COVID-19 update with Dr. Benjamin Marcum

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Myth 15: We should get this over with as fast as possible.

For thousands of years (since, at least the 3rd century BC, perhaps starting in Egypt), smallpox ravaged populations all over Earth.  The virus, named variola, caused a fever and progressive rash.  Many people recovered, but a staggering 3 out of 10 people died.  That mortality rate is much higher than the mortality rate of Covid-19.  Some survivors were left scarred due to the severe rash all over their bodies and others were left blind.  Smallpox is clearly a devastating disease and yet I have not been vaccinated for it.  The reason?  No need.  The last smallpox outbreak occurred in the US in 1949.  It has effectively been eradicated in the wild and no longer has a foothold anywhere else in the world.  

In 1796 an English doctor named Edward Jenner noticed milkmaids who had gotten cowpox did not show signs of smallpox after variolation.  (Variolation was the practice of putting material from smallpox pustules containing variola virus on scratches or inside the nose of people who had otherwise never had smallpox, thus inducing a mild form of the illness and subsequent immunity.)  His study resulted in the first vaccine for smallpox, made from cowpox.  In the 1800s the vaccine for the virus changed from being made from cowpox to vaccinia virus.  Jenner predicted in his original treatise on the subject that the result of this vaccination discovery ought to result in the elimination of a scourge that killed 3 out of 10 people it touched.  Vaccination continued throughout the years, but due to an insufficient vaccination rate worldwide, the virus continued to pop up in outbreaks throughout the world.  In 1959, the World Health Organization initiated a plan to eradicate smallpox.  It finally came to fruition in 1977 when the disease was eradicated from the final continent, Africa.  

The reason I don’t have a scar on my upper arm from the smallpox vaccine is because we were able to eradicate it through herd immunity.  Herd immunity is the concept that if most (or even better, all) people in a population are immune to a pathogen, someone who is not immune is protected because there are no hosts around that person to transmit the virus.  If I came into contact with smallpox today, I would likely suffer infection and would be at risk of dying, but the WHO and countries around the world did me a favor and starved the virus of fuel, non-immune hosts through which the virus could spread, and the long smoldering fire of smallpox was snuffed out, thus eliminating the need for vaccination.  

We accomplished this level of herd immunity through a comprehensive, well thought out, and aggressively managed vaccination program in combination with immunity built by smallpox survivors.  Those are the two methods of developing immunity, one is more costly than the other, as many fewer people die from vaccination than actual infection with the virus.  SARS CoV-2, the coronavirus that causes Covid-19 has no vaccination… yet.  One will not be forthcoming for many months, likely into 2021.  The only herd immunity we have been able to develop thus far is through people who have become infected with the virus and survived – at the cost of those who did not.  Fortunately, the survival rate is 98% (much higher than smallpox at 70% or the devastating H1N1 avian flu at 40%).  The high survival rate is a double edged sword.  In guaranteeing that more people live, it also guarantees more people will spread the infection and the disease will be spread to more vulnerable people before the epidemic is over.  And the epidemic will end… the question is when, and how many people will get sick and how fast?

Clearly, herd immunity is the best protection we will have from the coronavirus.  We will be past the epidemic when the herd immunity rate is high enough to deny the virus a strong foothold in our population.  Epidemiologists who are smarter than me must predict what portion of the population should be immune before we reach that point.  By issuing  a shelter in place order and avoiding personal contact through limiting business activity, we have been successful thus far at minimizing the rate of infection in Erath County.  We have 13 confirmed cases and counting.  There are more than that among us and we trust people who feel sick or have been exposed are staying at home as well to limit the spread.  Fortunately, to my knowledge, we have not had an infected person hospitalized, yet.  For us to get through this epidemic many people will have to get sick with the coronavirus and survive – and that will involve some hospitalizations and, unfortunately, some loss of life.  Should we just open wide our markets and restaurants and parks and let the virus run rampant so we can be done with it? Or should we continue to clamp down as tightly as we can and let the cases trickle through and build herd immunity over 6 or 12 or 18 months?

If you have a lake with too much water in it, it stresses the dam and causes ecological damage.  There is no room for more water and the reservoir’s capability to participate in flood control measures is limited.  Any more water and the dam is at risk of bursting all together.  So we need to let some water out.  But, we don’t open the floodgates for fear of washing away farms and homes and towns downstream.  You let water out of the dam at a measured rate – as fast as you can, safely.  So how do we allow a “safe” number of infections?  Do we open some businesses and encourage personal interaction in the young population and continue to isolate our older neighbors and those with compromised immunity?  Before we had a varicella vaccine, many parents would host chicken pox parties, where an infected child invited their friends over for the purpose of spreading the infection and building immunity to just get it over with.  Anyone want to sign up for a Covid-19 party?  I don’t.  Healthy young people and even children have died from this strain of the coronavirus.  The survivability is 98% and so the chances we survive are high, but it’s still a chance. 

On the other side of the argument, if you have a fire in a dry grassy field (a highly contagious virus among many non-immune hosts) and you don’t have water (a vaccine) to put it out and you just keep the fire away from the grass until the fire is starved of fuel and almost out, only to turn your back on the smoking coals, pretty soon the field becomes a conflagration that is out of control.  If we open business as usual, go back to school, church, restaurants, congregate in the park, play on playgrounds, play baseball and cheer in the stands we will be quickly overrun with cases of Covid-19.  I was thinking this weekend about how many cases of Covid-19 could have resulted from our community wide Easter egg hunt in the park and was thankful we had the foresight to postpone it.  But the point is, we can starve this virus of hosts by continuing the lock down for weeks and weeks, but the fire will never totally be extinguished without a vaccine.  It will continue to pass through essential workers and people who do not follow the recommendations from local, state and federal sources.  And then if we do relax the economy, the fuel will ignite and all the cases of Covid-19 we avoided will flood the medical system.  

So we have to find the middle ground.  We have to open our economy with surgical precision and be prepared to shut off the spigot of new cases the minute we start to see the spread become out of control.  To do that we need more available testing and faster results.  We need a population that will, down to every single person, take responsibility for the role they play in preventing the spread.  When we start to relax our restricted economy – if you feel sick, stay home.  If you live with someone who is sick, stay home.  If you go to a business, practice social distancing and wash your hands and wear a mask and don’t touch your face.  This is our new normal and will be for months.  Practice it.  Embrace it.  Live it.  Support your local officials because they will be the ones responsible for monitoring the rate of spread in our community and determine whether tighter regulations are warranted or we can loosen up a bit.  A blanket restriction from the State or Federal Government is too blunt an instrument to address the rate of infection in our community.  Also, if Erath County’s number of cases peak a couple of weeks after the Metroplex, we have a better chance of transferring patients if we have more than we can handle.  Their ICU and ventilator capacity will have improved and we can have more support.  

It seems counterintuitive for a physician to say we should become infected as a population so we can be well.  But with a new virus, that is the unfortunate truth of where we find ourselves.  We must strike a balance between population health and individual health.  It was the right thing to do to clamp down as much as we could control the spread of the virus.  Until we have more testing ability and a better handle on our medical resources, it is still the right thing to do.  Your medical leaders and local elected officials are monitoring the spread closely and will balance the number of cases we have vs the economic damage that is piling up.  We understand the risk of swinging the pendulum too far one way or the other.  I can tell you as we look back on this story, we will identify decisions that perhaps should have gone the other way.  We don’t have the benefit of predicting the rate of spread as a result of relaxing or tightening economic restrictions.  Our elected officials can only take into consideration all the factors and make the best decision based on the data available.  The relaxation of the economy will cause more cases.  How many more depends on how every individual responds to the relaxation of those restrictions.  If we take it as a sign the pandemic is over and we can go back to life as usual, the fire will erupt.  If we cautiously, thoughtfully restart our businesses with a sense of responsibility to our neighbors, the fire will smolder and steadily harden our population against the threat.  One person will not determine the outcome of this pandemic in Erath County.  It will be determined by the collective actions of all of us.  Unfortunately, those more irresponsible members of society have the potential to cause more harm than the most responsible of us can prevent the spread.   One fly spoils the ointment.

So, as we look toward the coming months and decide that we should relax restrictions a bit in the name of building herd immunity, do what you can to control the spread.  Prevent a conflagration.  The virus still kills.  Your loved ones are still at risk.  We can easily exhaust our medical resources.  We must protect the most vulnerable among us.  

It’s a tough problem without great solutions and for better or worse, we ARE in it together.

BAM

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