Dear Bellingen Shire
6 October 2020
Well, not much happened so I was able to take a break from thinking about Covid19 last week. When you’re swimming a long marathon sometimes you just need to get your head above water, breathe, and look around.
In the meantime we have done very well, and there was not much exciting to report. Hasn’t that changed in the last few days?!
So, first priority = current status. You no doubt know that there have been no cases of community transmission of Covid19 in NSW for many days. That makes >160 days of no cases for the Mid North Coast Local Health District, with only 2 residents in NSW in ICU but neither still on ventilators. Best wishes to them and their families.
It feels very safe. The risk of getting an infection here now is very low and I feel very relaxed about it. Yes, it is school holidays, and the long weekend, and lots of people visiting because this is a nice area to visit, and they can’t go anywhere out of the state anyway, … but the risk is still very low.
So can we feel it’s over? Absolutely not. There is still a firestorm across the water. I feel terrible for the Aussies still trying to get home – trapped overseas in an uncertain world, and wrestling with a less than transparent/capricious border control system, as well as “rich people only” airfares. As we pointed out 6 months ago, we’re on a long haul for 1-2 years, even though it feels so distant in this little bubble of paradise.
In response to the lower risk/lower demand, and the now rarity of people having respiratory symptoms (because people have been social distancing, washing their hands), we daily adjust the times of our local covid19 clinic. Please remember the Doctors and Nurses are doing this on top of our normal work so we need to make the best of the time. We are still very happy that this little offsite clinic has meant our pharmacies, hospitals, and General Practices have been able to go on without any closures or suspicions of infection, or worse – suspicion of people walking through the doors.
We are currently opening from 1.30 pm to 2, Weekdays. Of course if something happens we will quickly expand it again – We are all now so agile!! There are still clinics at Coffs Hospital and the old Macksville Hospital site.
Speaking of Agile, there was an article in this month’s Medical Journal of Australia that uses some Metadata to show that soon after the news broke on Covid19, all around the world, people rapidly restricted their movements by 50% or more. This occurred BEFORE governments moved to lockdowns or restrictions. Especially in Hong Kong and Singapore. Remember these 2 spots had past experience with Covid1 – or SARS. It seems to show that whole populations (when honestly informed) can actually work this stuff out and be agile in their lives. Once again emphasising the necessity of open, consistent, and honest information on matters of national importance.
I hope some politicians are shown this report
Other items of interest in Journals and medical mags/opinions include inquiries into why some countries do so incredibly badly while neighbours did so well, especially in Europe. It is not just a product of the different government responses.
There apparently is a wedge of countries in Central Europe who have been spared – if you count deaths per million population. For example little Slovakia has had only 7/million vs Belgium losing 856/Million! This is more than just divergent governments, or even different societies. Those who have been to Europe know these countries are not that far apart. Watch this space.
We are still awaiting results of research trying to clarify what markers are reliable when we get to the stage of assessing immunity – either from actual infection or from a vaccine. This is proving elusive, as apparently coronavirus markers left on your immune system are notoriously unreliable. It is why the rapid action tests still turn out to be not useful – only about 50% accurate – and why we are still discouraged from testing antibodies to see if someone has had the virus in the past. Next year we may have some better results.
Next year we will also have some phase 3 vaccine trials reporting. Everyone will want to know which vaccine actually works in the real world. There are now apparently >200 candidates, and 7 currently in phase 3 trials. Hopefully at least 1 or 3 of the 200 will actually work.
Interesting, there is a proposal in Australia to set up citizen juries to decide how such a vaccination program will role out – so that it is not at the whim of pollies, or bureaucrats or doctors.
But all the above is a bit of more of the same. So what got exciting? “POTUS.”
While he is not your or my President, the US leader has a huge impact on our national progress. All of my sentient life we have followed so many aspects of American culture by a few years, and now even shorter. This obviously has good and bad aspects. What happens in the US very much affects what happens here.
So what does this very high profile infection mean? The news is awash with hot discussion about what if Mr Trump dies? And then we have pictures tonight of him jumping out into the motorcade and encouraging fans, while supposedly in quarantine and under treatment.
Now I am being careful not to make any partisan opinions in this space. The role is very, very important and the potential ill health of such a powerful leader is very distressing for all. Historically, sudden demise of powerful leaders in many countries has had huge destabilising – sometimes violent – consequences.
However it should be remembered that while folk over 70 have a much higher mortality risk with Covid 19 than for influenza, or than younger folk, for an individual non smoker without diabetes the likelihood of surviving is still very good, i.e. ->90 – 95% when you have good health care and support. And a national leader will certainly get the best health care.
The problem has been that in the pandemic situation the best care gets sucked up and exhausted quickly, then for the rest it is all “nature takes its course”. No world leaders will be in the same pandemic as their subjects!
This illness may help Mr Trump learn more empathy with his people and create a new policy program for health care, including removing the political filter shackles from the US Center for Disease Control whose impartial scientific information we as doctors, all around the world, have relied upon and contributed to for decades. Or it may be that he recovers superbly and is reinforced in his resolve to push on as he has done. Ultimately it is still early days, and there is still the famous 8-day point where a seemingly mild illness suddenly goes bezerk. I just wished the seven doctors who have been giving press conferences, in staged military formation, could just be simple and straightforward in their reports. And answers. Anyway the constitutional crisis being feared is for our allies, the Americans, to sort out themselves.
One interesting aspect of this famous illness is the cocktail of drugs that was mentioned being administered by the most advanced doctors in the world– zinc, Vitamin D, Melatonin! Sound familiar?
To this was added a single dose of a “polyclonal antibody “ from the company Regeneron, and Remdesivir. It is bold and big of such a high profile patient to take an experimental treatment. Don’t you wish you had shares in Regeneron?
While these are experimental, we will all be talking polyclonal antibodies as if we know what those words mean, so I thought I would drop a few bits to even the ground for those who haven’t done a bio molecular science degree lately.
“Poly” = many. Clonal = identical copies of original . Anti = against. Bodies = a something.
Medical students in the middle of their degrees suddenly get sick with everything, or at least paranoid about it. Especially after studying microbiology. Everything wants to rot and eat you!! But then one studies the immune system and its many, many layers of elegant troops and weaponry developed, learned, prepared and ready to dispatch instantly, or very quickly, against new or old microbial invaders. Some immune weapons are like sea mines -just floating around in your blood and exploding on unfamiliar objects. But the real cool stuff is Antibodies. These are protein chemicals produced by certain cells that are uniquely shaped to key into a specific component of a perceived invader. The antibody may gum up and disable a critical part of the germ target – I understand this is what one of the Regeneron antibodies is doing to the Spike protein in the corona of the coronavirus invader. Or it will tag the invader, stimulating and attracting lots of other immune cells to the task, to release their unique weapons.
Certain groups of your white blood cells, once familiarised with their particular invader, then clone themselves and produce millions of copies of that antibody as well as a residual rapid response population, in case you ever meet it again. This evolves from when you are first born – like a whole of life machine learning. And you never even know it’s happening most of the time. This is also what vaccination tries to stimulate – for the future so that you don’t have to get the life threatening disease and then see if you survive it.
One wonders that if we could just manage the immune system better, we could have far more effective treatments, for everything. Most of our medicines are still relatively blunt objects. So many bits of your body chemistry are used over and over in every cell for different roles – from your toes to your eyes. Same chemistry but different milieu – gives a very different outcome. So when we change that chemistry with a drug to achieve a hopefully beneficial effect on an organ, hence more or less side effects.
Attempts to manipulate the immune response have been very difficult and fraught, so an alternative has been to outsource the job. We have been using mixed antibodies taken from plasma at the blood bank – effectively a random mix – on the basis that in that mix there is a high likelihood someone has made those antibodies to your specific disease before, be it infection or autoimmune disease. Intravenous immunoglobulin is still a blind shot when nothing else worked.
Now we are in a whole wave of monoclonal antibody treatments – super targeted actual antibodies for one specific purpose. The antibodies are produced from living cells – yeasts, mice, bacteria cultures, organisms that have been bred or altered to produce just that specific complex protein, and lots of it. It is then purified and used. This technology has brought us great, much safer, treatments for some cancers, or previously untreatable asthma, terrible dermatitis, crippling inflammatory disease, some infections.
Combine a few of these targeted antibodies and you have a polyclonal antibody, which hopefully will be even more effective. Great idea. We will see. Unfortunately for most of us mono- or polyclonal antibodies are incredibly expensive. The cost is something in the order of hundreds or thousands of times the price (per weight) of gold or platinum!!
In Australia, for such medication, doctors need special rights and approval to prescribe such medications because, lucky for us, we have the PBS, which pays for most of your medications – with certain conditions.
Stay safe and alert, enjoy spring, look after our visitors, and remember all this is a personal perspective. Check with your own GP.
Dr Trevor Cheney