We are made up of trillions of cells. Bacteria are made up of one cell. Viruses aren’t even cells; they are smaller than bacteria and are parasites on other cells. They are made up of genetic material that is surrounded by an outer protein coat. They hijack our cells and reassemble replicating their RNA or DNA and repackaging it to make baby viruses that can spread. Viral infections are not new and have been the source of plagues and pandemics all throughout recorded history. The word “corona” comes from the latin for garland or crown. Coronaviruses are a large family of viruses – with spikes like a crown.
SARS-CoV-2 is a newly discovered coronavirus that spreads through droplets and contact. It came from bats and is thought to have originated from a market in Wuhan City in the Hubei province in China. By the end of December 2019 there were 44 cases in China, 11 of whom were severely ill. By January 3 there were 41 confirmed COVID-19 cases admitted to Wuhan hospitals. 32% had diabetes, hypertension or cardiovascular disease. The median age was 49 and 27 had been exposed in the Huanan Seafood Market. Fever was present in 98% of cases and cough 76%. 55% developed shortness of breath within 8 days and 63% had lymphopenia. All had abnormal chest CT findings. Complications included acute respiratory distress syndrome (29%), and acute cardiac injury (12%). 6 (15%) of the patients died.
Within a few days there had been 4,593 cases in several countries including Australia, North America and Europe. On January 9 the mysterious disease was announced by WHO. By January 20 there were 6 deaths (see above) and the next day WHO acknowledged that the disease spread person to person. As the disease was spreading throughout China the Centers for Disease Control and Prevention (CDC) announced that US airports would screen for the disease. The first case appeared in the United States on January 21 in Washington state, a recent traveler from Wuhan City. Contact tracing was then deployed in Washington state. Wuhan went into quarantine – the city and region strictly locked down 18 million people.
A global health emergency was declared by WHO on January 31, 2020 as the disease was spreading in the United States, Germany and Asia. In 2019 14,000 persons traveled to the United States from China each day, but with 10,000 confirmed cases in China global air travel to the United States from China had to be suspended. On January 31, the United States declared the disease a national public health emergency. In another week deaths from the disease, now officially named COVID-19 would surpass those of SARs from 2003. COVID-19 was declared a pandemic on March 11 and a national emergency on March 13. On that date a travel ban from Europe went into effect. Between March 19 and April 3 states went into lockdown, as each created stay at home rules curtailing nonessential activities. We saw travel between nations and even between cities and states come to a halt and an entire nation sheltered in place, avoiding social gatherings and working from home. Restaurants, schools and shops closed. Elective surgery halted.
Telemedicine was used by physicians to care for patients unable to come to the clinic, and was approved by the Center for Medicare and Medicaid Services (CMS). Kidney Associates was an early adapter of telemedicine, and patients can see us from home to avoid possible exposure. As patients saw their doctors through telemedicine portals, Zoom, Facetime and WebEx became standard methods of communication. Binging television series became a national pastime. Major meetings, travel plans and even the Tokyo summer Olympics were cancelled or postponed. The White House developed social distancing guidelines through April 30.Sheltering in place worked.The National Bureau of Economic Statistics determined that as a result of the executive order in California to avoid nonessential activities, the case rate dropped by 125.5 cases/100,000 between March 19 and April 20. The economic study also estimated that 400 jobs were lost for each life saved.
On March 27 the CARES Act was signed into law to help ofset the impact isolation would have on the economy. The disease continued to escalate and surpassed one million by April 4. By April 11 the death rates in the United States exceeded those of all other nations. Mathematical models were showing that a shutdown would delay disease spread, and proved right. As states reopened and gatherings took place, the disease surged. The shutdown that lasted approximately two months saw states starting to lift restrictions by May 20.
Sheltering in place became lax as the nation fatigued of it.National protests of COVID-19 restrictions put pressure of public officials to relax controls over working conditions. Demonstrations to fight police injustice against African Americans were sparked by the May 25, 2020 choking death of George Floyd during an arrest in Minneapolis. As a video taken by a bystander emerged, protests erupted in Minneapolis and other large cities starting that Tuesday and grew in intensity. During this period social distancing was all but forgotten. The large protests did not create a population spike in COVID-19 cases and deaths because during the periods of unrest, many people stayed home. But, as people celebrated holidays and gatherings, the disease surged. Meanwhile grave economic impact forced political divisions in the United States as heated discussions and controversies grew around wearking a mask v personal freedom, opening restaurants, bars and places of congregation to avoid financial ruin for many proprietors, and when to reopen schools. By June 30, the NIAID chief, Anthony Fauci, predicted that COVID-19 cases could escalate from 40,000 cases to 100,000 new cases per day.
Cases resurged since late June. During July serious debate took place between medical experts and sports associations, local and national leadership. The conflict was the same – how to balance safety with a halt in our lifestyles and economy. In the South records for the number of cases and the number of deaths were shattered. In mid July the disease claimed over 140,000 lives with Florida announcing 10,000 new cases prepay. As a flood of misinformation hit social media, doubt and fear were coupled with economic devastation and sickness. On July 19 Miami Beach, Florida imposed a curfew.
In the middle of July Arizona surged to the extent that the city of Tuscon was down to 17 free ICU beds. When the state escaped a large outbreak in April and May, bars and restaurants reopened, testing efforts grew lax and the state leaders and citizens assumed the danger had passed. But by the middle of July nearly 27% of the tests taken over the past week returned positive. The surge was coupled with anger and blame, and a flow of mixed messages. As the surge worsened the state shut down public gathering places like restaurants, bars and gyms.
New York City was hit particularly hard, and deserves special mention because of how people must move about – elevators and subways. It is no wonder that 5,700 persons were hospitalized there from March 1 through April 4, 2020. The mean age was 63 and many had hypertension, obesity and diabetes. 14.2% were in the ICU and 12.2% were on assisted ventilation. 3.2% required dialysis. In the end 2,634 people or 21% died.
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The first case of COVID-19 in Houston was March 4, 2020, identified as a Fort Bend County man in his 70s who had traveled to Egypt. By March 11 the Houston Livestock Show and Rodeo was cancelled as a result of a 40 year old Montgomery County man developing it from person to person spread, and not through travel abroad. The NRG Park was shut down and the county declared a public health emergency. This case was traced to the February 28 Bar-B-Que cookoff at the Houston Livestock and Rodeo. The contest that day was potentially attended by 73,433 persons. The Rodeo is a major Houston event, and was scheduled to run until March 22. Houston had 14 cases on March 11. Two days later the President issued a federal emergency declaration to free up public funds and enable the Federal Emergency Management Association to coordinate the pandemic.
By March 16, County Judge Lina Hidalgo ordered schools closed, restaurants closed for dining, bars closed. Takeout from restaurants was permitted. On March 19 the Texas Governor, Greg Abbott ordered limiting social gatherings to 10 people or less. Schools, bars and gyms remained closed and restaurants limited to takeout. He also banned visitation at nursing homes. Texas was declared a public health disaster. Hospitals stopped elective surgery. A stay at home order was put into place for Harris county and Houston on March 24. On March 31, churches in Texas were permitted to stay open per Governor Greg Abbott. On April 17 the ban on elective surgery was lifted and state parks were allowed to open. Around that period there were 252 new cases per day in Harris County. 96 people in Houston had died from COVID-19.
On April 27 masks were required in all public places in Harris Country. The stay-at-home order was lifted on May 1 as the state testing was only 14,000 per day. This was felt inadequate by health authorities. The state was now reporting 50 COVID-19 deaths per day. The Harris Country Stay at home order was extended through May 20. Violation in public health orders would not be punished by jail time. The state governor and Harris County/Houston officials clashed on coronavirus restrictions, with Governor Abbott feeling they were too restrictive. By May 18 all stay-at-home orders were lifted by the state, allowing businesses to reopen gradually. The death toll for the state was 58 cases per day. At the of May the percent new cases in Houston was 5.4. There had been 299 deaths thus far.
The May 25 Memorial Day was celebrated with partying, especially with social gatherings at beaches and ignoring rules of wearing masks. In Minneapolis, however, the brutal murder of Houstonian, George Floyd by a police officer sparked protests around the country. On June 3, 60,000 protested in Houston, but many ignored social distancing and the wearing of masks. Restaurants increased capacity from 25 to 50% capacity by June 3 and Houston traffic increased. Despite rules regarding social distancing and the wearing of masks, many either wore their masks improperly or not at all. With an incubation period of 3-7 days it was no wonder that over the next week the number of cases in Houston started rising. Despite over 2000 hospitalizations per day throughout the state, by June 12 businesses were operating at 75% capacity. Many stores in Houston required their customers to wear masks.
On June 19 many amusement parks opened at 50% capacity as the state testing rate approached 10%. By June 24 the rate approached 12% as hospitals felt they were reaching crisis levels of admissions. On June 15 there were 3,820 patients in Houston area hospitals where on June 1 there were only 519. The county averages 338 cases per day and Houston sustained 422 deaths. The surge in hospitalizations treatened that Houston would have to close back down. The following day elective surgeries in local hospitals were ordered postponed. Despite the surge in hospitalizations, the Lieutenant Governor stated that the increased number of cases was because of increased testing. Restaurant capacity was again rolled back, but many at at home, ordering take out and grocery deliveries. The percent new cases rose from 6.71 on June 15 to 16.89% on July 15. As most people celebrated Fourth of July in front of the television, Governor Abbott ordered masks to be worn in public throughout the state. On Independence day, 7,890 persons in the state were in hospital beds with COVID-19, the number of admissions doubling from the week before. Over the month of July the number of hospitalizations in Harris Country rose. It reached 2,672 on July 15, but by Aug 6 was at 1,559. The number of new cases in Harris county continues to rise, 1685 on August 6. School openings were delayed and many Houston Independent Schools are offering home learning. Houston deaths were up to 1866.
Viral infections are not new and have been the source of plagues and pandemics through all of recorded history. A virus is a life form that includes DNA or RNA, molecular chains that can cause amino acids sequencing and manufacture proteins. They can also replicate. A virus is protected by an envelope of proteins and sugars that will allow it to migrate through the environment. The characteristics of the virus determine how it attacks human cells. Since they multiply in great numbers the frequency of mutations may be very high.
We are all too familiar with viruses – smallpox, influenza, measles, polio, rhinovirus, adenovirus, and even other coronaviruses. The coronavirus known as SARS-CoV-2 is unique for it has protein spikes on its envelope. The tip of the spike, known as the receptor binding domain (RBD) has mutated so that it attacks a specific receptor on the cell. This is known as the ACE2 receptor, and is found in many organs, particularly lungs, kidneys, heart, pancreas and blood vessels. When the virus attacks, the body responds through an innate immunity system, recruiting a type of lymphocyte known as a T helper cell to the vicinity. The helper cell then recruits a number of other cells types through the release of cytokines – hormones on a cellular level. The reaction to these hormones plays a key role in what happens next. It is ideal for helpers recruit killer cells that destroy the virus, and regulatory cells that modulate the response so that normal body cells are not injured. Cells that will make antibodies are also recruited, as these antibodies will be necessary to neutralize the virus in there is recurrent exposure. In the elderly and in patients with diabetes, CKD, heart or lung disease, as well as those with any type of immune compromise, the immune system may not react to a virus properly. Either the virus multiplies unchecked or the cytokines are overly destructive, or the body cannot make antibodies that will protect the person another attack. For these reasons people who are vulnerable have a greater odd of becoming critically ill or being overcome by the infection.
Herd immunity occurs when a percentage of the population has become immune to the virus, having either been vaccinated or acquiring the disease and developed neutralizing antibodies or cellular immunity to the virus. At the point of immunity the transmission rate is no longer exponential, and this is represented mathematically. It is the point at which the disease ceases to be an epidemic, but will not be 100% of the population for SARS-CoV-2. Once herd immunity is reached, it is unlikely that those patients who were not candidates for a vaccination will acquire the disease. We are not yet at the point where herd immunity can be achieved, and until then the focus should be on protecting the vulnerable from exposure.
Risk of severe illness:
Vitamin C – Vitamin C is an antioxidant that removes the free radicals that can damage other cells. It thus has antiinflammatory properties and can stimulate the immune system. It may protect the blood vessel walls from damage. Since patients who have a severe illness like COVID-19 may require increased vitamin D, it is being studied and data from large trials should be available soon. there are 15 clinical trials that are pending for both critically ill and asymptomatic patients. There are thus far no trials that either recommend using or not using vitamin C in asymptomatic patients.
The renin angiotensin system is designed to be a protective mechanism from stress. Renin is secreted from the juxtagloerular apparatus in the kidney in response to low sodium, low blood pressure or neurogenic stimuli. It then causes the breakdown of angiotensinogen to the 10 aminoacid peptide, angiotensin 1. Angiotensin I is activated to angiotensin II, an 8 aminoacid peptide by converting enzyme 1, for which their is a receptor – the ACE1 receptor. There is also a receptor for the enzyme’s deflation product, ACE 2. It is the ACE 2 receptor that is the target for SARS-CoV-2. Angiotensin 2 is accountable for vasoconstriction, blood pressure elevation, inflammation and fibrosis. Since it is activated during illnesses involving the kidney, it is associated with progressive kidney disease. The angiotensin II receptor blockers block the receptor for AII, not ACE2. Because angiotensin is a potent stimulator of blood pressure, its blockade is a major treatment for hypertension.
ACE2 receptors are on many cells, particularly the heart, lungs and kidneys. There are most prevalent in the lung. They are actually upregulated with the antihypertensives like converting enzyme inhibitors and angiotensin receptor blockers. Since they have a beneficial effect of blocking the formation of AII, their up regulation is beneficial. When SARS-CoV-2 attacks the receptors, the theory is that does not fully saturate them in patients on medications, and is less dangerous.
A study has shown that older patients taking ACE inhibitors have a lower risk for hospitalization from COVID-19. However current recommendations are to continue ACE and ARB therapy if already on it, but neither drug should be added for the care of COVID-19 patients pending further evidence.
Contact families when someone positive
Strict precautions are necessary when testing
Researcher from around the world are working on a vaccine. Vaccines, like medications have to go to three phases of clinical trials before they can be shown to be safe and effective – and must be approved by the FDA. Currently Moderna has developed a vaccine that is undergoing phase 2 testing. (SOURCE: https://www.raps.org/news-and-articles/news-articles/2020/3/covid-19-vaccine-tracker) BCG vaccinations were developed several years ago for tuberculosis immunization and are currently being tested in Melbourne Australia and at Massachusetts General Hospital in Boston. The question surrounding BCG is whether or not the cellular immunity that it confers will protect against the respiratory infection in SARS like viruses. It has not been shown to protect against respiratory, only systemic tuberculosis.
There are several other candidate vaccines are either not as far along or will not serve US markets.
Yes. A study by the National Bureau of Economic Statistics determined that as the result of the March 19 executive order in California to shelter in place for nonessential activities COVID-19 cases were reduced by 125.5 cases per 100,000 population to 219.7 per 100,000 by April 20. This resulted in 1661 fewer COVID-19 deaths but resulted in 400 jobs lost for each life saved during the month.
Since the droplets are contain in our breath, we must wear a mask to contain the spread. Viruses attack the body through receptors on targeted cells. The receptors for SARS-CoV-2 are known as ACE2 receptors, and are on the heart, lungs and kidney.
A virus spreads by a transmission rate that is calculated by how many persons will be infected. The Ro transmission rate for SARS-CoV-2 is between 2.3 to 2.6. We also look at the Rt – or transmission rate in a community. That will fall as persons contain the spread. The disease has an incubation period of 5 days give or take 2. That means that if exposed to the disease, you may become symptomatic in less than 7 days. You will be contagious until you are free of the disease for around two weeks or less.
SARS-CoV-2 binds to ACE2 receptors on renal tubular cells and viral DNA has been identified inside kidney tissue and in the urine od COVID-19 patients. The virus activates helper T cells that release cytokines. These cytokines attract killer T cells to kill the virus, but meanwhile the cytokines can harm local tissue.
The incidence of AKI in hospitalized COVID-19 patients varied widely between .5 and 39%, and was mostly related to shock, hypoxia and heart failure. SARS-CoV-2 attacks the ACE2 receptors on heart. Its time from exposure to development is also varied, with Zhou (Zhou, Lancet 2020) reporting between 13-19.5 daya and Cheng reporting it to occur within 7 days.
Take lessons from nursing homes
COVID-19 in dialysis units
Reopening needs to be flexible – when spiking we need to cut back and when trending down we can open.
heltering in place does work – it was drastic but reduced the numbers of cases. We are seeing a spike now. Reduced to 15000 per day – now 60000 per day
Age tested is younger – but they spread to grandparents
Rules – distancing, congregating, sanitizing, masks
Can limit spread to 8 inches with proper masking
Can spread in poorly ventilated areas and aerosolize on surfaces like elevator buttons