October 22, 2020

The worst is yet to come (Part 1)

“If you still want to expose yourself unnecessarily, nothing will stop you now. COVID-19 is awaiting.”

The number of people wiped out by COVID-19 worldwide to date, exceeds the population of Atlanta. As if this were not enough tragedy, Tedros Ghebreyesus, Director-General of the World Health Organization (WHO) has an apocalyptic prognosis: “the worst is yet to come.” 

In the U.S., coronavirus fatalities exceed the population of Allentown, the economy is in agony and 42 million people have lost their jobs. “The worst is yet to come,” warns Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases of the National Institute of Health.

The worst it yet to come. As if a distasteful joker had said “I’ve got good news and bad news” and half a million corpses and the four out of five jobs lost on the planet were the “good news” part of the joke.

So, what would the worst be like?

It would be thousands more getting ill; hospital(s) lacking enough beds, doctors and nurses; inadequate supplies of reagents and PPE and exhausted doctors having to decide who will occupy the few beds left and who will be abandoned to their fate (as has already happened in Bergamo, Italy).

It would be dozens of refrigerated trucks outside hospitals side-by-side, packed to the brim with corpses in plastic bags waiting for autopsy, not enough funeral homes, long waiting lists for cremation and families not allowed for the last farewell.

Or if you’re still alive, it would be falling behind on the rent or mortgage, utility bills and many others, living your days in terror thinking that the next victim could be your son, your brother. Or yourself.

Above all the worst would be having to endure a second round of quarantine, paralyzed with no income, with no schools and struggling to continue bringing groceries home.

Do it once and it will be done experts envisioned: treat current cases, minimize opportunity for spread, let the disease take its course in those already infected and then allow “the curve to flatten,” slowly returning to near zero cases. Then, rationally prioritize the cautious opening of key sectors: factories, businesses, schools. This was the path that a few effective countries followed.

What makes COVID-19 so mighty, that it’s shaking the foundations of medicine?

This article has gathered key, disperse information accumulated over the months on symptoms, diagnosis, prevention, treatment and the overall impact of being infected.

Originated in Wuhan province, China, it spread like wildfire. In three months it took over the planet.

COVID-19 passes from person to person though droplets expelled when infected people cough, talk or breath or through objects (fomites) such, doorknobs, cell phones, etc. The virus penetrates through the mucosa of the nose, eyes and mouth. The WHO just recognized the airborne (aerosol) transmission of COVID-19, meaning the virus remains in the air particularly in closed, poorly ventilated environments.

COVID-19 caught scientists by surprise. Different from influenza and respiratory diseases like the severe acute respiratory syndrome (SARS), with no drugs to treat it, no vaccine to prevent it, it ignored borders and killed by the thousands. It demanded quick and firm decisions to prevent further propagation, gain people’s support and rectify the daily misinformation campaign.

From the beginning getting a portrait of the disease was elusive and unclear like a picture without focus. A handful of symptoms were known in China: dry cough, high fever, general weakness, shortness of breath. Over the days, weeks and months that followed, hospitals worldwide reported various other unknown sides of the disease. Additional symptoms such as anosmia (loss of olfaction) and ageusia (loss of taste) were described.

Kids with COVID-19 presented multi inflammatory syndrome in children (MIS-C), inflammation of key organs – heart, kidneys, brain, eyes, gastrointestinal body parts.

Another symptom, discolored lesions, appeared on feet and hands amongst children and young people. 

Months within the pandemic, two striking observations emerged. The first by Dr. Cameron Kyle-Sidell (Maimonides Hospital, Brooklyn, New York) who verified that as high as four in five patients connected to ventilators, machines that pump air into patient’s airways, died.

 Lungs are composed of tiny balloon-shaped structures, alveoli, where blood releases carbon dioxide, CO2, and brings in oxygen, O2. Once infected by the virus, mucus fills the alveoli and this critical gas exchange becomes difficult.

Thus, a ventilator was the best option for SARS patients. However, lungs of COVID-19’s patients were too weak to handle the high airflow that the procedure called for. Dr. Kyle-Sidell recommended to lower the flow and even then, only at the very last minute, when the patient absolutely won’t survive without.

The second observation brought hope. According to Dr. Matteo Basetti, an expert from Genoa , Italy, the strain would lose strength over time and become “weaker” to the point where it would no longer be a danger. Genetic research indicated that changes in the virus that causes COVID-19 had occurred a few times yielding variants (strains), such as D614G, which appeared more severe than the original and ended the hope of spontaneous diminished ability to infect.

Over the months, a profile was assembled of individuals likely to get hit harder: the elderly, men, people who are overweight, people with medical history (such as diabetics – comorbidity situation – or under immunosuppressant medication), young black and Latino Americans, blood type A individuals (less resilient to COVID- 19 than blood type O-positive).

A current consolidated list of COVID- 19 symptoms includes fever or chills, dry cough, tiredness, congestion or runny nose. Less common symptoms are aches and pains, sore throat, nausea or vomiting, diarrhea, conjunctivitis, headaches, loss of taste or smell, a rash on skin or discoloration of fingers or toes. Serious symptoms requiring immediate medical attention are difficulty breathing or shortness of breath, chest pain, loss of speech or movement. (Source: WHO and Centers for Disease Control, CDC).

As to how the disease progresses, consider the example of Dr. Samuel Chen, a political-science faculty member at Northampton Community College. Early in May, he had a 102-degree fever and chills, spiked heart rate and blood pressure and “the worst headache of [his] life.” He ended up in the ER, diagnosed with COVID-19 and a partial collapse in one lung. Chen’s vitals couldn’t be stabilized and he had to remain in the hospital.

After three days he was discharged and put in at-home isolation, with prescriptions that kept his vitals under control. Rest was recommended and in fact, so needed because every day activities caused him extreme fatigue and shortness of breath. His isolation lasted 35 days. Today, Chen is recovering well and in the process of finishing the manuscript for a book. “I consider myself blessed,” he wrote in an op-ed in the “Morning Call.”

Hospitalized patients who don’t recover, remain there much longer. When normal breathing is not sufficient a tube is introduced in the trachea and connected to a ventilator. If this fails, an extreme procedure is to pump the blood out to a machine that performs the CO2 – O2, exchange, a procedure known as extracorporeal membrane oxygenation (ECMO).

The possibility of COVID-19 embodying so many symptoms often left scientists in dark. It was hard to make a connection among effects on multiple organs (the brain, heart, liver, kidneys). A clue was the discovery that COVID-19 attacks the single layer of cells, called the endothelium of blood vessels (think the internal layer in contact with liquid in a pipe).

Damage to the endothelium is a signal that the body interprets as blood loss or hemorrhage, needing an immediate stop, so it triggers a cascade of signals for clotting. These clots obstruct the tiny blood vessels that bring nutrients and oxygen to organs such as brain, heart, liver, kidneys. Such obstruction causes disarray: mental confusion, strokes, kidney failure. The worst is that it may be irreversible and will last for a lifetime.

In fact, autopsies of COVID-19 patients conducted at New York University found blood clots in almost every organ.

One reason for the rapid transmission of COVID-19 is that it takes a few days for the symptoms to appear. This called presymptomatic phase is extremely infectious. Unaware of being infected, a person continues a routine life, in close contact with family, friends, coworkers. A dangerous silent transmission is then taking place.

An intriguing fact is that some people carry the disease without manifesting any critical signs. These are the asymptomatic. The publication of the National Academy of Sciences reported that presymptomatic and asymptomatic constitute 50% of COVID-19 cases.

Massive testing, although desirable, is limited by the availability of kits. In mid-June, some people were turned away from Easton Hospital’s free drive-in testing. Nurses collected samples only from those presenting symptoms.

Two types of tests are available, the molecular assay that checks for current infection and the serological that checks for past infection.

For the former, swabs (think a long Q-tip) sample the patient’s back throat or deep nose. For the latter, blood is taken, by finger prick for example. Past infection is evidenced by the presence of antibodies — molecules produced by the body as reaction against the COVID-19 virus. The so called “herd immunity” or “herd protection,” relies on this. Most viral infections lead to individuals carrying antibodies.

Once the majority gets infected, the population would be protected from reinfection. Currently, this is a hot topic of discussion, since the possibility of reinfection is real, according to National Institutes of Health (NIH) Director Dr. Francis Collins (July 14).

A word of caution: tests can yield the wrong result. If, on the first type, sampling is not done by experts, from back throat, it may not detect the virus.  On the second type, if the person is too early into the disease progression, the body hasn’t produced the level of antibodies that the test detects.

Additionally, commercially available antibody tests may be unreliable; as the “removed tests list” on the Food and Drug Administration (FDA) website points out.

All this new knowledge and sometimes conflicting data in hospitals and laboratories all over the world is generating a gigantic amount of data.

“The literature on COVID-19 expands daily, so a review like this is out-of-date the moment both fingers cease tapping the keyboard,” wrote professors Moore and Klasse (Weill Cornell Medical College, New York) in a review article on SARS-CoV-2 vaccines.

To date, there is no specific drug to treat the disease. Two medicines “of compassionate use” (not approved for COVID-19, but used since no specific drug is available) are Remdesivir and, more recently, Dexamethasone, for severely affected patients. They are not for patients in early stages.  

For prevention, there are a few promising vaccine candidates, but even in the best-case scenario, availability won’t be until early 2021. Despite the enormous hope that people are placing on the COVID-19 vaccine, Dr. Fauci takes a conservative stand (July 7). When available, the vaccine may not be a one dose for lifetime protection, as the anti-measles is, but would rather protect temporarily. Dr. Fauci hopes that its effect will last long enough to get us out of the current cycle.

To minimize transmission of the disease, experts came up with individual measures and public measures. One is not effective without the other. Individual measures are cheap and easy to follow: wear a face mask, wash hands frequently, thoroughly isolate infected people and practice social distancing (keeping a 6-foot distance from others).

Public measures aim at isolation, cancelling school, working from home (when possible), minimizing traveling, etc. People remain at home for a specific period. This is the quarantine or lockdown. A few countries have demonstrated the importance of designing effective measures and putting them into strict practice. They did it once and they did it well. Nowadays, without lowering the guard, they’re back to normal, fully focused on economy recovery.

In the U.S., 140,000 people have lost their lives to COVID-19. The nation is witnessing record new cases, exceeding 55,000 every day for the last 14 days. Florida reopened prematurely and registered a single-day record of 15,300 new cases (July 13). It’s now the epicenter of the pandemic as once was New York, Italy or Wuhan.

In spite of these alarming numbers, many Americans still don’t take the pandemic seriously. Here are a few considerations for those who might be open to changing their mind:

“By exposing yourself unnecessarily to COVID-19, you’re taking many risks.”

  • Be ready to suffer. The illness can be very painful. “It’s like having fine pieces of glass inside the lungs”, every breath is torture, as a British woman described in a YouTube video. “The worst headache I had yet experienced,” Dr. Chen of NCC said “Everyday tasks – from brushing my teeth to walking the stairs felt like running a half-marathon.”

Your body will be in disarray: blood pressure, fever, permanent discomfort. 

When normal breathing worsens, painful dangerous intubation takes place. Once in the hospital you will not see relatives. From then on, you’re in the middle of strangers, whose faces you will never see. Plus, many hospitals are in it for the profit, somebody will have to pick up the check ($29,000 per case in Elmhurst, New York).

  • Be ready to die. Californian Thomas Macias, age 52, attended a party without a face mask. He paid for the neglect. “This is not a joke” Macias regretted on Facebook two weeks later. “If you have to go out, wear a mask and practice social distancing. Because of my stupidity I put my mom and my family’s health in jeopardy.” Macias died the next day.

In Long Island, New York, 23-year old Daniel Moran, held his COVID-19 dying father’s hand to pray. Sixteen days later he was buried next to him.

A 30-year-old man from San Antonio attended one of the infamous “COVID parties,” to which infected people are purposely invited. He believed the virus to be a hoax. “I think I’ve made a mistake,” he told the nurse before dying.

To make things worse, you may die, but before symptoms appear, unaware of being infected, you might have contaminated family and friends. You will be dead, but you are leaving a legacy of COVID-19, hospital bills, funeral and cemetery bills to others.

  • Be ready for months of agony, in limbo. Recovery or death may not come quickly, as is the case of “the long-haulers, long-termers,” patients who after more than 100 days, still feel the symptoms, despite testing negative. “Business Insider” has tracked 17 long-haulers. Doctors can’t explain this yet.
  • Be ready for long-term, even lifetime limitations to physical and mental abilities. Because the disease has been around for less than a year, many long-term physical consequences are not known yet. In March, recovered patients in Hong Kong, presented a drop of 20-30% in lung function. Other studies identified post-recovery seizures and hallucinations and myocarditis in addition to lost kidney function.

COVID-19 will hit you, your family or your friends’ pockets and health.

If you still want to expose yourself unnecessarily, nothing will stop you now. COVID-19 is awaiting.

Watch these short videos to learn more:

(Contact the author of this article, Jesus Zaldivar, associate-editor of The Commuter: jzaldivar@nullspartan.northampton.edu)

Jesus Zaldivar

Jesus Zaldivar, associate-editor of The Commuter, is a freshman at NCC. Previously, he conducted biomedical / environmental research in South America, Europe and six states in the U.S. (Contact: jzaldivar@spartan.northampton.edu)

View all posts by Jesus Zaldivar →
%d bloggers like this: