COVID 19 and Sickle Cell Disease: What you need to know.

A brief summary of the COVID 19:

From what is known the virus belongs to the class of Coronaviruses, a large family notorious for respiratory tract infections.  Notably the Middle East Respiratory Syndrome (MERS virus) and the Severe Acute Respiratory Syndrome (SARS) virus belong to this class. COVID 19 is a novel type discovered sometime in December and is responsible for the current outbreak.

How is the virus spread?

First it is zoonotic. This means animal to human contact and human to human is possible.  It was initially thought to have passed on from infected animals to humans.

The main mode of spread that has actually resulted in the current worldwide pandemic is human to human. Infected person spread the virus via droplets released through coughing, sneezing or any other aerosol generating act.

There are arguments as to whether it is airborne or not. When droplets are released, they don’t remain in the atmosphere they settle on surfaces. How long they remain in the atmosphere though short might still pose a risk of infection be it minutes to hours. When the droplets settle on surfaces, clothes etc, if an uninfected person comes in contact with them by way of hands and these hands without being sanitizer or washed get to the eyes, nose, month portals of entry, that individual becomes infected. So, mainly contact with an infected droplet. But I would like to think there’s some airborne risk. People can also breathe in the droplets if in very close proximity to infected person.

What’s the incubation period?

This is the time it takes from picking up the infection to showing the first symptoms. It’s roughly 2 to 14 days. The average time symptoms appear is about day 5

What are the symptoms?

While presentation might vary from person to person, fever (38 and above) and dry cough (Dry cough means cough that does not produce phlegm) have been the most consistent. Other reports have been

  • Muscle aches
  • Tiredness
  • Headache
  • Diarrhea, nausea, vomiting
  • In some instances, flu like symptoms of sore throat, catarrh
  • Red eyes
  • Pneumonia and shortness of breath

More importantly, some people may not show any symptoms but may be carriers of the virus. This has been one main source of spreading. Because these individuals do not feel sick, they might not bother to adhere to instructions given: hand washing, social distancing and isolation. They are a very good source of spreading the virus

While most people recover, around 15% will develop more serious symptoms of pneumonia. Pneumonia occurs when the virus progresses down the airway and overwhelms the body’s immunity causing inflammation of the lungs. This means swelling and soaking up fluid.

When this happens, the lungs don’t perform gaseous exchange properly and are unable to expand because of the fluid. The individual becomes hypoxic (deprived of oxygen) and needs ventilatory support either by way of high flow oxygen through masks or intubation in the worst-case scenario.

The multi-organ failure

Statistics show that 1 out of 6 anyone those who develop critical illness develop multi-organ failure including:

  • Respiratory failure
  • Renal failure
  • Heart failure
  • Shock
  • General systemic compromise leading to death

This multiorgan failure is the most feared complication as it accounts for most deaths recorded. There are a number of theories trying to account for what actually causes the organ failure. Some say that it appears to be as a result of something called a cytokine storm. When the body responds to a virus or bacteria, the immunity releases mediators called cytokines. The amount of cytokines released if in excess can actually damage vital organs. So, people conclude that having an over whelming immunes response might be just as bad as having a low immunity to combat the virus

Another explanation is the development of something called DIC (Disseminated Intravascular Coagulation). This happens when the infection causes instability in the vascular system. DIC predisposes to formation of emboli (clots) which block the airway.

What puts people at risk of serious illness from the virus?

This is the main reason for today’s discussion.

WHO has outlined individuals with preexisting medical conditions as vulnerable as listed below:

  • Cardiovascular diseases
  • Diabetes
  • Long term respiratory diseases like severe asthma, lung diseases like COPD and emphysema, lung Fibrosis et al
  • Hypertension
  • Those with cancers

The common issue with these conditions is impaired immunity over a long time and for the lung diseases impaired ling function.

However, other healthcare systems like the NHS UK have expanded this list to include:

  • Organ transplant recipients
  • Rare diseases, inborn errors of metabolism, and homozygous sickle cell diseases 
  • People on any form of immunotherapy or immunity suppressing medication
  • Pregnant women

Extremes of age such as the very young or the very old does not strictly make one vulnerable. The mortality in children is very low with 0 to 9 yrs having no fatalities and we have recorded elderly people recovering completely from the disease. The more coexisting medical issues the more the vulnerability and this is more likely to be observed in elderly.

Why sickle cell diseases? What causes increase vulnerability?

Back to our knowledge of sickle cell there are a few things that make the immune system sub optimal.

1. Asplenia occurs early on life. The spleen is an organ of immunity. The average adult with sickle cell disease does not have an immunologically functional spleen.

2. Anemia results in malnutrition at cellular level. Due to the low HB level, cells are not optimally nourished. Malnutrition greatly correlates to immunosuppression.

3. Folate and B12 deficiency commonly seen contributes to anemia.

4. In some with sickle cell disease patients, lung scarring from repeated crises might have occurred by adulthood. Coupled with anemia, the lung function is impaired already. An infection like COVID 19 in such a scenario would be disastrous as such individual will likely progress to develop respiratory failure.

So, in today’s pandemic PLWSCD are classes amongst the extremely vulnerable

What can be done?

The measure to reduce spread and hence contact has been outlined as follows;

1. Self isolation first: Today has proven to be a most effective step. By staying home, PLWSCD can stay safe and increase chance of not getting infected.

For people who stay in crowded homes where others still go about daily activities outside minimize socializing and staying in groups. Avoid the crowd as much as possible

2. Where self isolation is not possible and you have to go out: Social distancing which is keeping a distance of at least 2 meters (6ft) from the next person should be cautiously done

3. Regular hand washing with soap for not less than 20 seconds or regular use of alcohol-based hand sanitizer with more than 62% or more alcohol content at least

4. Facemask: Although not recommended, but if you have to be in a crowd or if you have someone with respiratory symptoms in close proximity, use.

Ideally use an FFP 3 type or N95

Sorry to say but the regular facemask or clot facemask may not provide total protection but any level of protection has been advised as important. 

Remember, you are better off isolating.

5. Nutrition: Unfortunately, the nutrition that builds up immunity is not achieved in days. It is gotten over time. 

Many people misinterpret the role of multivitamins. This is not bad but don’t count on it as a total life saver. You are better off in self isolation and avoiding contact. However, if you must have multivitamins consider regular hematinics to optimize blood levels and vitamins C, D and E supplements

Eat healthy, now and always

6. Immune boosters: Many people taking immune boosters as well. While it is not a bad idea, still don’t count on it for 100 percent protection.

Immunity is built over time and with exposure to pathogens. The body will not develop specialized immunity to a novel bug by you taking an immune booster. 

That’s why we give vaccines. A vaccine sensitizes the body to a bug and creates a memory in the defense cells, so that when the actual infection comes, the body knows how to respond.

Immune booster does not have this property. You are better off staying at home and avoiding contact

How is COVID 19 treated?

As of now there is no specific drug. As of now there is no vaccine.

Treatment is symptomatic:

  • Anti fever drugs
  • Analgesia
  • Lots of hydration
  • Lots of rest

Most viral infection runs a course. COVID runs for about 2 weeks following which the individual might completely recover. If there is further deterioration then hospital admission should be sought.

In some advanced countries trials of different medications are being used:

  • Interferon
  • Antivirals
  • Chloroquine and Azithromycin
  • Steroids
  • Others have developed successful herbal formulations to combat the virus

How to stay optimally healthy in self isolation?

  • Hydration is key
  • Eat healthy. Stock up food and fruits
  • Mental exercise (read a book, learn something new)
  • Entertainments (watch a movie; connect with friends on social media)
  • Keep up with antimalarial and other regular meds
  • If you have hospital appointment scheduled, call your doctor first before taking the next step
  • By all means avoid a crisis this period
  • Have friends/family who are aware of you and who can help

What is the Protocol in Nigeria if you suspect you have symptoms of COVID 19?

If you have symptoms without being from a high-risk area you can call your doctor whilst in self isolation. If you have recently traveled in, call the NCDC hotline. The state rep will contact and keep in touch with you.

WhatsApp Discussion on held on 29th March 2020

Facilitator: Dr J O Agbi

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