News

Coronavirus: Myths, open questions and overhyped treatments


Doug Hendrie


21/04/2020 4:32:55 PM

GP Dr Magdalena Simonis sifts through the sea of information on the coronavirus and separates facts from fiction. 
 

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Sorting truth from untruth is important during the pandemic.

 As the global coronavirus crisis deepens, misinformation, exaggerated breakthroughs and over-hyped ‘cures’ are circulating widely.
 
For GP and medical educator Dr Magdalena Simonis, it’s not an abstraction. Her patients bring in all kinds of theories and anxieties picked up on social media.
 
‘There are all sorts of peculiar things circulating, coming in from dribs and drabs from various patients,’ she told newsGP.
 
She’s not alone.
 
RACGP President Dr Harry Nespolon has been taking on pseudoscience, antivaxxers and ‘cures’, by calling on Australians to be sceptical of what they read on social media.
 
Meanwhile, Chair of the RACGP Expert Committee – Quality Care (REC–QC) Professor Mark Morgan told newsGP that it is hard to identify all of the ‘quack remedies and myths that are circulating through social media’.
 
Dr Simonis has gone through some of the most common myths, open questions, and overhyped treatments to sift the truth from falsehood – or to say that we simply don’t know enough yet one way or another.
 
MYTHS
Myth: 5G mobile phone networks spread the virus by affecting human immune systems
 
GP response: This one is really important.
 
The World Health Organization has addressed it because it is so widespread. This myth is propaganda about the potential radiation emitted by these phone towers.
 
The difference between 5G and previous generations of mobile services (4G, 3G) is that the earlier generations use lower radio frequencies (in the range of 6 gigahertz), while 5G uses frequencies in the range of 30–300 gigahertz, which gives the increased speed of communication.
 
In the range of ​​30–300 gigahertz, there is not enough energy to break chemical bonds, or impact the human immune system. This technology, 5G, has been approved by the Australian Government’s Radiation Protection and Nuclear Safety Service, which is on record as stating that 5G does not have the negative health effects of more intense radiation.
 
The very widespread fear that has circulated has resulted in the vandalism of telecommunications systems at a time when we really need access to the internet to work from home. That vandalism can interfere with our ability to manage this pandemic in this difficult time.
 
Myth: The coronavirus is an escaped bioweapon, not a naturally occurring virus
 
GP response: Pandemics will always occur. Coronavirus epidemics have occurred three times in the past twenty years: in 2003, with severe acute respiratory syndrome (SARS); in 2012, Middle East respiratory syndrome (MERS-CoV); and now COVID-19.
 
The SARS-CoV-2 strain that causes COVID-19 that has now been identified and spread in humans is the seventh coronavirus able to infect humans and the third able to cause serious disease, following the viruses that cause SARS and MERS.
 
What we need to understand is that when a disease develops in a human population it usually has more to do with our behaviour on the planet than deliberate engineering.
 
Viruses such as the COVID-19 strain we are seeing have existed in animals such as pangolins and bats for generations. Whenever humans come into close contact with animals, either through destroying wild habitats to expand our farming, or hunting for bushmeat, the risk of transmission to humans is increased.
 
Very often, these viruses are novel to humans and therefore deadlier, as we have no immune memory that can mount an appropriate response to them.
 
The tendency to accuse other nations for these diseases, I believe, results from a human tendency to externalise whatever threats arise. This is often politicised and becomes counterproductive to the international collaboration required to finding the solutions urgently needed for this pandemic.
 
Myth: People needing healthcare should stay at home to avoid overloading the health system or contacting the virus in a clinic or hospital
 
GP response: This is a major concern under discussion in all medical circles as the disruption caused by the coronavirus is leading to widespread difficulties, such as caring for cancer patients, and screening for cancer, or even ensuring people with cardiac conditions seek emergency care.
 
Elective screening procedures such as breast screening and colonoscopies have been ceased temporarily, and follow up of abnormal screening results is also being delayed.
 
The regular cancer screening programs will be under enormous strain when this all ends, which means it’s important for GPs to have systems to track their patients to ensure they attend their follow-up appointments, especially where there has been a positive result. Recall systems needs to be put in place to prevent patients from missing key follow up appointments.
 
Another very important issue that of glycaemic control for people with diabetes. Older, diabetic people with poor glycaemic control who contract the virus are more at risk of being overwhelmed by the infection and dying, with a 7% risk of death according to the Centers for Disease Control and Prevention. The mechanisms considered to be the catalyst for this are related to the elevated blood sugars, which can render the immune system weaker or encourage replication of the virus, or both.
 
In short, seeing the doctor for chronic disease management is very important, even during a pandemic.
 
Some patients have interpreted the recommendation to stay home to mean that their chronic conditions don’t need care or aren’t a high priority and that monitoring with testing can wait. This is potentially risky, as good chronic disease control might make the difference between overcoming infection or becoming overwhelmed by it.
 
Patients with chronic disease should be attending for pathology tests and health monitoring, and encouraged to access their results by telehealth.
 
Some people are anxious attending their doctor because they think they can contract the virus from walking in open spaces in public to get to the clinic. Some people are fearful of leaving the house, while others fear that a clinic waiting room is high risk.
 
However, given the systems now in place, which include triage online and by phone to separate out patients who may have had contact with coronavirus patients, or who have had recent travel, upper respiratory tract infections or fever, the likelihood of being in a room with a subclinical carrier is an incredibly low risk.
 
Patients should be reminded that healthcare can now be provided over the phone, which can provide comfort for those needing to remain in touch with their doctor but anxious about attending. Telehealth is a timely innovation which GPs can use to prevent patients from falling behind in their care.
 
OPEN QUESTIONS
 
Are people on ACE inhibitors and ARBS more at risk?
 
GP response: Two cell proteases, namely Angiotensin Converting Enzyme (ACE) and ACE-2, are important in maintaining blood pressure homeostasis through regulating the renin-angiotensin system (RAS).
 
Currently, research is being undertaken to explore the relationship between ACE and ACE-2 receptors in humans and COVID-19 infection. The SARS-CoV-2 virus has been found in lung, kidney, and the gastrointestinal tract tissue, all of which possess ACE-2 receptors. These findings have fuelled negative associations between ACE inhibitors and COVID-19 infection.
 
The question, as always, is causation. Older, hypertensive patients appear to be more at risk of developing overwhelming respiratory distress syndrome and as ACE inhibitors are one of the first line treatments for hypertension, these were initially considered to be a potentiating factor.
 
However, the pathogenesis of severe disease is still poorly understood and it may well be that these same medications might even play a protective role. Until controlled studies are conducted, it is important to recommend that patients remain on their medication and maintain good blood pressure control.
 
So there are questions around medications people are already on and medications being trialled for treatment. To add to that, we have the concept of the ‘inflammatory storm’, which occurs in some patients, and can affect the myocardium.
 
As a result, long term cardiac complications are expected in some patients even after recovery. Research is being conducted in a number of countries, monitoring these outcomes.
 
I’ve had patients ask if they should take themselves off their medications because they’re really scared. Being aware of these potential sequelae is important for GPs in order to address these questions, such as the ongoing need to take blood pressure and diabetes medication, front on.
 
At present, there is no convincing evidence that ACE inhibitors pose an increased danger for patients.
 
Experts have rightly warned against abruptly stopping them and as GPs, we can be confident that good chronic disease management should continue without the added complication of ceasing effective medications. If patients are concerned, they should be encouraged to express these fears and consult with their GP.
 
Should patients avoid ibuprofen?
 
GP response: The World Health Organization (WHO) had to withdraw the initial statement it made suggesting people should avoid ibuprofen. Given the exposure that claim had, it’s unfortunate.
 
The WHO’s new guidance is that it doesn’t think it’s a risk factor, but that people should take paracetamol for fever just in case.
 
What we do know broadly is that some nonsteroidals such as ibuprofen can exacerbate asthma, and as a result, asthma-prone patients are advised to take paracetamol as a precaution during a febrile illness.
 
The aetiology of the cytokine ‘inflammatory storm’ has been suggested in COVID-19 but is unclear. What we don’t know is why some immune systems overreact to the COVID-19 infection.
 
Some theorise it is due to virulent mutant strains, while others suggest it is due to an individual immune system reacting overwhelmingly to a virus it finds unfamiliar. The evidence as yet is unclear and it could be a combination of both.
 
At present, we can’t discern who will be overwhelmingly affected by this, which is why it has been so necessary to practise physical distancing and to flatten the curve. 
 
Are smokers more at risk?
 
GP response: Yes. There’s not enough said about this.
 
When we think of what has happened in Italy (where 25% of the population smoke), China (27.7%), Spain (29.2%), and France (27.7%), very little reference has been made to the large proportion of smokers in those countries and the likelihood that the virus is more lethal in those with compromised respiratory function.
 
Younger people are far more commonly smokers in those countries than in Australia. For example, in Italy, men between 25 and 44 have the highest rate of smoking, at 36%. By contrast, the Australian rate is 14.7%.
 
This may provide a good opportunity for GPs to help concerned smokers to reduce or quit their habit to boost lung function.
 
What about asthma?
 
GP response: A predisposing underlying lung condition increases the risk of poor outcomes as seen in those with chronic obstructive pulmonary disease (COPD). The COPD may be as a result of smoking, years of uncontrolled asthma or exposure to irritant inhalants. So far, asthma has not been identified as a predisposing risk to infection.
 
Despite that, it makes good sense to advise asthma patients to increase their preventive inhaler if they develop any upper respiratory tract infection, rather than wait for their symptoms to deteriorate. The tendency for viruses to trigger worsening symptoms of asthma, has been well established.
 
OVERHYPED TREATMENTS
 
Claim: Hydroxychloroquine is a wonder drug that can ‘cure’ the disease
 
GP response: During a pandemic, we try different things, in different contexts. Hydroxychloroquine is one of those, and it has been tested in conjunction with an antibiotic, azithromycin.
 
Chloroquine is a widely-used anti-malarial which also has immune-modulating activity and has recently been reported as a potential broad-spectrum antiviral drug (see for instance Savarino, Trani, Donatelli et al 2006 and Yan et al 2013).
 
In a small French trial during this pandemic, the use of chloroquine appeared to be associated with a reduction in viral load and in some cases, complete disappearance of the virus, with its effect reinforced by azithromycin. This trial has been questioned over its methods, however.
 
So far, the studies revealing these optimistic outcomes are small (28 patients in the French trial), and the recommendation from academics internationally is to wait for more evidence before accepting it as a treatment.
 
We know hydroxychloroquine may have some positive benefits during the development of the disease, but it has also significant toxicities which can affect people, ranging from renal failure to fitting and even death, so we need to wait and see whether it does in fact have a positive effect.
 
At present, this treatment is not evidence based and should not be used outside of a clinical trial setting, so that we can validate its effectiveness – or prove otherwise – and mitigate any harms.
 
What about remdesivir, another much-touted drug?
 
GP response: 
Remdesivir is an antiviral drug with a safety track record in humans, and it has also been found to be highly effective in the control of COVID-19 infection in vitro.
 
Since this compound has been used in human patients and shown to be effective in small studies, it is being assessed in human patients suffering from the novel coronavirus disease. At present, however, using this drug to treat COVID-19 is not evidence-based as trials are under way in clinical settings.
 
The hope of finding drugs that can assist in the care of infected patients should not deflect us from upholding the standards of scientific rigour.
 
The RACGP has more information on coronavirus available on its website.
 
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Dr Bryan Sean Connor   22/04/2020 8:22:32 AM

All true and very useful but I am concerned that as a profession we are not addressing the issues around excessive social isolation and loss of jobs and purpose. There is always a balance in life and the effects on long term mental health are likely to adversely affect morbidity and mortality in thousands more people than the 100 odd severe cases and deaths so far.


Dr Debbie McKay   22/04/2020 8:35:50 AM

Thank you for this sensible, solid article.


Dr Horst Paul Herb   22/04/2020 12:10:28 PM

Speaking of myths, bad science, misinformation etc. - it is not just the usual "nutters" creating confusion, but sadly our mainstream agencies as well.

1) pretending we know incidence in the population and basing modelling on fictive numbers. Since we have not done any random cohort / representative community testing, we have absolutely no idea of incidence, hence cannot calculate any CFR because we do not have a denominator.

2) failing to update modelling when new evidence arises (eg CFR and incidence estimates after community testing in Iceland, Germany, and Santa Clara County in California) - we no know the threat was overestimated by about 2 orders of magnitude, and yet we continue basing decisions on the overestimates

3) failing to mention studies that don't align with ideology / politics. When it comes to Hydroxychloroquine, why do we even mention Raoult's study with Azithromycin and HCQ when we have proper randomized one (http://dx.doi.org/10.1101/2020.03.22.20040758)


Dr Paul Vincent Mackey   22/04/2020 2:55:12 PM

Re the potential concern re ARBs: this hopefully provides some reassurance. https://www.ahajournals.org/doi/10.1161/circresaha.120.317134


Dr Oresti Mellios   28/04/2020 11:22:52 AM

Interesting in today's news that the French have noted smokers are 80% less likely to get CoVid-19 and are commencing studies to see if transdermal nicotine protects people. They do have large numbers to work from but I suspect they may be on the wrong track...likely the tar film over the lung tissue that is the protective effect rather
than nicotine itself but we shall wait and see. Looks like a dead end to me.