19): Strategies to Optimizing the Body’s Immune System at Home”.
COVID-19 by the Scientific Numbers
Keep in mind that all of the statistics are based on the time of this writing and will certainly change over time. According to the Center for Disease Control (CDC) 98%-99% of all individuals infected by Coronavirus COVID-19 will recover with >85% being asymptomatic or having only mild to moderate symptoms. The fatality rate is most likely much less than this 1-2%. A Stanford University study showed up to 85 times more cases (5% of the general population) than documented due to being infected with COVID-19 but having no symptoms (medrxiv.org) According to a Johns Hopkins study, greater than 525,000 people have recovered. In the US, there are over 706,779 cases with 37,079 deaths of COVID-19. This number has been recently inflated as many municipalities do not need a positive COVID-19 test to report the death as being from COVID-19. To keep it in perspective, COVID-19 is still less impactful than the 2009 swine flu pandemic which is killed between 200,000 and 575,000 people worldwideInterestingly, most people would not even know the 2009 Swine Flu pandemic even existed. The pandemic the world would never want to revisit is the Spanish flu of 1918, which sickened up to 40% of the world’s population, killing an estimated 50 million people COVID-19 is nothing like that pandemic.
Fortunately, COVID-19 does not significantly impact children and adolescence. A study showed < 1.7% of all COVID-19 infections (most mild) were children or adolescence, with 68% having no symptoms at all. (MMWR Morb. Mortal Wkly. Rep 2020 Apr 6, CDC, 2020) In the adult population, approximately 25-50% of COVID-19 infected people will have no symptoms (CDC, 2020). A study in the New England Journal of Medicine showed, 87% of pregnant women who tested positive for the virus had no symptoms. Due to the large number of asymptomatic individuals and the lack of testing the total number of documented COVID-19 cases is significantly lower.
COVID-19 or Influenza (Seasonal Flu) Testing is Essential
Despite the multifactorial impact, there are few COVID-19 tests available, with only 1% of our US population being tested. (CDC, 2020) Some local health systems such as, Lehigh Valley Hospital is only testing those ages > 65 and individuals at high risk for serious illness (Mercury News Paper, April14/20). Due to a lack of test availability even if an individual has symptoms they still may not get tested. This leaves much of our community with continued fear and uncertainty on how to proceed with their daily lives. Keep in mind, a positive COVID-19 test (quarantine 14 days and contact tracing) results in a dramatic treatment course versus the common cold, seasonal allergies, or the seasonal flu.
Not all respiratory tract symptoms (fever, cough, difficulty breathing) are COVID-19. At the Upper Dublin test site at Temple University Ambler campus (from March 20-April 9), 4,800 individuals (with respiratory symptoms) were tested for COVID-19 but only 16.8% tested positive. There are many other conditions that produce upper respiratory tract symptoms such as; common cold, seasonal allergies, sinusitis, and influenza (flu).
Contrasting COVID-19 with this year’s seasonal flu, it is estimated that 39-56 million Americans have gotten sick with 410,000-740,000 hospitalizations and 24,000-62,000 deaths. Last year’s seasonal flu, killed 61,200 Americans with 42.9 million getting sick (CDC.gov). In 2017-2018, 48.8 million Americans got the seasonal flu with 79,400 deaths. Unfortunately, children are more severely affected by this year’s seasonal flu with 166 deaths; contrast that with only 3 deaths from COVID-19 (all had preexisting conditions). (MMWR Morb Mortal Wkly Rep 2020 Apr 6). The seasonal flu is much more deadly to our children. In looking at our local numbers, the population of Montgomery and Berks County combined is roughly 1.2 million people. There have been 4221 positive COVID-19 cases with 169 deaths. With the Flu, there have been 13,940 positive cases, with 3,336 hospitalizations, and 102-697 deaths. (health.pa.gov)
COVID-19 Herd Immunity and Rate of Spread
Herd or community immunity is a form of indirect protection from the spread of infectious disease when a large percentage of a population has become immune to an infection, through previous infections or vaccination. Herd immunity provides a measure of protection for individuals who have not had the disease or infection. The herd immunity could ultimately protect the most vulnerable in reducing their exposure to COVID-19. (Public Health and Epidemiology at a Glance)
Herd immunity is based on the “basic reproduction number” (R0) of a disease. The R0 is a mathematical model to determine how fast a disease will spread in a given community. The seasonal flu has a 1.3 (R0), whereas COVID-19 is 2.3 (R0). Seasonal flu and COVID-19 are considered mildly contagious. (Cureus. 2020 Apr) Contrast this with the highly contagious measles that has a reproduction number of 12-40 (R0). For example, if someone is infected with COVID-19 they typically spread the disease to 2.3 people who have not been infected. With measles, 1 individual could spread it to 40 non-infected people. This is why social distancing has been important to “flatten the curve” during the COVID-19 pandemic. The R0 is then used to predict how many people need to get the infection to create herd immunity. With COVID-19, an R0 of 2 would mean that 50% of the population would need to be infected to create herd immunity. The concern with public health officials is that if 50% of our population got COVID-19 it could lead to a lot of severe illness and or death for those >65 years of age and or individuals with underlying health conditions. As herd immunity develops, the most vulnerable must be protected. As more people become infected with COVID-19 the R0 will gradually decrease meaning the disease is no longer spreading and herd immunity is happening. The goal is to get the R0 below 1. People will still get COVID-19 but it will be difficult for it to spread in the community. (sciencefocus.com)
Regardless, herd immunity is happening whether we like it or not due to; the ease of spread of the respiratory virus, the significant lack of testing, and the high number of asymptomatic or mild symptoms. A vaccine would help with herd immunity, however, it will take approximately 12-18 months to develop and it must be proven safe and effective. Vaccines are no guarantee of protection, as demonstrated with the season flu vaccine being only 40-60% effective annually. (CDC, 2020)
Flattening the curve
“Flattening the curve” (epidemic or pandemic curve) refers to community isolation measures that keep the daily number of disease cases at a manageable level so that the medical system will not become overwhelmed. The faster the infection curve rises, the quicker the local health care system gets overloaded beyond its capacity to treat people with the disease and other life-threatening emergencies. A “flatter curve”, on the other hand, assumes the same number of people ultimately get infected, but over a longer period of time. A slower infection rate means fewer hospital visits on any given day and fewer sick people being turned away, thus fewer deaths overall. Keep in mind that whether the curve is “spiked” or “flattened” roughly the same numbers of people still get the disease. So, social distancing and the closures of schools and business have “flattened the curve” but it will not reduce total infections. In a sense continuing strict social distancing at some point is just “kicking the can down the road”. We will have to deal with COVID-19 sooner or later. The original reason to close businesses and schools was to “flatten the curve”, that has happened. It will not eliminate the disease.
Protecting the Most Vulnerable to COVID-19 and the Seasonal Flu
According to the CDC, 92.3% season flu and 94% of COVID-19 deaths had at least one reported underlying medical condition, the most commonly reported by percentage were; high blood pressure (49.7%) cardiovascular disease (27.8%), metabolic disorder (diabetes 28/3%), obesity (48.3%), and chronic lung disease (34.6%). (CDC 2020) With the seasonal flu, the highest rate of hospitalization is among adults aged ≥ 65, followed by children aged 0-4 years of age. (CDC, 2020) COVID-19 patients are 2-3 times more likely to require hospitalization than those 19-64 years (New England J of Med, April 2020). In Montgomery and Berks County, 65% of all COVID-19 deaths are coming from nursing homes and long-term care facilities. (Montgomery county health dept, 2020)
Science has clearly shown that we must protect the most vulnerable by isolating them until a significant amount of herd immunity has been acquired, this would be true for COVID-19, as well as, seasonal flu. As we transition back to our normal lives we must practice the CDC COVID-9 prevention techniques.
The Need for COVID-19 Testinal
There is a significant need for viral testing and serological antibody testing (evaluation of antibodies in the blood to determine COVID-19 exposure). Antibodies are created in 7-10 days following COVID-19 infection. These antibodies protect the individual from re-infection while creating herd immunity. If we know who is immune we can start to resume a more normal life. Countries such as South Korea, Denmark, Sweden, and others have shown the best results with; “test, trace and treat”. These countries have ample tests available and test everyone who has symptoms or wants testing. Following a positive test, public health care workers trace the people who have had contact with the positive COVID-19 individual and quarantine them (if they do not have antibodies). Lastly, they treat those infected.
As we continue to move past the peak of COVID-19, we can use the best available science and CDC prevention techniques to end the panic while confidently taking on the controlled risk to transition back to our normal lives.
In part II, I will review how we can optimize our lifestyle choices, improve our body’s immunity, and prevent or minimize the impact of the underlying conditions (chronic preventable disease) that allow opportunistic infections to thrive in our communities.
Dr. Mishock is one of only a few clinicians with doctorate-level degrees in both physical therapy and chiropractic in the state of Pennsylvania. Mishock Physical Therapy & Associates has 7 convenient locations in Gilbertsville, Skippack, Phoenixville, Barto, Limerick, Pottstown, Steiner Medical at www.mishockpt.com. If you are interested in previous articles visit our blog page.
