Coronavirus updates, COVID-19 myths and chiropractic practice

Given the current environment of anti-science and conspiracies, there is considerable misinformation circulating on causes, treatments, drugs, and vitamins regarding coronavirus updates

The current COVID-19 pandemic, at the time of this writing, has exceeded 1.2 million cases and more than 80,000 deaths in the U.S. alone. It has created challenges for all health care practitioners with respect to business and safety. 

In most states, chiropractors have been designated as essential providers. As such, we have a responsibility to the public to ensure that we take necessary precautions to protect patient safety and ensure accurate scientific information. As with any profession, we have those who decide they know better than the experts and put forth misleading and even false information. Regulatory boards may view such information as false advertising or professional misconduct and may sanction doctors.

COVID-19 and coronaviruses

COVID-19 is the name for the disease caused by the SARS-COV-2 virus.  Coronaviruses have been around a while and there are two versions: animal and human. The human species survives in 33-35 degrees C and lives better in the upper respiratory tract because it’s cooler. The animal species replicates at 37 degrees C (body temperature) and is more dangerous as it can go into the lower respiratory tract and replicate. The virus is a zoonoses meaning it can pass from animal to human. 

The first major outbreak, SARS-COV-1, was in 2002 when the virus migrated from bats in China to civets sold in wet markets to humans. Another outbreak (MERS-COV) in 2012 occurred when it moved from bats in Saudi Arabia to camels and then humans. The third outbreak occurred in 2015 when it moved from Saudi Arabia to South Korea. South Korea acted at that time which helped them prepare for the latest outbreak.  Although the exact source is unknown, the current SARS-COV-2 is similar to the one that started in Wuhan China (CDC2) passing from bats to pangolins or snakes then to humans.² There are already multiple mutations of this virus.

Coronavirus updates: pathophysiology, transmission, and risk factors

SARS-COV-2 is a betacoronavirus that gets its name due to numerous protein spikes (S protein) giving it a fuzzy or crown-like appearance.³ This glycoprotein likes to bind to ACE2 receptors on our cells helping it stick to the cell.  It is speculated that this connection might be why it is so transmissible and contagious.

It subsequently hijacks cellular organelles and membranes and uses the cell machinery to replicate. It is an enveloped protein stealing part of our cell membrane. Enveloped proteins have a shorter survival, usually 2-3 days depending on surface properties, heat, and moisture. It will survive longer on nonporous moist surfaces. Naked proteins (lack membrane) have a longer survival. The enveloped protein membrane allows the spikes (fur) which prevents stomach acid penetrating and killing the virus. Wastewater monitoring has been one proposed strategy to track hot spots.⁴ 

Once the virus attaches to ACE2 receptors, it sets off massive inflammation and may also start a cytokine storm. The massive inflammation (almost everyone) and cytokine storm (some) are responsible for the damage to the lungs and patients can go from a cough to intubation in 5-6 hours. Such rapid deterioration is not common with the flu. People most at risk are those with respiratory problems, smokers, obesity, autoimmune disorders, cancer, immune compromise and other comorbidities.⁵ Although cases tend to affect the elderly more, there have been cases in all age groups.

Transmission of the virus has three possible routes:  person-to-person contact via respiratory droplets (mainly), surface contact, and although no evidence exists, fecal-oral contact.^{6, 7, 8}  The respiratory spread zone is controversial and there is no evidence for the 3-6’ rule.⁹ A recent study suggests a possible connection between elevated NETs (fibers containing neutrophil DNA) and the severity of cases. The improper regulation of NETs could result in an abnormal inflammatory response like that characteristic of COVID-19.¹⁰

Chinese data regarding coronavirus updates has identified four stages: asymptomatic, mild, severe, critical. Incubation of the virus is 2-14 days, and up to 24 days with a median of five days. The 4-5-day window is dangerous because there may be significant shedding of the virus. Each victim usually exposes 2-3 others and the subsequent additional exposures result in a logarithmic explosion of cases. Destruction of lung tissue starts in 3-4 days and within 14 days it can be massive. Mild cases (81%) have fever and dry cough. Severe cases (14%) have shortness of breath and need high flow oxygen therapy. Critical cases (5%) require intubation and 3% die. A victim is considered recovered after 10 days free of symptoms and two negative swabs.

Myths and misinformation

Given the current environment of anti-science and conspiracies, there is considerable misinformation circulating on causes, treatments, drugs, and vitamins mostly based on bad science and lack of critical thinking skills.  Some coronavirus updates videos put out by medical and chiropractic doctors contradict the experts and sometimes provide dangerous and irresponsible information, which could be a state board issue. 

Myth 1:  Hydroxychloroquine (HCQ) and combinations can cure the disease or prevent it. 

Facts: HCQ data currently is severely limited. The drug itself has a very narrow safety window and is generally used when all other forms of therapy are not working, i.e., the patient is likely to die anyway. It was FDA approved for emergency off-label use for COVID-19. There is evidence that HCQ kills the virus in vitro but no data regarding its use as a prophylaxis. HCQ is also used to treat CNS problems such as glioblastoma. Since neurological symptoms and the possibility that HCQ could reach antiviral brain concentrations, it might be of benefit as a treatment or prophylaxis to mitigate brain symptoms. 

HCQ has several characteristics that might mitigate inflammation and the cytokine storm by inhibiting viral entry to ACE2 receptors, inhibiting viral release (affects acidity of organelles-ER, Golgi complex), reducing viral infectivity (affects glycoprotein receptor binding), and immunomodulation (tamping down cytokine expression). HCQ decreases T cell expression, B cell activation, and dendritic cell action all reducing inflammatory response.

Pros:^{11, 12, 13} Some experts are advocating HCQ as a post-exposure prophylaxis (tested or not) using SLE treatment protocols adjusted for body weight and tissue concentration. The argument is that it takes about six days for the HCQ to stabilize its blood concentration and it has long term efficacy due to its terminal half-life of about 50 days. This viewpoint is due to the immunomodulary properties, possible viral replication decrease, and in vitro antiviral effects of HCQ against virus such as, HSV1, HIV, MERS, SARS-CoV, HCoV-OC43, Chikungunya, hepatitis, and coronaviruses. Proponents consider the antiviral activity higher than its cytotoxicity. 

Cons: In addition to lack of evidence for prophylactic use, there are concerns over toxicity and side effects without evidence of benefit. The drug has a very narrow safety window and can result in death if not properly prescribed.¹⁴ What evidence that does exist is mostly anecdotal when it comes to COVID-19. Recent studies by the VA and NIH have found HCQ to not be effective and may cause more deaths.¹⁵   

Myth 2:^{16, 17, 18} Vitamins C & D. Taking mega doses can prevent or cure COVID-19. Vitamin C (water soluble) helps with the Electron Transport Chain (ETC), helps reduce reactive oxygen species (ROS), and helps synthesize collagen. It also helps with phagocytic activity, neutrophils, natural killer cells (NKC), epithelial cells, and water channels. Vitamin C will help with the immune system and lung epithelial tissue. Some studies have shown mega doses reduced or prevented respiratory symptoms of cold and flu.¹⁸ IV mega doses are under study in coronavirus updates from China. Although it may help fight it, there is no current evidence that it will prevent or cure it. Having normal levels of vitamin C available when sick is important for the immune system and when the infection starts may need to be increased to help. Good sources of vitamin C include citrus fruits, oranges, and broccoli to name a few. Vitamin D is fat soluble and can be toxic. It does help with the innate immune response when maintained at normal levels.²⁰

Myth 3: Drinking hot water and hot showers washes the virus away. This myth is nonsense beyond belief. Drinking or showering in a temperature hot enough to kill the virus would cause tissue destruction and death. Homeostatic regulation would prevent you from raising body temperatures high enough to kill the virus. A French study found that even at high temperatures the virus replicates. One study in prepublication does suggest that a rise by one degree centigrade in environmental temperature could retard growth. ²¹

Myth 4 (profession specific):^{22, 23, 24} Chiropractic manipulation can strengthen the immune system. Statements by the WFC, ICA, and ACA have all noted that there is no credible scientific evidence that adjustment/manipulation can have a clinically relevant or direct impact on the immune system and provide improved protection from COVID-19. The ICA, however, goes on to assert “there is a growing body of evidence there is a relationship between the nervous system and the immune system.”

Other Myths: We seem to live in a society where conspiracies about the deep state have overtaken critical thinking skills in some – such as claims of 5G causing COVID-19, and that it is man-made by the deep state. Bill Gates has been accused of using the coronavirus to implant brain chips via vaccines and QAnon claims he patented the virus and is deliberately spreading it. 

Additional conspiracies involve drinking methanol, ethanol, bleach and disinfectants (dangerous), and eating hot peppers can all cure or prevent COVID-19. This is the world we live in; searching for answers and explanations in all the wrong places. 

Practice safely

Prevention, social distancing, and safety practices are imperative to prevent your practice from becoming a vector locus point. Much like we do with computer security, practice hygiene and safety could be considered on a tiered basis. Habitual thinking patterns must be abandoned to deal with complexities of COVID-19 and perhaps a new practice paradigm developed.

Level 1:  Practice Hygiene and Office Procedures. Office procedures will need to be rethought and steps taken to implement safe social distancing and allow adequate decontamination. Scheduling, patient entry and exit, waiting room layout, entry and scheduling screening (COVID-19 questionnaire, temperatures), and exposure areas must all be taken into consideration to limit transmission within the office environment. 

This will help minimize the office becoming a transmission vector as well as legal exposure. Volume practices will be significantly challenged and well-person care should be temporarily abandoned for acute care. Time between patients must be allowed for deep cleaning contact surfaces before and after patient contact. Personal Protective Equipment (PPE) packets for office personnel and patients should be a strong consideration. 

Scheduler’s should pre-screen patients using the COVID questionnaire prior to setting up appointments. Practices should prescreen patient entry by setting up an area in the entry, like the VA does, to screen patients for symptoms and temperature. No one with a temperature should be allowed in the practice until COVID-19 has been ruled out. Policies should be clearly communicated to patients and notices placed on entry doors. Entry door handles must also be regularly cleaned as well as any sign in areas and sitting areas. Treatment tables need to be thoroughly cleaned after each patient with CDC recommended chemicals. Any examination or treatment instruments should also be decontaminated after every patient use. As former enforcement chair for the TBCE, cleanliness complaints were not uncommon. DCs do not generally see infectious patients and sometimes become lax in cleaning standards.

Level 2: Doctor and staff protection. Doctors and staff should wear protective masks, face shields, and gloves and avoid contact with their faces and regularly exposed surfaces where possible. Clothing should be changed in the office and if possible laundered. No one should wear office clothing home or in public after seeing patients. All staff should, where possible, be given N95 masks and face shields and, if possible, masks and gloves should be provided to patients as well. You can likely charge for patient safety equipment. Patients could be requested to bring their own masks and gloves. Hand sanitizers should be readily available.

Level 3: Doctor, staff, and patient education. Doctors need to be diligent in staying abreast of current information, epidemiology, and safety to educate patients. This can help quell conspiracies, tamp down the curve, and minimize future waves. Awareness of the scientific literature and the conspiracies that abound is important in combating disinformation, internet scams, and other dangerous beliefs.

DCs play an important role in the health care environment. As such, we have a responsibility to ensure patient and staff safety and with coronavirus updates to educate our patients about the steps they can take to self-protect and enhance their immune systems. We also have an important role in tamping down myths and disinformation by providing evidence-based facts and recommendations.

John H. Riggs III, MBA, DC, DIANM is a semi-retired, board certified chiropractic orthopedist. He teaches anatomy and physiology at local colleges and resides in Dowagiac, Mich. He develops and teaches online continuing education classes and has published 21 peer and non-peer reviewed articles. He also teaches aikido (5^th degree black belt) and has published articles on aikido internationally.

References:

1. Liu, Cynthia et al. 2020.  “Research and Development on Therapeutic Agents and Vaccines for COVID-19 and Related Human Coronavirus Diseases.” ACS central science vol.  6(3): 315-331.
2. CDC:  https://www.cdc.gov/coronavirus/2019-ncov/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Fchildren-faq.html#How-COVID-19-Spreads.
3. Principles of Virology. 4^th Edition. J Flint, GF Rall, VR Rancaniello, AM Skalka, LW Enquist.  ASM Press, 2015.
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5. NIH:  https://covid19treatmentguidelines.nih.gov/overview/.
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12. Zhai P, Ding Y, Wu X.  2020.  The epidemiology, diagnosis and treatment of COVID-19.  International Journal of Antimicrobial Agents.  Article in press.  https://doi.org/10.1016/j.ijantimicag.2020.105955.
13. Gautret P, Lagier J-C , Parola P, Hoang VT , Meddeb L, Mailhe M , Doudier B, Johan Courjon , Giordanengo V, Vieira VE, Dupont HT, Honore S, Colson P, Chabriere E, La Scola B, Rolain J-M, Brouqui P, Raoult D.  2020.  Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial, International Journal of Antimicrobial Agents, doi: https://doi.org/10.1016/j.ijantimicag.2020.105949.
14. Goodman & Gilman’s:  The pharmacological basis of therapeutics.  2018.  Eds. Brunton LL, Hilal-dandan R, Knollmann BC.  13^th edition.  McGraw-Hill Education.
15. Magagnoli J, Narendran S, Pereira F, Cummings T, Hardin JW, Sutton SS, Ambati J.  Outcomes of hydroxychloroquine usage in United States veterans hospitalized with Covid-19.  Medrxiv preprint.  https://doi.org/10.1101/2020.04.16.20065920.
16. Lippincott Illustrated Reviews:  Biochemistry.  2017.  Denise R. Ferrier.  7^th edition.  Wolters Kluwer, 2017.
17. Vitamin D-Can it help fight COVID-19?  Mobeen Syed, MD.  Medical Education videos.
18. Vitamin C-Can it help fight COVID-19.  Mobeen Syed, MD.  Medical Education videos.
19. Gorton HC, Jarvis K.  October 1, 1999.  The effectiveness of vitamin C in preventing and relieving symptoms of virus-induced respiratory infections.  JMPT.  Volume 22 (8), pp. 530-533.  .
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21. Sil A, Kumar VN.  2020Does weather affect the growth rate of COVID-19, a study to comprehend transmission dynamics on human health.  medRxiv preprint.  https://www.medrxiv.org/content/10.1101/2020.04.29.20085795v1.
22. World Federation of Chiropractic:  https://www.wfc.org/website/images/wfc/Latest_News_and_Features/Coronavirus_statement_2020_03_17.pdf.
23. https://www.acatoday.org/News-Publications/Publications/ACA-Blogs/ArtMID/6925/ArticleID/1551/Let%E2%80%99s-Work-Together-to-Protect-and-Serve-Our-Patients-Staff-Families-and-Communities.
24. ICA.  http://www.chiropractic.org/wp-content/uploads/2020/03/Updated-Report-of-3-28-wtih-fixed-biblio.pdf.