Alan Zelicoff, MD – Coronavirus Questions and Answers

Air Date: 3-6-2020|Episode 576

This week we welcome Alan Zelicoff, MD for a discussion of how to respond to an epidemic/pandemic. We will start with an update and resources for listeners, then we will play back our interview from earlier this week with Dr. Zelicoff. Our focus was on how a proper response should work and how the world is responding to COVID 19. Dr. Zelicoff has a unique perspective on the topic, he also joined us to discuss H1N1 and Ebola when those topics where front and center.

Alan Zelicoff is a physician (board certified in internal medicine 1992, clinical fellowship in rheumatology, 1983) and physicist (A.B., Princeton, 1975), who has had a varied career including clinical practice, teaching, and operations research. In the latter roles, he was Senior Scientist in the Center for National Security and Arms Control at Sandia National Laboratories from 1989 to 2003.

Dr. Zelicoff’s interests include risk and hazard analysis in hospital systems and office-based practice, and in technologies for improving the responsiveness of public health offices and countering biological weapons terrorism. Dr. Zelicoff has traveled extensively in countries of the former Soviet Union and has led joint research projects in epidemiology of infectious disease, while establishing Internet access at Russian and Kazak biological laboratories. He is the author of numerous text book chapters and articles in these subjects, and is a frequent contributor to Op-Ed pages in the Washington Post and other newspapers. Dr. Zelicoff’s book on this subject is: Microbe: Are we Ready for the Next Plague? Available on Amazon.

Z-Man’s Blog:

Coronavirus Questions & Answers -Dr. Alan Zelicoff, MD

Alan Zelicoff, MD is a physician (board certified in internal medicine 1992, clinical fellowship in rheumatology, 1983) and physicist (A.B., Princeton, 1975), who has had a varied career including clinical practice, teaching, and operations research. In the latter roles, he was Senior Scientist in the Center for National Security and Arms Control at Sandia National Laboratories from 1989 to 2003. Dr. Zelicoff’s interests include risk and hazard analysis in hospital systems and office-based practice, and in technologies for improving the responsiveness of public health offices and countering biological weapons terrorism. Dr. Zelicoff has traveled extensively in countries of the former Soviet Union and has led joint research projects in epidemiology of infectious disease, while establishing Internet access at Russian and Kazak biological laboratories. He is the author of numerous text book chapters and articles in these subjects, and is a frequent contributor to Op-Ed pages in the Washington Post and other newspapers. Dr. Zelicoff’s book Microbe:Are we Ready for the Next Plague? published by AMAZOM Books.

Nuggets mined from Today’s Episode:

Pandemics are diseases prevalent over a whole country or the world.

Zoonotic (plural Zoonoses) diseases are bad. Endemic in the animal population. Zoonoses are infections that are spread from animals to humans. Humans are “dead-end” hosts, meaning that there is no subsequent human-to-human transmission

Zoonotic (plural Zoonoses) diseases are bad. Zoonotic diseases are endemic in the animal population. Zoonoses are infections that are spread from animals to humans. Humans are “dead-end” hosts, meaning the organism does not require humans as hosts in order to continue to survive in the environment.  Other hosts (animals in particular) serve that role.  Nonetheless, some zoonotic diseases DO transmit from human-to-human (like Covid-2019 caused by the virus now called SARS-CoV2) and some do NOT transmit from human to human (e.g. hantavirus pulmonary syndrome virus).  Obviously zoonotic disease organisms DO transmit routinely from animal host to animal host.

COVID19 has an animal reservoir in bats and mammals. Humans are likely to be incidental hosts organisms that do not require humans as hosts in order to continue to survive in the environment.  Other hosts (animals in particular) serve that role.  Some zoonotic diseases WILL transmit from human-to-human (like Covid-2019 caused by the virus now called SARS-CoV2) and some WILL NOT transmit from human to human (e.g. hantavirus pulmonary syndrome virus). Clearly, zoonotic disease organisms DO transmit routinely from animal host to animal host.

RNA viruses mutate a lot. Viral replication is error prone. Mutations are most often a dead end for viruses. Retroactive counting of mutations shows COVID19 has been in Washington state for 6 weeks. Are mutations causing worse disease?

COVID19 coronavirus is different from the coronavirus that causes the common cold and is less lethal than SARS1. COVID has much worse symptoms than common cold. COVID19 transmits more readily than common cold. During cruise ship Diamond Princess quarantine, the disease continued to spread, indicating capability of airborne transmission.

There are many unknowns about COVID19. Many asymptomatic indications. 80% of effected have mild symptoms. Older group with underlying disease don’t do well. COVID19 is not influenza. Currently there is no COVID19 treatment or prevention.

Viruses are little packets of genetic material in a box. They don’t require moisture nor nutrition. Bacteria survive, die or form spores. Bacteria usually require a host. Viruses await, ready to do something.  Viruses can be denatured by environmental factors such as UV light. Viruses are comprised of RNA, DNA and maybe enzymes within a protein/lipid shell. Viruses must get into another cell in order to multiply. Virus surface proteins bind to specific molecules on surfaces of cells. COVID19 has a spiked shape protein which binds to lund tissue cells in the alveoli.

Epidemiology- epi means next to or around and demos means people, it’s the study of things around people. Epidemiologists characterize disease by gathering info about groups of people who either experience an outcome or not. Disease spread based upon risk factors in people; ability to get sick and likely outcome.

Hantavirus is a vicious lung disease.“Hantavirus Pulmonary Syndrome (HPS) is a severe, sometimes fatal, respiratory disease in humans caused by infection with hantaviruses.” CDC

The New Mexico public health system has a very short reporting chain. Good personal relationships between Santa Fe and doctors interested in infectious disease, concerned callerare routed directly to correct person.

In 1994 in Gallup, NM which borders former Navaho reservation. Young healthy native American person sought treatment at the IndianMedical Center for a bad pulmonary illness. The two thoughts that came to Dr. Bruce Tempest, MDtreating physician’s mind were: influenza and plague. The very ill patient was declining very rapidly, noticing something odd, Bruce called Gary Simpson, MD an infectious disease specialist. Simpson assembled a Syndrome: Signs & Symptoms that needed further investigation. Within a few days made a definitive decision to send people to households hogans, 1 room traditional Navaho homes. Found that aduklts slept on beds, children slept on floors. Found mouse droppings, nesting materials. Basic hypothesis was that mice carried the disease. A field biologist spent his career gathering small local animals which were frozen with liquid nitrogen and thenarchived.

The story came to a conclusion quickly when the virus was found in the bladders of Peromyscus mice. A diagnosis and risk factor were identified.  Be careful when cleaning up mouse droppings. Hantavirus Pulmonary Syndrome (HPS) is a severe, sometimes fatal, respiratory disease in humans caused by infection with hantaviruses. Named after the Haantan virus of the Korean war. A triumph of public health. The observation of a bright doctor, coupled with lack of bureaucratic delays, and cooperation.

2020 COVID19 retroscope. The Chinese quickly isolated, sequenced and published data regarding COVID19 online.

In the US, the overwhelming number of states have dozens of public health departments. Big states lack cooperation and relationships between departments.

Of all the thousands of people who returned to the US from China in December the lack of chance for COVID19 transmission is ZERO.  Should have led to local health departments get an idea of flulike symptoms, muscle aches, fever & cough. There is lots of influenza and nothing close to real time surveillance. Real time surveillanceand the addition of additional info (e.g. flu immunization, travel history) could have dramatically improved response. A bureaucratic quagmire of raising the alarm resulted in an inherent delay to information sharing. As learned from Hanta virus and other rapid debilitating diseases hours matter and are the difference between life and death!

In the US our known reporting of disease is good due to lab tests and disease presentation (e.g.: measles and TB). Hours matter. Lab tests that take days are too late.

Definition of Syndromic Surveillance Syndromic surveillance is an investigational approach where health department staff, assisted by automated data acquisition and generation of statistical alerts, monitor disease indicators in realtime or near real-time to detect outbreaks of disease earlier than would otherwise be possible with traditional public health methods (CDC).

The main purposes of syndromic surveillance are: To identify illness clusters early, before diagnoses are confirmed and reported to public health agencies, and to mobilize a rapid response, thereby reducing morbidity and mortality. To monitor disease trends in the community.To provide reassurance that a large-scale outbreak is not occurring in the community

Nurses and doctors are HEROs!

Secondhand aerosol exposure poses a risk to healthcare workers during mechanical ventilation.

COVID19 patients who have died show diffuse alveolar damage. We aren’t sure how the virus gets there. PM2. 5 (particles less than 2.5 micrometers in diameter) can penetrate deeply into the lung, irritate and corrode the alveolar wall, and consequently impair lung function.

Approximately 90,000 ICU beds in the US. Also need respiratory nurses, doctors, pulmonologists, intensivists. Most are full because hospitals run lean. US has minimal surge capacity. This has been recognized by disaster planners.

Voluntary self-isolation an unlikely option in the US, due to our culture and lifestyle.

Preparation recommendationshopping list:

  • Purchase 2 weeks nonperishable food.
  • Obtain your favorite go-to sickbed foods.
  • Have your medications filled.
  • Toilet paper
  • Kleenex
  • Hand sanitizer.
  • Cleaning and sanitizing products
  • PPE, gloves.
  • Clean and reclean high-touch surfaces

Behavior modification:

  • Social Distancing
  •  Strong recommendation to stay at home as much as possible.
  • Avoid nonessential travel, do I really need to go?
  • Avoid crowds and crowded places.
  • Single greatest risk is contaminated surfaces.
  • Avoiding high touch surfaces
  • Avoid shaking hands.
  • No utility to masks if not performing patient care.
  • If you get sick and aren’t desperate don’t go to hospitable or urgent care center.

Dr. Zelicoff’s final comment:

Get a flu shot if you haven’t gotten one.

Z-Man signing off

Trivia Question:

What is the etymology of the word influenza?

Answer:

From the Italian influenza, literally “influence”

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