Category Archives: COVID-19

COVID. ‘With’ ‘Of’ or ‘Because of’

6th April 2020

Here is a section from the Health Service Journal (HSJ) in the UK, discussing the current fears of NHSE (NHS England). The article is behind a paywall.

NHS England is an executive non-departmental public body of the Department of Health and Social Care. NHS England oversees the budget, planning, delivery and day-to-day operation of the commissioning side of the NHS in England as set out in the Health and Social Care Act 2012>/p>

Exclusive: NHSE to act over fears covid-19 focus could ‘do more harm than virus’

‘NHS England analysts have been tasked with the challenging task of identifying patients who may not have the virus but may be at risk of significant harm or death because they are missing vital appointments or not attending emergency departments, with both the service and public so focused on covid-19.

A senior NHS source familiar with the programme told HSJ: “There could be some very serious unintended consequences [to all the resource going into fighting coronavirus]. While there will be a lot of covid-19 fatalities, we could end up losing more ‘years of life’ because of fatalities relating to non-covid-19 health complications.

“What we don’t want to do is take our eye off the ball in terms of all the core business and all the other healthcare issues the NHS normally attends to.

“People will be developing symptoms of serious but treatable diseases, babies will be born which need immunising, and people will be developing breast lumps and need mammograms.”…

Nuffield Trust deputy director of research Sarah Scobie said it was “a considerable worry that people are keeping away from routine and urgent health services, and also from emergency departments”.

She added: “The PHE (public health England) data suggests there could be significant problems already developing for heart disease related conditions patients, for example. Attendances relating to myocardial infarction at emergency departments have dropped right down, whereas ambulance calls in relation to chest pain have gone right [up].

I suppose my first response would not be one of great surprise. In fact, it confirms what I have been saying for some time. When the great Swine Flu epidemic (that killed hardly anyone) created the last pandemic crisis in the UK, exactly the same thing happened. If, whatever you were suffering from, wasn’t Swine Flu, it didn’t seem to matter.

In my small part of the world a small but significant number of people were diagnosed with Swine Flu. This was done over the phone, by poorly trained operatives. These people were then prescribed the (almost entirely useless Tamiflu), they then died. It turned out that they had other conditions that could, and would, have been properly treated had we not been overcome by a massive over-reaction to Swine Flu. They died because of swine flu.

Last week, in Intermediate Care, we sent two patients into the local hospital who were seriously ill. They were both sent back almost immediately. They both died. Yes, they were ill, and may have died anyway. But I believe they should both have been admitted, and treated, and they could both still be alive. They died because of COVID.

Ambulance crews are under very heavy pressure not to admit anyone unless absolutely necessary. Some of those, not admitted, will die.

These people, all these people, are dying ‘because of’ COVID. Because of the fact that almost the entire focus of the NHS is now on COVID – to the virtual exclusion of anything else.

Our local hospital now has more empty beds than at any time in history. Elective surgery has stopped, to free up resources. There is enormous managerial pressure to clear more and more people out of hospital, out of Intermediate Care beds, back home with little support available. Some of them will die because of this.

My last blog focussed on the economic costs of the reaction to COVID. My argument was that economics, and health, do not exist in isolate bubbles. Harm to the economy will result in harm to health and vice-versa.

Equally, if you spend all your healthcare resources trying to treat one thing, everything else will suffer, because resources are not infinite. At present we have virtually shut down the NHS to deal with COVID.

I saw several patients yesterday while I was working in “out of hours”, who were not critically ill, but they were ill. Two of them, I felt, really needed to be followed up. A girl with weight loss over the last three months, a man with clear signs in his chest that could have been malignant.

They will not be followed up any time soon. If at all.

At present there is a lot of discussion about how we are categorising deaths from COVID. Anyone who dies, having been diagnosed with COVID, is considered to have died of COVID. Even if they died of something else. The died with COVID, not of COVID.

There is, I believe, an even greater immediate problem here. Which is those who are dying because of COVID. This is not just me saying this, this is NHS England:

While there will be a lot of covid-19 fatalities, we could end up losing more ‘years of life’ because of fatalities relating to non-covid-19 health complications.”

For many years, there has been an old medical joke. It will not make you laugh out loud, but it goes like this.

The operation was a success, unfortunately the patient died.’

A Health Economic perspective on COVID-19

29th March 2020

The current COVID pandemic has brought a very thorny and difficult issue to the forefront. How much money should we, as a society, spend on keeping people healthy/alive? No-one has ever fully got to grips with this question, but it has never been more important than now.

The reason why I say this is that the US Govt has set aside two trillion dollars to deal with the crisis, in the UK it is over three hundred and fifty billion pounds, which is almost three times the current yearly budget for the entire NHS. Is this a price worth paying?

I know that some people will instantly dismiss such a question as being cold-hearted, and simply stupid. ‘You cannot put a value on a human life.’ Is an argument that I have heard many times, almost whenever health economics is discussed.

The counter argument is that – if funds are not limitless – then we should focus on doing things whereby we can do the most good (save the most lives) for the least possible amount of money. Or use the money we have, to save the most lives. In fact, this is why the National Institute for Health and Care Excellence (NICE) was established.

NICE reviews interventions and decides whether they provide value for money. The economic term for this is cost-effectiveness. This work is complex and often relies on assumptions that can be difficult to verify.

However, keeping this as simple as possible, NICE tries to compare healthcare interventions against each other by using a form of ‘currency’ called the cost per QALY.  A QALY is a Quality Adjusted Life Year. One added year of the highest quality life would be one QALY.

People with conditions such as cancer, or severe heart disease, or who are suffering from chronic pain can be considered to have a quality of life less than one. For the sake of argument, we can say that their quality of life is 50%. Thus, one year of additional life gained for them, would have a value of 0.5 of a QALY.

It also needs to be borne in mind that not everything that is measured using a QALY, relates to saving, or extending, lifespan. For example, someone could have chronic hip pain, and a quality of life of 0.5. Then they have a hip replacement, and their pain goes away, their quality of life can improve from 0.5 to 1. If they live another twenty years, they will have gained 20 x 0.5 QALYs = 10 QALYs.

Obviously, things can get significantly more complicated than this, and the validity of the measured quality of life is a matter of considerable debate.

However, the fundamental question as always, comes down to the following. How much are we willing to pay for one QALY? [How much can you afford to pay for one QALY?] Not just the NHS, but the country as a whole? The current answer, in the UK, is that NICE will recommend funding medical interventions if they cost less than £30,000/QALY. Anything more than this is considered too expensive.

This figure is not set in stone and can vary depending on circumstances. Interventions for young children tend to get more spent per QALY, and powerful lobbying groups can bring pressure to bear on that figure.

However, the figure of £30,000 is generally accepted – if not widely publicised.

Which means that, if we are going to spend £350,000,000,000.00 in the UK, on managing the coronavirus, how many QALYs do we need to get back? The simple answer is to divide three hundred and fifty billion by thirty thousand. Which leaves us with slightly more than eleven and a half million (11,666,666).

To put it in more stark terms. In order to spend three hundred and fifty billion pounds, we require a return on investment of eleven point six million QALYs. If not, NICE would reject it.

[For those who think this an impossible/inhuman calculation, you always have to consider how many other lives could be saved, how much other suffering, or death, could be prevented, by spending three hundred and fifty billion pounds in another way. Because that is what you are really trying to work out].

Are we likely to achieve this level of benefit? Of course, any attempt to model this requires several assumptions to be made. However, the model we can use in this case only has four variables, two of which are (pretty much) known. The variables are:

  • How many people will die?
  • What is the average age of death?
  • What is the average reduction in life expectancy in those who die?
  • What is the average quality of life of those who die?

[In truth, average age of death is only needed to calculate the average reduction in life expectancy.]

So, for example

  • 500,000 die
  • Average age at death 78.5
  • Average reduction in life expectancy 3 years
  • Average quality of life of those who die 0.7

QALYs lost: 500,000 x 3 x 0.7 = 1,050,000

Using these figures, if we spend three hundred and fifty billion pounds – in the hope of reducing the ‘QALYs lost’ figure to zero, then each QALY will have cost £333,000. Which is more than eleven times the maximum cost that NICE will approve.

Of course, people will immediately object to this model, and for valid reasons. How do we know how many will die, how do we know the average quality of life of those who die, how do we know the average reduction in life expectancy?

In fact, we do know two things with reasonable accuracy. First, we can be pretty certain about the average age of death, and we can also be fairly clear on the average quality of life of those who have died.

What is less certain is how many will die, and the average life expectancy of those who have died. At this point we need to look at the ‘variables’ in the model in a little more detail. This is UK only.

Number who may die

The 500,000 figure for possible deaths, that I used in the calculation above, is the absolute upper range of the numbers that have been proposed, and it comes from modelling that was developed by the Imperial College in London. Their modelling has been since used around the world to guide Government responses. 1

On the other hand, the UK Government has used an estimated 250,000, for the upper limit of deaths – if nothing is done to prevent spread. Other figures have been much lower, but I am going to use 500,000 as the maximum, and 250,000 as the ‘most likely number’ in this model.

My minimum figure will be 20,000, as this has recently been suggested by the same Imperial research group. It seems low.

Average age of death

In Italy – which has had the greatest number of deaths – the average age at death is 78.5. This is comparable with age of death in other countries. I am going to use this as a non-variable 2.

Average reduction in life expectancy

This is more complicated. Using Italy, again, the average life expectancy is 82.5 years (both men and women). However, if people die aged 78.5, this does not mean you have reduced life expectancy by 3 years.

The average life expectancy in Italy, at birth, is 82.5 years. However, once you reach 78.5, you can expect another eight or nine years of additional life. [You will have avoided car crashes, early cancer, suicide and suchlike which reduce the ‘average’ life expectancy of the entire population].

On the other hand, those who are dying of COVID have multiple medical conditions. On average they have three serious underlying problems such as: diabetes, COPD, heart disease, previous stroke, active cancer and suchlike.

Which means that these 78.5-year olds do not have a life expectancy of eight or nine years. It will be far less. How much less? This is virtually impossible to calculate. I am going to estimate a half – or 4.5 years (an average).

Which means that, in this model, my lower figure of years of life lost will be three years. My upper figure is nine years and my ‘most likely’ figure 4.5 years.

Average quality of life of those who die

Again, this is difficult to establish. However, studies have been done to work out the ’reported’ quality of life in those with multimorbidity. Perhaps the most accurate figure I could find with that elderly people with three underlying serious health problems have a quality of life of 0.8.3

Using different figures in the model

Having put figures to the likely range of the variables, we can look at the cost per QALY in various scenarios. I am only going to look at three. ‘Best case’ ‘Most likely’ and ‘Least benefit.’

Best case

I am going to start by inputting the figures that would provide the greatest possible gain in QALYs. This is 500,000 deaths prevented, and an average gain in life expectancy of nine years [This assumes all 500,000 lives will be ‘saved’ with the actions taken]. Quality of life is kept constant at 0.8.

The calculation is:

500,000 x 9 x 0.8 = 3,600,000 QALYs

Which gives a cost per QALY of £97,200 [£3,5Bn ÷ 3.6m]

Most likely

We can then run the ‘most likely’ scenario, which is 250,000 deaths prevented, with an average gain in life expectancy 4.5 years.

250,000 x 4.5 x 0.8 = 900.000 QALYs

Which gives a cost per QALY of £388,888 [£3.5Bn ÷ 900K]

Least benefit

Finally, we can tun the ‘least benefit’ scenario, which is 20,000 deaths prevented, with an average gain in life expectancy of 3 years.

20,000 x 3 x 0.8 = 48,000 QALYs

Which give a cost per QALY of £7,291,666 [£3.5Bn ÷ 48K]

As you can see, none of these models achieves a cost per QALY that would be approved by NICE.

Disability Adjusted Life Years

I fully recognise that looking at human life in from this purely economic perspective can seem harsh, almost inhumane. Can we really stand back and watch an elderly person ‘drown’ as their lungs fill up with fluid ‘Sorry, we are not spending money on more ventilators, because it is not cost-effective.’ Or suchlike.

However, there is also a health downside associated with our current approach. Many people are also going to suffer and die, because of the actions we are currently taking. On the BBC, a man with cancer was being interviewed. Due to the shutdown, his operation is being put back by several months – at least. Others with cancer will not be getting treatment. The level of worry and anxiety will be massive.

Hip replacements are also being postponed and other, hugely beneficial interventions are not being done. Those with heart disease and diabetes will not be treated. Elderly people, with no support, may simply die of starvation in their own homes. Jobs will be lost, companies are going bust, suicides will go up. Psychosocial stress will be immense.

In my role, working in Out of Hours, we are being asked to watch out for abuse in the home. Because we know that children will now be more at risk, trapped in their houses. Also, partners will suffer greater physical abuse, stuck in the home, unable to get out. Not much fun.

Which means that we are certainly not looking at a zero-sum game here, where every case of COVID prevented, or treated, is one less death. There is a health cost.

There is also the impact of economic damage, which can be immense. I studied what happened in Russia, following the breakup of the Soviet Union, and the economic and social chaos that ensued. There was a massive spike in premature deaths.

In men, life expectancy fell by almost seven years, over a two to three-year period. A seven-year loss of life expectancy in seventy million men, is forty-nine million QALYs worth. It is certainly a far greater health disaster than COVID can possibly create.4

In Lithuania, the impact of the break-up of the Soviet Union was also dramatic, and damaging. Below is a graph, looking purely at deaths from cardiovascular disease. As you can see, starting in 1989 (when the Berlin wall fell) there was an enormous spike, representing hundreds of thousands of premature deaths. These same spikes, in death and disease, were seen across most countries in the former Soviet Union. 5

These, the downsides, can be calculated, using the figure that is the opposite of the QALY, which is the DALY. The Disability Adjusted Life Year. Or, to put it another way, how much harm are you causing with your interventions? I am not doing this calculation here, because it would have about ten thousand variables and would take far too long.

Despite this, the message here is that severe damage to an economy does not simply affect bank balances, it can be deadly. If we look at the result of social deprivation in the UK, the effect is (potentially) immense

This was highlighted in a review by Michael Marmot, who studied two areas of Glasgow. Lenzie, which was rich, whilst the other area, Calton, was poor (socially deprived). The findings were stark:

…we can see this in Glasgow. When we published the report of the WHO Commission on Social Determinants of Health (CSDH) in 2008, I drew attention to stark inequalities in mortality between local areas of Glasgow: life expectancy of 54 for men in Calton, compared with 82 in Lenzie.’ 6

A twenty-eight-year difference in life expectancy between people living approximately five miles apart. The difference? Money.

This, I hope, puts into some perspective the discussion on cost per QALY. I framed it, to start with, as a discussion about money, but it is not really about money. Health does not exist in some bubble, sitting apart from the rest of society. Health and wealth are closely interrelated.

Which means that I fear that we are taking actions that could, in the longer term, if we are not very careful, result in significantly more deaths than we are trying to prevent.

Even if we restrict the analysis purely to the cost per QALY and narrow the ‘health’ analysis purely to COVID, and deaths from COVID, it remains difficult to justify spending £350 billion pounds to control a single disease.

I know that many people will violently disagree with this analysis and will think I am some cold-hearted fiend. ‘People are dying, we must do absolutely everything we can. No matter how much it costs.’ ‘What would you say if it was your mother…’ and suchlike.

Well, I have spoking to my mother, who is 92. Her view is that she has lived long enough. She thinks the Government actions are a ridiculous over-reaction. She is going out shopping and chatting to friends… she will take no advice on the matter.

So, what would I do if it was my mother that is dying? I will say that she made her choice, and who am I to argue with it.

1: https://www.imperial.ac.uk/news/196234/covid19-imperial-researchers-model-likely-impact/

2: https://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_20_marzo_eng.pdf

3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818872/

4: https://en.wikipedia.org/wiki/Health_in_Russia

5: https://www.bhf.org.uk/informationsupport/publications/statistics/european-cardiovascular-disease-statistics-2012

6: https://journals.sagepub.com/doi/full/10.1177/1403494817717433

COVID – 19 update

22nd March 2020

I thought I should do a quick update on COVID-19, as some interesting and important information has been published in Italy. Looking at deaths in various age groups, underlying conditions etc.

It can be seen here https://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_20_marzo_eng.pdf

Points of greatest importance

  • Far more men are dying than women, with a ratio of around 3:1 – reasons unknown
  • Mean age at death is 78.5 years (women slightly older than men)
  • 2% of those dying had no comorbidities (other diseases e.g. heart disease, diabetes, cancer)
  • ~50% had three or more comorbidities.

Symptoms

  • 1% were coughing up blood (haemoptysis)
  • 8% had diarrhoea
  • 40% had a cough
  • 73% had difficulty breathing (dyspnoea)
  • 76% had a fever.

[5.7% were admitted with no symptoms at all – not clear what they came in with. Presumably admitted with something else, then developed the symptoms later]

What did they die of?

96.5% died of acute respiratory distress syndrome.

‘Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. The fluid keeps your lungs from filling with enough air, which means less oxygen reaches your bloodstream. This deprives your organs of the oxygen they need to function.

ARDS typically occurs in people who are already critically ill or who have significant injuries. Severe shortness of breath — the main symptom of ARDS — usually develops within a few hours to a few days after the precipitating injury or infection.

Many people who develop ARDS don’t survive. The risk of death increases with age and severity of illness. Of the people who do survive ARDS, some recover completely while others experience lasting damage to their lungs.1

Treatment is with oxygen and ventilation but has a low success rate in the very elderly.

Deaths under 50 years of age

To date (March the 20th), 36 of 3200 (1.1%) COVID-19 positive patients under the age of 50 have died. In particular, 9 of these were younger than 40 years, 8 men and 1 woman (age range between 31 and 39 years). For 2 patients under the age of 40 years, no clinical information is available; the remaining 7 had serious pre-existing pathologies (cardiovascular, renal, psychiatric pathologies, diabetes, obesity).

There do not seem to have been any deaths below the age of thirty.

ACE-inhibitors and Angiotensin Receptor Blockers (ARBs)

There has been much debate as to whether or not ACE-inhibitors (angiotensin converting enzyme inhibitors) and ARBs may increase the risk of death [these drugs are widely used to lower blood pressure]. This is because COVID-19 appears to enter the body through ACE2 receptors – found in high concentrations in the lungs and can cause upset to the neurohormonal system where ACE, and ACE receptors, play an important role.

The data from Italy is that:

‘Before hospitalization, 36% of COVID-19 positive deceased patients followed ACE-inhibitor therapy and 16% angiotensin receptor blockers-ARBs therapy. This information can be underestimated because data on drug treatment before admission were not always described in the chart.’

That is 52% who were on one, or the other (it is very rare for anyone to be on both). That was clearly, as they state, an underestimate. Possibly a considerable underestimate.

Knowing this, it is important to know how many (elderly people) take either of these drugs, to see if there is a correlation between taking them and dying from COVID-19. The figures from Italy are not clear at all. However, the latest data on prevalence of high blood pressure in the adult Italian population was, around 52% (This is an absolute maximum).2

However, the number of people known to have had their high blood pressure recorded by their general practitioner is around 20% 3 . Which means that most people with high blood pressure are not treated with anything.

Bringing these figures together, it can be estimated that a maximum of 10% of the Italian population are taking antihypertensive medications. These figures may be a little out of date, and these data are not specifically for the age group of, around, 80 years of age. Here the figures on diagnosis of hypertension, and use of antihypertensives will probably be higher, possible double.

So, we can say that 10% of the adult population is treated for hypertension, and that this may be around 20% in those aged around 80. Taking the figures one step further, it is estimated that about 67% of those who take antihypertensive in Italy use ACE-inhibitors, or ARB. 4

Bringing all of these figures together, it is likely the average percentage of eighty-year olds taking an ACE, or ARB is

67% of 20% of 52%x 2 = 14.0%

Which means that amongst 80-year olds ~14% are taking one, or other, of these drugs.

I cannot say either of these figures in carved in stone and I believe 14% is probably a overestimate. I wish there were more fully accurate figures to be had. So, what does this mean?

It means that:

  • A (probable) maximum of 14% of the elderly population in Italy are taking ACE-inhibitors/ARBs
  • A minimum of 52% of people in Italy who are dying from COVID-19 are taking ACE-inhibitors/ARBs.

Which suggests you are four times as likely to die from COVID-19 if you are taking one of these drugs, prior to contracting the virus. This, of course, does not take into account confounding variables – many of which are currently unknown. By a confounder I mean that people taking these drugs may have more comorbidities, such as heart disease, diabetes etc.

However, it remains a very strong signal, and I do not think it can be ignored, particularly in the light of the knowledge that the COVID-19 virus has a significant impact on the ‘ACE system’.

On this basis I would strongly recommend that elderly people, with any comorbidity, who is taking an ACE-inhibitor/ARB should look to change their antihypertensive treatment to something else – whilst the threat from COVID-19 is high.

I should point out this runs contrary to the advice from the authors of a study in the European Heart Journal 20th March:

SARS-CoV2: should inhibitors of the renin–angiotensin system be withdrawn in patients with COVID-19?

‘In conclusion, based on currently available data and in view of the overwhelming evidence of mortality reduction in cardiovascular disease, ACE-I and ARB therapy should be maintained or initiated in patients with heart failure, hypertension, or myocardial infarction according to current guidelines as tolerated, irrespective of SARS-CoV2. Withdrawal of RAAS inhibition or preemptive switch to alternate drugs at this point seems not advisable, since it might even increase cardiovascular mortality in critically ill COVID-19 patients.’ https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa235/5810479

It should be borne in mind though, that their advice does acknowledge that they had no evidence about the number of people who were taking ACE-inhibitors, or ARBs, who then died. The data from Italy came out a day after the EHJ article was published.

Of course, no-one can be certain about what exactly is happening. I cannot be certain, but the signal from Italy on ACE-inhibitors and ARBs, seems very strong, and concerning. Based on it, I think my advice would be to change medication, if possible.

Stating this, I am aware that most GPs will not change anything, unless they get instruction from the acknowledged experts. Unfortunately, this is likely to take far more time than many people actually have.

1: https://www.mayoclinic.org/diseases-conditions/ards/symptoms-causes/syc-20355576

2: https://www.escardio.org/static_file/Escardio/Subspecialty/EACPR/Country%20of%20the%20month/Documents/italy-country-of-the-month-full-report.pdf

3: https://www.nature.com/articles/jhh200914

4: https://academic.oup.com/ajh/article/25/11/1182/115788

CORONAVIRUS [COVID-19]

18th March 2020

I thought I should say something about the coronavirus for readers of this blog. I need to state that the situation is fast moving, facts are changing, and I am not asking anyone to go against any current medical advice.

Here, I am simply providing advice that I believe, currently, may be of benefit to people out there. I am acutely aware that there is controversy swirling about, but I will not promote anything that can cause any significant harm – but may cause significant good.

I have tended to look back a few years in time for some evidence, because current, emerging evidence is subject to massive bias and controversy, with various vested interests getting involved. The ‘older’ evidence has not been done in a rush and is therefore more measured.

1: Anti-inflammatories (NSAIDs)

COVID-19 appears to impact the lungs more than any other organ and COVID-19 can be thought of as a ‘viral’ community acquired pneumonia. There has been evidence for several years that anti-inflammatory agents e.g. ibuprofen, naproxen (NSAIDs) may worsen community acquired pneumonia. As highlighted in this 2017 paper:

‘Non-steroidal Anti-inflammatory Drugs may Worsen the Course of Community-Acquired Pneumonia: A Cohort Study:

CONCLUSIONS:

Our findings suggest that NSAIDs, often taken by young and healthy patients, may worsen the course of CAP with delayed therapy and a higher rate of pleuropulmonary complications.’ 1

There is now anecdotal evidence, particularly from France, that patients who take NSAIDs do considerably worse. It has been suggested they may lead to an increased death rate.

ADVICE: Avoid NSAIDs if possible

2: Vitamin C

Vitamins always cause massive controversy, and the mainstream medical community tends to be highly critical of the use of vitamins. However, vitamin C has been found to have many, many, positive impacts on the immune system. It also protects the endothelium lining blood vessels – thus preventing/delaying passage of pathogens from the bloodstream.

I include the full abstract from the 2017 paper ‘Vitamin C and Immune Function.’ It contains a great deal of medical jargon, but I have highlighted the most important parts.

Vitamin C contributes to immune defense by supporting various cellular functions of both the innate and adaptive immune system. Vitamin C supports epithelial barrier function against pathogens and promotes the oxidant scavenging activity of the skin, thereby potentially protecting against environmental oxidative stress.

Vitamin C accumulates in phagocytic cells, such as neutrophils, and can enhance chemotaxis, phagocytosis, generation of reactive oxygen species, and ultimately microbial killing. It is also needed for apoptosis and clearance of the spent neutrophils from sites of infection by macrophages, thereby decreasing necrosis/NETosis and potential tissue damage.

The role of vitamin C in lymphocytes is less clear, but it has been shown to enhance differentiation and proliferation of B- and T-cells, likely due to its gene regulating effects. Vitamin C deficiency results in impaired immunity and higher susceptibility to infections. In turn, infections significantly impact on vitamin C levels due to enhanced inflammation and metabolic requirements.

Furthermore, supplementation with vitamin C appears to be able to both prevent and treat respiratory and systemic infections. Prophylactic prevention of infection requires dietary vitamin C intakes that provide at least adequate, if not saturating plasma levels (i.e., 100–200 mg/day), which optimize cell and tissue levels. In contrast, treatment of established infections requires significantly higher (gram) doses of the vitamin to compensate for the increased inflammatory response and metabolic demand.’ 2

In short, Vitamin C can help prevent respiratory infections. It can also help to treat established infections, although much higher doses are required. This seems to fit with emerging Chinese data which appears to be showing considerable success with high dose intravenous Vitamin C in treating coronavirus.

It is unlikely that anyone working in the medical system in the West will agree to using high dose Vitamin C as part of any management plan. However, if your loved one is extremely ill in hospital I would recommend speaking to the doctors and asking if this can be added.

Whilst it is possible that vitamin C may prove ineffective, it also does no harm. Those who are currently attacking the use of Vitamin C and attacking those who believe vitamin C may be beneficial are, I believe, mainly concerned with their personal reputations.

ADVICE: Take at least 2g of Vitamin daily C to ‘prevent’ infection, probably more like 5g. Increase the dose to at least 10g if you are suffering symptoms.

3: ACE-inhibitors/ARBs

COVID-19 appears to enter the body using the ACE2 receptor (found on the surface of many cells, particularly in the lungs. Also found in high concentrations in the heart and kidneys.

Because of its affinity to ACE2 receptors (and the more widespread Renin Aldosterone Angiotensin System or “RAAS”) COVID-19 is causing upset with the whole system – in complex ways. The system itself is complex.

To remind those of a more technical bent, here is the system:

 

I wished to make it clear that if COVID-19 impact on the RAAS system, trying to work out the resultant abnormalities, is not easy.

There are two main drugs that are designed to lower blood pressure by ‘interfering’ with the RAAS system. ACE-inhibitors (angiotensin converting enzyme inhibitors), and ARBs (angiotensin II receptor blockers). They are very widely prescribed.

Some people have suggested that these drugs should be stopped. Others have suggested that they should be continued. You may be able to see why the advice is contradictory, given all the possible interactions.

However, it does seem the COVID-19 creates hypokalaemia (a low blood potassium level). A rising potassium level indicates recovery from the virus. This is probably due to interference with the hormone Aldosterone due to degradation of many ACE-receptors in the body.

ADVICE – currently not enough information to provide any advice on ACE-inhibitors and ARBs. However, increased consumption of potassium, if symptomatic, can be advised. Dose?

People who eat large amounts of fruits and vegetables tend to have a high potassium intake of approximately 8000 to 11,000 mg/d,’ 3

So, up to Ig a day appears perfectly safe, and if more is being lost through the kidneys with COVD-19, there appears to be little danger of overdosage.

4: Chloroquine and Hydroxychloroquine

These drugs normally used to treat/prevent malaria (and are also used to treat various ‘immune’ disease). However, they have been found to be effective in treating other viruses and seem to have been highly effective against COVID-19 4. These drugs will only be available as part of medical management. They cannot be bought over the counter (in any country, as far as I know).

If you, or a loved one, is seriously ill, I would urge you to ask for – one or the other – to be used. Hydroxychloroquine has fewer side effects (drug related adverse effects)

ADVICE – Ask for one of these drugs if you, or a loved one, is seriously ill with COVID-19.

5: Vitamin D

This one is simple. Vitamin D has important effects on the immune system 5. A low vitamin D level in the winter is almost certainly why flu epidemics occur in the winter months. [Vitamin D is synthesized in the sun by the action of sunlight].

ADVICE – take at least 2000iu vitamin (preferably D3) daily.

I hope some people have found this useful. If anything I have written here proves to be wrong, or dangerous, I will change it. However, I am working on the basis here of ‘first, do no harm.’ The worse thing that any of this advice can do, I believe, is to NOT work.

1: https://www.ncbi.nlm.nih.gov/pubmed/28005149

2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5707683/

3: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485434

4: https://www.connexionfrance.com/French-news/French-researcher-in-Marseille-posts-successful-Covid-19-coronavirus-drug-trial-results

5: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3756814/