I want to address some rumors I've heard.
The virus is killing more and more young people/more young people are in the ICU
On a population level, there are generally more people under 50 than over. In addition, many of the very elderly population have advanced directives and will not wind up in an ICU. Moreover, young, fit, "atypical" patients are more shocking and their deaths are more tragic, so we hear about them more. Everyone heard about the 33yo Chinese physician, Dr. Li Wenliang, who was instrumental in discovering and documenting this disease who died.
But in China almost 4,000 healthcare workers were infected and only 13 died.
Blood pressure medications might increase your risk of severe disease
No. This assumption is based on the finding that taking medicines in the angiotensin converting enzyme inhibitor (ACEi) class (benazepril, lisinopril, ramipril, fosinopril, etc.) or angiotensin receptor blocker (ARB) class (losartan, valsartan, candesartan, olmesartan, etc.) increase expression of the ACE2 surface protein, which is the surface protein on cells to which the virus particle attaches.
1) This requires a very simplistic assumption that surface ACE2 receptor concentration is the rate-limiting factor in the progression of the disease. Viral infections and immune responses are far more complex than that and even when expressed at low levels, there would be enough surface ACE2 on the surface of AT2 cells (a minority of cells in the lung) to allow for infection in any event. Moreover, once the virus infects a cell, it can cause formation of a syncitium, which is a fusion of two cells, allowing viral components to traverse directly from one cell to the next without needing to use any surface receptor.
2) These medications also increase the level of SOLUBLE ACE2, which means that there are the virus-binding pieces of this protein floating around freely, which would actually block the virus from binding to surface-bound ACE2.
3) In one sample in China, only 35% of hypertensive patients that had critical disease were on an ACEi or ARB, which is less than you would expect.
NSAIDs like ibuprofen make the disease worse
I maintain that this was irresponsible of the WHO and erodes confidence in large leadership organizations. There is only a tiny bit of data to support this, which is that some French intensivists found that more patients in the ICU than not had taken ibuprofen prior to hospitalization. There are multiple interpretations to this finding (they were sicker so they were taking more, perhaps they were unhealthy "pill popper" types, so already more at risk, wholly spurious observation, or maybe ibuprofen really does make it worse) There are no studies to support the claiim that NSAIDs increase ACE2 expression, and as I explained above, that is more likely protective than not. Moreover, indomethacin, an NSAID, was found to inhibit SARS-CoV replication during the 2003 SARS epidemic.
That said, my general guidance in acute febrile illnesses is to use medications like NSAIDs and acetaminophen (paracetamol for those of you outside the US) as sparingly as possible and only when the discomfort from the fever is unbearable. There is evidence that BOTH classes of medications suppress the immune response and fever is adaptive and protective.
Asthmatics are at particular risk
Health authority after health authority has made this claim.
Two studies have examined this:(1)(2) and both found that Asthma was surprisingly underreported as a comorbidity. Moreover, in Japan, an asthma medication called ciclesonide (ALVESCO) was found to improve COVID pneumonia. This is not what I would have expected, either, (given that other coronaviruses trigger asthma attacks) but there are the data. Perhaps we will eventually find that asthma is protective (and I am not claiming it is; we have no data to support that claim yet, either). This would not surprise me for some complex immunological reasons having to do with the kind of immune response that people with asthma/allergies tend to mount (called a Th2 response, found to be protective in COVID-19). But for now, asthmatics should still take careful precautions. They can and do still wind up in ICUs, but evidently no more than anyone else.
Children under 15 never get critical disease or die
This is *almost* true. To date three children aged 15 or under have become critically ill and one has died.
*One was an 8yo who had recovered from leukemia less than a year before. His outcome is unclear.
*One was a 14yo and his medical history was not clear. This patient died.
*One was a 1yo who needed mechanical intubation for 5-6 days. I am skeptical that COVID-19 was the cause of the disease here as there are eleventy other respiratory viruses common in temperate climates that would land a child this age on a ventilator for 5-6 days and while he might have tested positive for SARS-CoV-2 (the virus that causes COVID-19), I suspect that that this virus was just along for the ride and that another virus (parainfulenza, metapneumovirus, adenovirus, coronaviruses OC43, HKU61, 229E, or NL63, RSV, and influenza) was responsible for the child's illness.
That said, severe disease in children is rare and critical illness in children is extremely rare. This disease remains remarkably polite to children. It does infect them and some studies have shown very high copy numbers (amount of virus present) but they very seldom get sick.
The illness is flu-like[/i]
I think this is a dangerous misconception. It is sometimes flu-like. And it is very often very much milder. A bit of a tummy ache and a few loose stools, which you might dismiss as something that you ate not agreeing with you. A vague sense of being hot and cold and tired, which you might dismiss as some variation of the normal state (work, stress, kids). A bit of pain in the chest, as if you did a workout, nothing to worry about. A tickle in the chest and maybe an occasional cough, which you might dismiss as spring allergies. So you go to work. You kiss your elderly parents. You shake hands with business associates and customers. And his is why now studies are saying that as many as 75% of cases go undetected. I suspect that once this is all over we will discover that it's over 90%.
So if you get those little nagging things, don't ignore them. STAY HOME.
[b]There is no immunity and you can get renfected
Particularly in elderly patients, there was an initial finding that they would improve, test negative, and then worsten again. This raised concern for reinfection. But now we know that both humans and primates do make protective antibodies against this coronavirus and others.
So what was going on? A common pattern in critically ill patients was that they would improve and relapse. At first this was taken as reinfection, but the Italian intensivists summarized their experience and repeatedly said: "DO NOT TRUST THE FIRST IMPROVEMENT!! DO NOT BE CAUGHT UNPREPARED!!" The test is only 50-75% sensitive. So it's possible that many of these patients had a false negative test and then relapsed.
Thank you so much for another enlightening post.
I have one question: Am I understanding it correctly that I should not be very worried if I have hypertension and take Candesartan daily? I also have asthma and use Ventoline. I am being extra cautious these days and have self quarantined myself for a week now.