Dr. Cook: Everything you need to know about viruses right now!

Hi, my name is Dr. Matt Cook. Today I'm gonna talk about the Covid 19 viral outbreak. I'm gonna talk about the history and biology of pandemic infections. And I'm also gonna talk about some approaches to staying healthy and some integrative strategies that we use in our practice for patients with wellness.

I'm also gonna talk about some approaches that we've used to taking care of patients with complex vi viral infections over many years. I'm here to educate and inform, and I don't want to recommend any particular treatment. There are many scientific trials and case studies going on all over the world.

I'll be referencing some of this work. It's a rapidly evolving Problem. And I think some of the research is gonna be rapidly evolving and I'm just gonna be having an academic conversation pointing in direction of some, some some small successes and potentially some future options for care as well.

I'm gonna be discussing some things that are not FDA approved. The FDA and the FTC have a position that the only treatment right now is supportive care, although I think that based on some early evidence that's gonna come out, it may be that there are some. Some antiviral drugs that that will be approved.

They've sent warning letters to a number of companies. And so I just want to be explicitly clear that I'm not recommending any specific treatment, but just trying to start an an intellectual conversation that is hopefully constructive. I've been interested in viruses for 25 years. I actually did a, a research project in college in a virology lab, and we were studying the feline immunodeficiency virus, which is a model for hiv.

I ended up going into anesthesiology and I have a practice in interventional pain management and also have a functional, integrative and wellness practice. I'm probably well most well known for doing ultrasound guided injection into joints in the spine, and doing nerve hydro dissection for peripheral nerve pain.

But I had an evolving and interesting experience in functional and integrative medicine because I had a lot of patients who had chronic pain, but who also had chronic infections. The most common was Lyme, but we've, we've had a lot of patients with viral. Illness that complicated their pain.

And because of this, I ended up really digging into that and getting interested in that. And so I've, I have a long experience of taking care of patients with viral infections on a weekly basis for years and years. And have found it quite interesting is I'm gonna share some of my personal experience in, in this space.

And know that I'm speaking, speaking generally, and, and this is a rapidly evolving science scientific experiment that's going on across the world. And so know that I'm not in any way trying to influence you to, to buy any product or, or seek out any treatment because I don't think we know quite yet what the best treatment is.

But at least we can begin to talk about it. These these infections the flu is always going around, but probably every a hundred years one will come around. That's just a lot worse than, than the average. The average flu the, the, the, the biggest one that hit the world in recent times was a hundred years ago.

In 1918, there was an influenza pandemic and it was caused by H one N one influenza virus. And it, it absolutely swept all the way around the world. And the thought is that it infected about 500 million people. It was in Europe it included the Pacific islands that went to the Arctic.

And it had a death toll that was somewhere between 17 and 50 million. But it may have been as high as a hundred million people Now that, that pandemic actually happened during World War I. And the, the wartime sensors didn't wanna scare people, and so they kind of put their head in the sand and they didn't allow the press to report on it.

And so the only press that was able to report on it was the, the Spanish press. And so it, it became known as the Spanish flu, even though it was happening all over the world. And I think this is just a interesting point that I think it's important that The press is free to talk about and discuss these, these problems and, and get as much information out there so that people can make the best decisions.

So when we look back at that epidemic from 1918 people, sometimes people ask, well, what happened? Was it a, was it some form of a perfect storm that created the possibility for that that pandemic? And certainly there may have been because the war, the, the ravages of war were going on, there was large camps of pigs, sick and injured people.

There were large numbers of birds and pigs and other animals in, in those camps. And so it may be that there was a, a number of different circumstances that combined to, to. Enhance the, the probability of people getting and, and ensuring a, a infection. However even though that may have been a perfect storm probably there was also something called a cytokine storm.

And I, I'm going to go into this a little bit later in de in more detail. But the, the thought is, is that sometimes a virus can trigger something called a cytokine storm. And what, what that means is it triggers and a very extreme. Activation of the immune system, that that causes inflammation.

And that inflammation starts in one place, often in the lungs, but then it starts to spread all over the body. And it's actually the cytokine storm, which can lead to something called sepsis that is actually what does more damage than the virus. And so, we'll, we'll talk about that. And so there was probably a perfect storm and a cytokine storm that, that led to that pandemic.

And we, we are probably looking at something similar to that. But now, and so, and I will go into what I mean by that, the, the 1918 pandemic, interestingly Had a predilection towards killing younger people and younger adults. And it may be that older patients had been exposed to a similar flu, the Russian flu 20 years prior to that.

And so they may have had some immune protection from it. Or it may be that the pan, the pan that pandemic had a real strong predilection towards causing this extreme inflammatory immune activation. And that was the problem that, that affected and, and caused that pandemic to be affecting more younger people.

This is probably gonna be a similar situation, although it's, it's different in, in, in that there's a predilection in this one for the, the people who get most affected and the people who get affected by the cytokine storm to be a little bit older to be immunocompromised or to have other problems.

And, and we'll talk a little bit about this. Since then we've had two other recent big viral infections that were respiratory. One was the SARS virus and one was the Mers virus. And these were both coronaviruses that were probably not quite as contagious as as this one but had a higher fatality rate.

So the sars had a 9.6% fatality rate, and I think the mers had a 34.4% mortality rate. The current fatality rate in for the covid 19 infection is, is, is unclear. And, but it, the ranges that we've seen are between, between 0.6 and three or 4%. So a lot of people ask me, well, what is this virus? And so it's the coronavirus.

And in the coronaviruses there's a whole bunch of different ones and they cause about 25% of the flu.

And this, this virus, SARS COV two cause causes the illness COVID 19. So viruses are very small, and so we, we with our eyes can't see a single bacteria. And I heard an expression that if bacteria had eyes, they wouldn't be able to see. Viruses. So viruses are, are really, really small and they're a protein shell with either DNA or rna and some enzymes that replicate.

So it has a genome. But it can't replicate without help. And so what they do is they infect cells and they, they bind onto a cell and then they insert them into the cell. And then what they do is actually get the cells to copy their genome. And then they, they turn that cell into a kind of a zombie that makes a whole bunch of viruses.

Those viruses get released, and then once they get released, then they try to duplicate that process and infect other cells. This this virus started in bats and then it went into Pangolins as an intermediate host before coming into humans. And it seems to go through the eyes and the nose and the mouth.

And it causes respiratory symptoms fever, cough, and shortness of breath. But some people can then progress onto the more dangerous complications such as a R d s, shock and, and sepsis. Now, by far the most important strategies are prevention. Avoid traveling to infected places.

Careful hand washing. And this goes especially for healthcare practitioners. Avoiding touching the T zones because our hands can pick up respiratory droplets that came off of an infected person. And then obviously avoiding crowded areas. So right now, the most people are not going into any crowded areas at all.

So the question, the next question, well, how is it spread? And it's not that interpersonal transition transmission is primarily from respiratory droplets and contact trans transmission. But there may be some fecal oral transmission as well. And there was some situations where there was buildings that did not have good venting and, and it, it probably is in the stool.

And so there was fecal, some, there's been fecal, oral transmission and, and in some of these buildings that didn't have good ventilation people in different parts of the building got, got infected because of it was able to transmit up up these these lines, which is kind of concerning.

I want to emphasize that the majority of cases are relatively mild, kind of, kind of a flume, and that's positive. But, but there are and, and that's probably 80 to 85% of people are gonna have mild cases, but 15 to 20% of people can have quite significant and complex problems. And so that's why everybody's so worried about it.

A fever at a dry cough are the most common presentations. Some people had shortness of breath and fatigue. Some people have had muscle pain, confusion, sore throat. Some people can have gastrointestinal symptoms. People have had diarrhea and, and vomiting as a presentation. And there, there have been a, a real number of people who presented without any fever.

I wanna really emphasize how important before we get into treatments, hand hand hygienists and cl cleanliness and even in the, in your home and at other areas wiping down the areas around where you are and making sure everything is clean, I think is, is gonna be quite important. And risk management from this perspective is gonna be is gonna be very important.

There are, are guidelines that are gonna be are, are and are continue to be released from healthcare organizations. And, and we're gonna try to post these guidelines both from a perspective of cleaning, from a perspective of taking care of someone who's been quarantined and at home.

And then from the perspective of taking care of people in a clinic and a hospital. I wanted to go through a little bit about the time chorus. Most people are gonna have a mild infection. The, the people who get real sick. Sepsis in one study developed median of nine days after the illness. A r Ds.

I developed a 12 days as a, and cardiac injury happened at 15. I'm gonna go into why, why this seems to affect a diffuse and, and broad set of organ systems. People developed acute kidney injury at 15 days and a secondary infection at 17 days. I found one real interesting study that they did with monkeys who were inoculated with the sars covid virus.

And they found that the older monkeys had a stronger host in eight response than the younger ones. And what that did is it affected how they responded to infections because they preferentially created a lot of inflammation. They had less T-cell and B-cell function, and they had more cytokines and that set them up for the cytokine storm that I'm gonna go into in just a second.

I've been having a lot of people ask me, why does the flu come in the winter? And somebody, somebody told me, well, the flu loves winter. In the Northern Hemisphere, it typically happens between November and March, but in the southern hemisphere happens from May to September. So viral outbreaks typically happen in the colder months, and sometimes in, in the, in the summer, things get better, but sometimes they can go from the northern hemisphere to the southern hemisphere and that, that may be what's gonna happen here.

In general the tropics probably have less much less in the way of flu infections than colder areas. And, and there's some evidence that even animals who are kept in a cold environment are, are less susceptible to, to viral infections.

So let's get into it. What is, what is the cytokine storm? This virus, the, the primary target is probably respiratory epithelial cells. So these are cells that line the line your airway, and they are the choreographers of cytokine application during infection. So I told you that when virus comes in, the virus can't replicate itself without going into a cell.

So it, it comes in and it gets into a, a cell, one of these epithelial cells, the cells that line your airway, and then they recruit that cell to make a whole bunch of copies. And and that's how it replicates itself in response to that the human body. Says, well, let's make a whole bunch of chemical messengers that will create an inflammatory response.

And the goal of that inflammatory response is to get a whole bunch of immune sys immune cells to come in to fight that infection and, and fight that virus. The way, the way that it happens is, is that the, we, the, the first thing that happens is that the, the pro-inflammatory cytokines are produced and they act like an alarm belt.

They drive cells of your immune system to come in and then fight the infection, and then after that acute, very inflammatory response, then there are some anti-inflammatory cytokines that calm everything down, and generally your immune cells were able to fight the virus, and then everything is cool.

What, what happens in a cytokine storm is that the inflammatory process goes outta control, and it goes so far outta control that the anti-inflammatory process doesn't ever get to take effect. And we get runaway inflammation and it was all targeted to kill something, but the, the virus actually is not nearly as bad as the over inflamatory response that the human body had in trying to fight it.

And the analogy I had was, imagine there was a bunch of kids and maybe a whole bunch of kids that were in a grocery store, shoplifting. Well, that'll be bad and probably we need to do something and, and get them. But one thing that you could do is you call it a drone strike that takes out the grocery store.

And that's kind of like what's happening here as, as, as an analogy. I'm just gonna give you a little bit of science and there's a, a couple names and you'll, you may be hearing some of these names in the press. There's a whole cast of characters of the inflammatory cytokines and then the whole cast of characters of the anti-inflammatory ones.

There's one called tumor necrosis factor alpha. TNF Alpha is often maybe the first one to initiate this fire alarm. And it typically will promote the generation of another one called interleukin one. And interestingly, the, the fact that these are, we have older patients who are more susceptible.

Some of them may have some genetic susceptibility. They may they may make a little bit more of these inflammatory cytokines. Or it may be that their immune system is somewhat weakened because of a variety of factors. And so as a result, instead of being able to rely on their cells to come in and do what they need to do, the they're, they're relying on an inflammatory response, but that inflammatory response goes out of control.

Now, what happens in this setting of this extreme inflammation is that those cells can undergo a process called apoptosis and they can die. And then when those cells that are lining your airway tracts start to die because of this inflammation, then That can cause all kinds of swelling and inflammation in the tissues where that's happening.

When that causes swelling and inflammation in the tissue of the lung, we call that a pneumonia. Often when this happens, it leads to a pneumonia and because it's it's systemically happening, it, it doesn't happen just on one side, it happens on both sides, and that can progress onto an acute lung injury or a R d s.

Now as, as a mechanism of healing, the first thing that happens with inflammation is it leads to vasodilation of the blood vessels. And the reason we try to vasodilate the blood vessels is this so that immune cells can start to go in and get out into the tissues where there's, that's happening. And so I like to give an example.

Let's say I was walking around and I bruised my leg. Well, the first thing that would happen is I might create that inflammatory response that we're talking about. So some cytokines come out and they create inflammation, they create swelling, they create heat, and then some immune cells come in. And what happens is when those immune cells come in, they're gonna choreograph healing.

And then what they do is they start to send more messages, which are anti-inflammatory, and then a coordinated response happens that calms everything down in the case of an acute lung injury that is progressing into a rds. What can happen is, is the, the, the inflammatory mediators that were causing vasodilation to.

Hopefully heal the lung, start to get into the systemic circulation, and then they start to cause a drop in blood pressure in, in the whole body. And so then this is one of, this is how sepsis starts to happen. There was inflammation in the lungs, but then all of a sudden there's inflammation everywhere in the body.

And then what happens is you have somebody with very low blood pressure. They also have not enough oxygen because because of all the swelling, the lungs can't exchange oxygen well enough. And so now we we're, we're having systemic collapse. And that's, that is physiologically what's happening.

The, the other thing that can happen is, is that this virus appears to have an effect of being able to bind onto some receptors called ACE two on the cell surface of cells in different tissues in the body. And, and so there are an, an ability for this virus to affect the lungs, but also it can then begin to affect and infect cells in the heart and the kidney.

And that's why we're, we're having a diffuse group of other problems that happen in, in addition to just traditional septic physiology. So I'm hopefully beginning to give you the idea that a little bit of an. Inflammation's a good thing, but when it's outta control, it's a bad thing. We have molecules in the body and, and proteins and regulators that at all times are either driving inflammation up or driving inflammation down.

And, and in general, this is the nature of life. Where we're we, we turn something up to initiate a healing response and then turn it down. We go into fight or flight to, to meet an event, but then we come back and to rest and relax. And so we're perpetually in some form of a yin yang cycle. The, one of the, the biggest drivers of of inflammation is a, a protein called nuclear factor kappa b.

And it turns out that activation of it is a, a central thing that can lead to sepsis. It also is broadly implicated in a, a whole host of illnesses and, and medical problems that are expressions of outta control, inflammation and, and sepsis, higher levels of nuclear factor CFA beer associated with a higher mortality rate, and and worse clinical outcomes.

And I think that it may be that some of these older patients that we're seeing who are either immunocompromised or have other contributing factors that make them more susceptible. One of the factors may be that they have greater levels of NF capa B or That is one of the only strategies they have cuz something else isn't working.

No. There's from a septic physiology perspective an approach to tr trying to inhibit NF CAPA b activation. But it's a also a, a fairly well known strategy that's used broadly in, in integrative medicine as there are a, a number of supplements and, and strategies that inhibit NF capa B.

And so I'm gonna go into this a little bit Now, the other, the other side of that coin so I've got inflammation. The other side of the inflammatory coin is a transcription factor called NRF two. And this is the master anti-inflammatory switch. And so we are able physiologically in our body to either turn up inflammation or turn it down.

And so there are gonna be strategies with vitamins and things like that that can turn down NF capa B. There are also strategies with vitamins and things like that that can turn up NRF two. If you wanna pneumonic to remember this, I think NF kappa B is nuclear factor kappa bad, and then NRF two.

I just remember that Nerf Nerf is good. So now I'm gonna go ahead and start to talk about some of the different treatment options that are out there. Now for those with mild illnesses, I think by far the most important thing is containment. And so avoiding other people, avoiding transmission, avoiding transmission to other family members having great respiratory hygiene, environmental cleaning limiting movement, limiting exposure, and staying away from other people so that you don't get infected.

Because if we do a great job with that 80%, then we have a hope to get this contained. And so it's like by far. The, the most important thing to think of in that category. Then with that being said as, as I go through the treatments treatments that may be beneficial in general could be also beneficial for these mild cases.

But then in addition to those cases, there's people who have cytokine storm and, and septic physiology and some of the severe things we were mentioning and above. So we'll, we'll talk about some of those strategies. If this is a fundamentally a model of runaway inflammation, then you begin to think, well, maybe something that would be anti-inflammatory.

And in Western medicine, one of our. Great ideas in terms of turning inflammation down is to use corticosteroids like prednisone. The good thing about corticosteroids is they are quite good at turning inflammation down. The downside is, is when when we give them sometimes they blunt how well the immune system works.

And in the previous coronavirus outbreaks systemic steroids was found to not give benefit and, and may have caused some harm. So unfortunately that one's probably not gonna be a useful, useful strategy for us.

And so then the next, the next, and I think most obvious and and rational thing is gonna be to look at the antiviral medications. I think the most exciting of these medications is there's one called Rimes Avir, and it's a small molecule that mimics one of the components used during the production of the replication of this the virus's rna.

Th these are RNA viruses, and when it's incorporated the, the, the replication of the viruses is halted. And early investigations have shown some promise for rimes avir in treating MERS and sars which were both coronaviruses. And it also had some benefit in Ebola. And it sounds like There's a, a, a fairly broad ability for Rees vir to affect a wide different variety of coronaviruses including the two bad ones that we've seen.

And a number of clinical trials looking at a, at its use in any Ebola. The the other drug, there's a drug that goes by the, I think the brand name Altra. It's K e l a t r a. And that's ritonavir and Vir. And this is a a drug that has been u used in Asia in a couple different countries to, to treat this infection.

And, and it sounds like there's some early evidence that this, this may have some value. We don't know how effective it is. It's been just crazy in terms of the inability to get supplies and get things right now. But I was able to, to, to get a small amount of this and so we'll be anxiously watching to see what the results are in terms of how effective it is.

There are another, a number of other antivirals. And as far as I can tell none of those are showing much effectiveness, although there are some people looking to see if Tamiflu combined with, with potentially the ritonavir is effective. And but, but Tamiflu well by itself, it, it sounds like was not one thing that's being looked at, looked at as therapies that are anti tnf.

So if TNF is this inflammatory cytokine that is starting the whole process, there is the idea of. Giving something that would decrease the, the, the TNF alpha. And I'm not aware of, of anything that has shown that much merit in this regard. Although there's, there's a lot in that space.

However it, it may be that ozone therapy, which I'm gonna discuss a little bit later may have an ability to, to lower some of the pro-inflammatory cytokines and in particular TNF alpha. So, so one idea is back to this theme, turn the bad guys off. TNF Elephant Ozone Mate may have Some ability to do that.

And then the other thing is to turn on the good guys to turn up the inhibitory cytokines that would normally come in and calm things down. One of those is something called TGF beta. And another one's called i L 10. And I'm gonna foreshadow where we're gonna go here a little bit. But the, it turns out that ozone, which is a modality that is one of the integrative strategies that is used in some parts of the world may not only decrease NF CAPA B, but it may actually increase NRF two.

So it's kind of interesting. And so when, so this kind of brings me to the, the idea of functional medicine. I, I've referenced that earlier. And so if you said, well, what is functional medicine? I think functional medicine is a, a system approach to looking at the whole body and diagnostically doing testing and trying to figure out how the whole body is working and seeing if there's things that can be done to optimize each component, each system to get the whole thing working together better.

Play-Doh said that The part can never be well unless the whole is well. And I would say that is true whether we're a person or society or the whole planet. I think this is, this is an example where what we're trying to do is improve each individual's total wellness. But, but then to go further to, to, we have to look, we really have to band together to help everybody.

It may be the thing to do that, to help other everybody more than anything else, is just gonna be, to make sure that people who are infected or exposed or isolated so that this stops as, as, as soon as possible. But this, the functional medicine idea is kind of interesting and entertaining to, to begin to think about because it's has some useful applications for wellness in life.

As an example A typical conversation in functional medicine. If we break down the different systems, we have immunology, we have neurology, we have the cardiovascular system, the pulmonary system. The I'll give an example that I, I see a lot which is, is that people will have a fairly significant problem in their gastrointestinal tract.

And so they may have bacteria 11, the small intestine that's called small intestinal bacterial overgrowth. They may have a bi, a biofilm there that has yeast in it as well. They could have mycotoxins there as well. Or they could have a parasite infection, small intestine. They could have any of those in the large intestine as well.

And then that inflammation and infection can start to lead to inflammation in the wall, in the, in the wall of the intestine. And that can start to lead to leaky gut. And so when that happens toxins from the gut can start to get into the bloodstream and sometimes little bits of undigested food can get into the bloodstream and then the immune system can start to have an inflammatory response that will come in and start to attack the wall of the intestine.

But it can also create antibodies and allergies to foods and, and other problems. And then this has the effect of making the immune system somewhat dysfunctional and, and not work quite as well. I. When I see people with real complex infections, usually there's four or five things going on. And so if somebody comes in fairly debilitated with Lyme disease, they don't come in with a perf, nobody come, nobody that's sick comes in with a perfect gut.

They all come in with a whole bunch of things going on and, and I generally think that that is an initiating factor that causes the immune system to get dysregulated. And then because of that, then their immune system's not working that well. And that's what set them up to be susceptible to the infection in the first place.

Because I'll see people who've had a blood test that show they were exposed to, to ly quote unquote, but they are totally fine and they're super successful and they have no problems at all. But then I'll see somebody else that has exactly the same testing, but. From a systems perspective, they've got four or five problems.

And, and because of that, the whole, the whole body can't work very well together. And so there's a problem and it's kind of like if there was a company and the company had a problem in marketing and a little problem in strategy and a little problem in operations, well that's a big problem. If all they had was just a small problem in marketing, They just bring a consultant and fix that marketing problem and then they're back to the races.

But if there is problems going on systemically in the company, then what's gonna have to happen is a strategic implementation of approaches to fix all of those problems. Cuz if we don't begin to, in, in, in broad terms, focus on the problems these people don't get better. And so when I, a lot of times when I talk to people, I, I say I'm, I'm thinking like I'm a McKinsey consultant, trying to go in and, and optimize.

Each system. And I think from a wellness perspective as we, we sit here and try to get ourselves as well as we possibly can in anticipation of this pandemics, we sweeping through the less toxins we put in ourself, the, the healthier we get, our intestines and our heart and our lung, and the more we sleep and the lower our stress and the, and the more we exercise and we, we ha we're doing everything to get our, our, our immune system and our biology working well.

Then that has potential to be a long term strategy of preventing infections. And I would say that has been born out in my clinical experience. And so when, when We use strategies to, to optimize our biology. A lot of that is lifestyle modification and a lot of that is just making great choices.

But then there's some interesting things on the supplement front that can be helpful and that'll relate to some of the biology that I've discussed as we're going through here. And the, one of the big ones is vitamin C. So there's some, some studies that have shown that vitamin C when it was given intravenously decreased mortality and prevented organ system failure in patients with sepsis.

Now, It kind of makes sense. And I think it's rational because I said that sepsis is runaway inflammation and vitamin C is an antioxidant. And so and the runaway inflammation is, is this overreaction to the body, the, the runaway inflammation is carpet bombing the grocery store in response to some kids that were just shoplifting.

And so in that sense, vitamin C I think has a, a, a good, a good logic. And I know that there's some trials that are looking at using IV vitamin C to treat this, this infection and, and and patients with a sepsis specifically from the, the covid 19 virus. I think i