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A Nurse Practitioner's Take on COVID-19

Video Transcript

Thank you everybody for joining! I'm Chelsea, I'm a family Nurse Practitioner at Voda Integrative Medical Clinic here in Newberg, OR. I have a primary care practice where I utilize functional medicine. Prior to being an NP, I was a critical care RN, more specifically I worked in the cardiovascular ICU.


I wanted to put this free webinar together for the community, just to educate you all and help you start thinking critically. There is a lot of information out there and a lot of things that are exaggerated or distorted by the media. In no way am I claiming to be a leading expert, or leading epidemiologist; I really just wanted to put a spin on it from a NP's perspective.

I do want to say, as soon as I post this information it will be out of date. This is how rapid all of this is changing. This is also not medical advise. I am not your medical provider, or maybe I am, but if so, for individual concerns you will need to call your primary care provider, schedule an appointment, and address that with them. This is just a general overview of some claims that have been made and a look at the research.

Some housekeeping rules: if there are any negative comments, or just mean things, they are going to be deleted immediately. This crisis is something that I think can change our American culture for the good. I think we're really at a tipping point, where we have been so divided, and I'm hopeful that a lot of good is going come out of this, we're going to start coming together.


I also just want to say, the media has turned this healthcare crisis into a political platform and it's not about that anymore. So, remember that when you are reading articles or are watching news. The media does well by increasing ratings, how do you increase ratings? You post things that create fear, opposition, and generate controversy. So, try to take these perspectives away. Try to go to knowledgeable resources when you are looking up information; this could be: the CDC, the World Health Organization, other countries, or even leading institutes like John Hopkins...

With that being said, I encourage you to still use discernment even when getting information here. Because we don't know a lot about this virus and we as clinicians are still learning.


So Coronavirus. What is it, how did it start?

Corona viruses are a large group of viruses that cause mild to severe respiratory illnesses. There are hundreds of corona viruses, most of which are circulating around animals like pigs, camels, cats or bats. It's very rare that these viruses will jump from species to species, but this is what we believe has happened with this current virus.


Regarding nomenclature, I'm sure you've heard it! Names such as SARS, Coronavirus, COVID-19, what do we call it? We just talked about how corona viruses are a large group, it's a family of viruses.

  • SARS-COV-2 is the name of the virus that is actually causing COVID-19

  • SARS stands for severe acute respiratory syndrome

  • COVID-19 is the disease itself, it's that set of illness symptoms that are creating a disease. So COVID-19 stands for Corona Virus Disease, and 2019 is when this all started.

For the sake of this video I'm going to try to refer to it as COVID-19. As you all already know, we believe this started in the markets of Wuhan city, China in November to December 2019.


So who's at risk?

Individuals with age 65 and older. Also if you live in a nursing home or long term care facility, if you chronic lung disease, asthma, heart disease complications, and if you are immuno-compromised; so this can be anyone receiving cancer or bone marrow treatments, bone marrow or organ transplants, immuno-deficiencies, it can be HIV aids, it can also be conditions that require the prolonged used or corticosteroids, or conditions with any immuno-weakening medications. That is something that you want to educate yourself on, what are the medications that you're on? I'm not recommending stopping those medications, again, but just know that there are some that will weaken your immune system.

And if you, at any age, struggle with severe obesity, that puts you at a large risk for contracting this virus and having poor outcomes. Certain uncontrolled underlying medical conditions such as diabetes, renal failure, liver disease, smokers... all of these things are risk factors too. Also pregnant individuals should be monitored closely, just because they are known to be at risk with other viruses, we're still studying what the risks are with COVID-19.

What are the symptoms of COVID-19?

The majority of cases will actually present themselves with a fever, shortness of breath, fatigue, dizziness, muscle pain, lots of appetite, chills, confusion, rash, sweats, GI disturbances, or upset stomach... all of these can be symptoms.

So what causes COVID-19 to become deadly

It can lead to sudden acute respiratory failure.

  • The virus damages the alveolar capillary barrier, where gas exchanges happens in the lungs.

  • It can cause oxidative injury, which means there is an imbalance of free radicals and antioxidants in the body that can damage tissues.

  • It can increase mucus productions, both because that's your body's defense mechanism and because due to damaged tissue you are not able to move that mucus outside the body like you once did.

  • A decrease of lung mobility.

  • The big thing that we are seeing with COVID-19 is something we call the "Cytokine Storm", which is uncontrolled inflammation from excess production of cytokines. Cytokines are a type of chemical messenger of the immune system, which is used to communicate such system with the rest of the body. A large influx


As a summary, the virus produces a large influx of cytokines and immune cells that cause a lot of damage, uncontrolled inflammation occurs, leading to the lungs' inability to clear mucus for gas exchange. The immune system can then attack the lungs, which can lead to lack of oxygenation and death. This is why co-morbidities that affect the immune system or the lungs lead to poor outcomes, and specially with contracting COVID-19. Again, the majority of severe fatal cases are indeed in the elderly population.

So transmission, what do we know?

We do know that it's spread via droplet, that is something we call all agree on. There are studies that suggest that there may be also be fecal-oral contamination.


So, let's look at our myths vs facts regarding this virus

Myth vs Fact #1: Is it Airborn?

This is something a lot of people are debating. First it was airborn, then it wasn't... so we're going to look at a study that has caused some of this controversy. This was posted in the New England Journal of Medicine, it was done by scientists at Princeton University, UCLA, NIH. Basically they used a nebulizer device to put samples of this new virus in the air, trying to imitate what might happen if an infected individual were to sneeze. So they did this by using a three-jet Collison nebulizer and fed into a Goldberg drum, creating an environment containing Aerosols (<5-microns).

Ok, so what are microns? So, if you sneeze you have the ability to produce aerosol droplets that can range from 0.5 to 5 microns, this is why they aimed for that protocol size.


Here is a direct quote from the study: "The half-lives of the particles existed in the air with a medium estimate of approximately 1.1 to 1.2 hours" This is where the 3 hours airborn claims comes from because half-life is multiplied by two. Another direct quote: "Our results indicate that aerosol and fomite transmission (so things that you touch) of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days"


The CDC is saying: well, we need to do more research on this. This study, other ones (some well done, some not), as well as an analysis of cases that occurred in an apartment complex in Hong Kong, where individuals were isolated in their apartments and they reported still contracting COVID-19, are what's causing physicians, respiratory therapists, nurse practitioners, and other clinicians to question the current mask requirement. What the CDC has agreed on is that during certain respiratory procedures we do need to take airborn precautions. So, sorry, I cannot solve that myth vs fact with you, that is something that we still are investigating, there are some interesting reports and studies out there that you can try to find.


Incubation period of this virus:


Basically an incubation period is the time-span between the moment you are exposed to a pathogen up until when you display symptoms. With COVID-19 we are seeing a mean of about 4 days but it can last up to 14. So, this means that you could have the virus, be asymptomatic, and be shedding or spreading the virus for up to 14 days. Yes, it's true, there are some cases that tested positive that were asymptomatic, however the majority of the cases are symptomatic.

Myth vs Fact #2: Covid-19 is just the flu

The Flu and Covid-19 have many similarities:

  • They're both viruses

  • They both cause respiratory symptoms and illness ranging from mild to severe

  • They have the same risk factors for contracting the illness and the same risk factors when it comes to fatality.

However, here are some of the differences:

  • Covid-19, as we just talked about, has an incubation period of 4 to 14 days, where influenza has an incubation period of 1 to 4 days.

  • We've lived with influenza for over 100 years, we've had time to study it. Covid-19 is novel, it's new, we're just now studying it.

  • The transmission rate is much higher in Covid-19 and we don't fully understand the treatments of this virus, and we certainly cannot agree right now on future projected mortality or infection rates.

Here is a quote from the director general of the WHO, Dr. Tedros: "Another difference: Covid-19 generally seems to lead to more severe disease than seasonal flu strains, in part because people have no immune protection against the new virus". Flu infections generally kill “far fewer than 1% of those infected, but as of now, about 3.4% of Covid-19 cases have been fatal." Again, this a comment that was made at the beginning of March but I did want to add that on here.


Myth vs Fact #3: When it's warm out, this will all go away.

So, studies are showing that Covid-19 can be transmitted in all areas, including hot, dry, or humid. There does seem to be a higher prevalence in colder climates, however, this does not discredit the fact that there are still outbreaks right now in warm, humid, and dry climates. Examples of this are Florida, Hawaii, Australia, the Phillipines, and sub-Saharan Africa. There are outbreaks everywhere, I don't think that just by having a warmer climate this is going to go away.


Myth vs Fact #4: It's contracted by mosquitos

At this time there are no studies or even reports that are suggesting that.

Myth vs Fact #5: If I get a pneumonia vaccine it will decrease my risk for contracting COVID-19

No, I'm sorry, It's a totally different virus, the same thing applies for the influenza vaccine, it's not going to prevent you from contracting Covid-19.

Myth vs Fact #6: I can get Covid-19 from my pet

At this time, we don't have any reports of pets of other animals in the United States becoming infected with COVID-19. However, since animals can always spread other things, I still recommend proper hygiene, don't rub your snotty hand with your pet and then send them to cuddle with your husband.



So what can you do? Prevention, prevention, prevention!!!

Stay at home if you can, be strict about social distancing. It's not about who is giving the orders or if you agree with them, listen to your healthcare experts, we do need to take this seriously. The only way to get ahead of this is prevention and decreasing transmission rates, this is that term that you keep hearing "flattening the curve".

Large corporations don't choose to close down major business events where they lose billions of dollars just on a political gain. So, that's insane, get that away from your mindset, this is far beyond that. If you're young and you're healthy, that's great, I'm happy for you, but this isn't just about you, it's about your ill friend, your grandma...


You know, if you are putting yourself at high risk situations and then coming home to your loved one or visiting with them while you're asymptomatic, you could have the virus, and what is the value in that? You just don't know everybody's medical history even despite what they look like. I have lupus, I'm super healthy because I take care of myself but who knows what were to happen if I were to contract an illness like this?


And again, obesity is another factor that we forget. So a lot of these lifestyle changes that we'll talk about... yes, start them today, but this is also another reason to just take care of yourself in general because this is stuff that is affecting your immune system from months ago, lifestyle decisions that you were making.


But this is serious, patients are dying, healthcare workers are dying and so just kindly educate your neighbor, be kind about it, show them this video if it'll help.

So, what else can you do?

We've all heard it by now, wash your hands. So, I want to ask you, are you irritated because you've been washing your hands too much, are your hands dry? If the answer is no, you're definitely not washing your hands enough! You should be washing them for more than 20 seconds, you should be vigorously scrubbing, getting the tips of your fingers, as well as under the nails, creating lots of friction... We don't even wash our hands the right way in the hospital system, there's a lot of studies that indicate it, which is very scary.


You've heard this before, don't touch your face, there's lots of memes about it.

Regularly cleaning and disinfecting surfaces, here in the clinic we've been using cavicide or bleach wipes, you can hop on over to the CDC page to see what their recommendations are for your household.


8-9 hours of sleep per night is super important. A lot of Americans don't get that everyday on a regular basis, and it's really important for a properly functioning immune system. Stress management is huge. Physical activity, you don't have to go to the gym, you don't have to really even leave your house to get this. There are plenty of subscription programs, you can go on Youtube, definitely don't stop being physically active while we're on this shelter and place order.


So, looking at your diet...

I know that we are in this situation where you're stuck in the house, and that's when cravings occur, but this is not a time to start reintroducing foods that you've developed a sensitivity to before, or that are triggers for migranes, ezcema, or allergies, because that is just going to harm your immune system even more. Avoid those, I recommend still trying to avoid processed foods, sugar, excessive alcohol, these are all things that negatively affect your immune system.

Your gut health is super important...

So your gut wall houses 70% of your immune system, therefore supporting your immune system via lifestyle modifications is important. You can also support your immune system with supplementation, however, like I said, these previous measures are way more important. If you don't have a healthy lifestyle, there is no supplement that you can take right now that's gonna make your immune system perfect.


I'm not going into as much detail with the science and behind how the immune system functions because I do offer an immune course that dives deeper into the patho-physiollogy and I give protocols for your immune system. It's something that I put some of my patients through and I'm going to be heavily discounting it right now because of what's going on... but i'm just going to keep moving on and if you're interested in that there will be more information at the end of this.


So, emerging studies for treatment and prevention

I want to reiterate, this is a new virus that we have not seen, studied, or run clinical test or trials on before. There's some really cool stuff happening right now but we also don't have a lot of data. With this being said, I also want say this: you don't need a randomized controlled study to tell you that you need to deploy a parachute after jumping out of a plane to safely hit the ground. Randomized controlled studies take time, they usually require sponsors and money, so just because something doesn't have a ton of data on it, it doesn't completely discredit it. I tell my patients this all the time: we go by research to prevent us from going off the deep end and prevent us from harming patients but it's not the gospel, it constantly changes, it's all about balance and all of this.


So, what is the treatment for COVID-19?

It's mostly supportive measures, there is not a well known cure, there are some that we're investigating right now and we will talk about those in a minute, but do find comfort that the majority of these cases are actually being managed in your own home. So with self-isolation, fluids, rest, nutrition, supplementation, oxygen therapy as needed, a lot of these things can be done in a home setting. Severe cases are the ones being managed in the hospital, those that may require intubation or mechanical ventilation in order to breath.


Also, more and more research is supporting and leading hospitals to natureceuticals or natural treatments at this time which is super cool!


Antimalarial drugs for Covid-19

So, the first new and emerging treatment that I want to talk about and has been buzzing around the media is the use of antimalarial drugs for Covid-19. There are both research articles that are very promising and there are a lot of anecdotal cases or reported cases of clinicians testing patients with antimalarial medication like hydroxychloroquine.

However, I will share with you, in Oregon I just received an email from the Board of Pharmacy on March 25th, that ruled and put an emergency ban on prescribing or dispensing of these, outside of malaria inflammatory conditions in confirmed Covid-19 cases. The reason why they did that is the same reason why all you guys went out and stocked up in all the toilet paper. We don't want to create a panic and we don't want people to stock up on medications or even providers to over-prescribe them because of research when we are still studying them. And if it is a breakthrough, we want to be able to conserve those for the most severe cases. However, it is being investigated.


Remdesivir, can it be used to treat Covid-19?

So, Remdesivir, this is a medication that has used to treat similar corona viruses in the past, like MERS, or SARS. It's not yet approved to treat Covid-19 but in emergency situations it has been given even in Washington State and other hospitals as well.


What about plasmapheresis?

So plasmapheresis is the removing of the blood plasma from an individual, concentrating it down, obtaining the anti-bodies or immunoglobulines, and transferring back into the patient's blood stream. There are hospitals right now trialing this for Covid-19. They're taking antibodies from an individual who has fully recovered from Covid-19 and then injecting them into another patient with severe symptoms. We've done this in the past with autoimmune disorders and so now we're kind of seeing what this might do with Covid-19. Researchers are hopeful that this is going to boost the immune system of patients and allow them to fight off the virus, or at least lessen the severity of the symptoms.

Could Vitamin C be used as treatment for Covid-19?

So, IV-intravenous Vitamin C, this is something that is really cool! I've used this in my practice in the past, it's really exciting that it's being utilized now in New York hospitals or over in China...

So basically, what I do want to tell you is that IV vitamin C is not the same as oral. You can never achieve the same dose orally, that you can with intravenous vitamin C therapy. So, it becomes a very powerful antioxidant and acts like a natural antiviral. We believe that it's suppressing the inflammatory response in the lungs, it's minimizing the release of cytokines, which we mentioned previously as a "cytokine storm". We believe that it's slowing down the replication of the virus within the body. More studies are coming out on this though.

Blood pressure medications and Covid-19...

So, one thing I want to talk about is blood pressure medications. I don't know if you guys have heard or read anything about families of blood pressure medications called ACE/ARBS. Enalapril and losartan are some examples of drugs that might fall in these families that are used to treat high blood pressure. So, there are claims that state both that they are being used in treatment and then there are claims that are stating that they have adverse reactions.

ACE and ARBs increase ACE2 expressions, which are the sites where the virus attaches and cause tissue damage in the lungs.

So, with that being said though, ACE2 receptor sites have two roles:

  1. They can be a protective one on the virus, specially what we've seen in children.

  2. Or another role can be inflammatory or fibrotic, initiating these pathways that can lead to the thickening of tissue.

No one knows which pathway the virus takes once it attaches. But I will tell you, most cardiology groups around the world have agreed on the consensus that you should not stop taking your blood pressure medication if you are on either of these. Remember, poorly controlled cardiovascular disease also puts you at an increased risk of Covid-19 complications. Basically again, talk with your primary care provider, I'm not saying you should stop you blood pressure medication, and again, most cardiovascular groups are saying: "stay on your medication".

So, NSAIDs or Steroids- are they harmful or are they helpful for COVID-19?

So, I'm going to read something directly from the WHO clinical guidelines on the treatment of Covid-19, specifically when it comes to steroids. "Given the lack of effectiveness and possible harm, routine corticosteroids should be avoided unless they are indicated for another reason" The WHO did a systemic review on observational studies and they said:

“A systematic review of observational studies of corticosteroids administered to patients with SARS reported no survival benefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance) (62). A systematic review of observational studies in influenza found a higher risk of mortality and secondary infections with corticosteroids; the evidence was judged as very low to low quality owing to confounding by indication (63). A subsequent study that addressed this limitation by adjusting for time-varying confounders found no effect on mortality (64). Finally, a recent study of patients receiving corticosteroids for MERS used a similar statistical approach and found no effect of corticosteroids on mortality but delayed LRT clearance of MERS-CoV (65). “

So, it has been given in hospitals right now but only after the clinicians have thoroughly weighted the risks and benefits.


What about NSAID (non-steroidal anti-inflammatory)?

These are drugs like ibuprofen, asparin, naproxen... So there have been claims, where these originated were from France, stating that NSAIDs were causing symptoms of Covid-19 to be worse. The European Medicines Agency states that there is no "scientific evidence" to support this but followed up with a comment from the French Health Initiative saying that there were grave adverse reports or events reported after using NSAIDs such as ibuprofen in patients with confirmed cases of Covid-19. They recommend treatment with acetaminophen instead. The FDA is currently investigating that claim. Again, talk to your medical provider, but if you're not on a high dose or anything like that, it doesn't hurt switching to a acetaminophen if you can. I'm not a huge fan of NSAIDs anyways. But again, check with your PCP before you make these decisions. I'm not really recommending anyone to stop any of these medications because a lot of this research is new.

So, what am I personally doing?

So, I have lupus as I previously shared. I'm taking social distancing very seriously. Actually, social distancing has given me really neat opportunities to hang out with friends over video platforms, or talking to them on the phone more, which I generally appreciate because I'm an old soul and my friends usually get annoyed with me because I want to talk on the phone rather than texting. And it's been cool to see people do this as well. I also have been continuing my healthy lifestyle through a diet, I personally eat a paleo-type diet, a very low inflammatory diet, and I make sure to prioritize my sleep.


I am taking supplements as well, but again, more important than supplements are lifestyle changes and lifestyle implementations. I'm taking immunoglobulin (IgG) orally. There are studies that are showing that the binding capabilities IgG have a positive effect on the gut barrier. And as we have already talked about, that is influencial on 70% of your immune cells. So, it also helps to keep your gut-lining healthy. There is a well done study on the IgG in calves of an older corona-virus in the GI tract. So that's why I'm taking that.

I also am taking probiotics for the same reason. I'm taking glutathione, which is a powerful antioxidant and it helps your immune system through this mechanism. It also helps lymphocytes and other cells of your immune system. I'm also taking Vitamin D, which really important for new cell growth, as well as modulation of the immune system. I'm also taking vitamin C orally, and I'm also taking immune system blend that has things in it like zinc, elderberry, vitamins B & A, and other botanical herbs.

Individualized dosing to supplement your immune system

If you want to get into more of the individualized dosing, I recommend signing up for my immune module, where I do cover a more in depth approach to that. I'm gonna be offering these classes very small, 3 -5 individuals is my goal for each group to keep it very intimate, and at the end of it there is going to be a live Q&A. Also, if you don't have a really good quality brand of supplements you can always email my office and we'll hook you up. Our email is info@vodamedicalclinic.com.


I'm gonna leave the information below as well. So, thank you so much for watching, I hope this was educational for you. I do want to give you some more information if you were interested in my immunology module. Due to current events, I have deeply discounted the module, I'm hosting it as a group tele-class, it's something that I've started putting some of my patients through as well. It's gonna be a