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Influenza and CoronaVirus: A Thoughtful Response

Influenza and CoronaVirus: A Thoughtful Response

How should you respond to the spread of the Coronavirus?  Renamed COVID-19.  What is the most rational and sane response?  Should we close off all the borders?  Should we cancel all conferences and outdoor events?  Should we cancel the Olympics?  What is the real prevalence and mortality rate?  The answer: this is a time for vigilance, preparation, with calmness.

This is your grand sweep of time overview.  This series will be updated as this is a fast moving story.

CoronaVirus Requires Organized Incident Command

Great leaders exhibit calmness and reassurance while at the same time exhibiting  the qualities of a effective incident commander.  That is how massive wild land fires are fought.  An incident commander is identified and the command structure is assembled. Plans are coordinated and executed purposefully with determination.

So the problem with the Coronavirus is the fear of the unknown.  In the end this will portend far greater economic, commercial and societal consequences than epidemiologic or medical outcomes.  We have already seen a precipitous fall in the stock market, amounting to $5 trillion ($5,000,000,000,000) in paper losses.  It will rebound, but will fall again.

We should heed the words of Franklin Delano Roosevelt.  The only thing we have to fear is fear itself.  You will not die.  You simply need to take modest precautions.

Disease Outbreaks — Four Horseman of the Apocalypse

We are always faced with the Malthusian Four Horsemen of the Apocalypse.  War, famine, pestilence and disease.  They will never fully disappear.

Throughout all of human history we have witnessed great epidemiologic challenges and disasters.  Leprosy, tuberculosis, the plague (the Black Death), smallpox, the pandemic flu of 1918, AIDS, SARS, swine flu, MERS, Ebola virus and now Coronavirus.  It will never end.

There were numerous recurrences of the plague through out the middle ages.  The worst in 1348 where an estimated 40% of population throughout Europe succumbed.  That must have seemed like the end of the world.  It was centuries before the germ theory of contagious disease.  No one knew the source.  So there were religious incantations.  There were whole groups who were shunned or dispossessed.  And then it stopped.

Half of Paris’s population of 100,000 people died. In Italy, the population of Florence was reduced from 110,000–120,000 inhabitants in 1338 down to 50,000 in 1351. At least 60% of the population of Hamburg and Bremen perished,[81] and a similar percentage of Londoners may have died from the disease as well.[67] In London approximately 62,000 people died between 1346 and 1353.[19]  — Wikipedia

1918 spanish Influenza pandemic

During the Spanish flu Pandemic of 1918, it is estimated that nearly 1/3 of the world’s population contracted the flu.  More than 500,000,000 people.  It followed the end of WWI, with mass troop movements.  With massive shifts in human populations.  The flu actually lasted 2 years.  There was a ping-pong effect between America and Europe.  The stories are legion of physicians working around the clock, tending to patients without antibiotics or antivirals as we have today.  That also was a draconian period of time.

But we survived.

Annual Influenza Review

Each year I compose a blog detailing the ineffectiveness of the influenza vaccine, because the flu mutates each year.  The vaccine is always based on last year’s virus.  It is always a guess.  Effectiveness varies between 10-60%.  But a more detailed look at vaccine effectiveness shows a distinct stratification according to age.  Where the effectiveness of the vaccine is even dramatically less in older and frail individuals.  That is why we are now giving triple or quadruple strength vaccines to older individuals.

And currently the number of fatalities from the flu, even this year, far exceeds the Coronavirus.  But the flu has become displaced as the topic du jour.

CoronaVirus in Perspective

Even last week a more detailed look at the viral spread in China is quite revealing.  At least 80% of all cases originated in one province.  From Wuhan.  Virtually no fatal cases in Shanghai or Beijing.  High density populations where you expect higher incident and mortality rates.  You never hear about this.  And with draconian infection control the rate of spread is beginning to diminish.CoronaVirus StatisticsIt’s interesting a whistleblowers complaint about known Coronavirus patients disembarking from a ship in Vallejo may have been the source of the recent death.  But what about all of the unprotected team members who were sent home?  As far as we know none of these have succumbed.

In the end all viral and bacterial infections are a host response.  If you are healthy and vigorous, your chances of contracting any illness are diminished.  Those that are older and frail are more subject to pneumonia and perishing.

I am not reassured by the current administration’s haphazard and amateurish approach.  This appears to be a Keystone Cops approach. There are some stars.  Dr. Anthony Fauci is highly respected at the CDC.

Treatment Modalities

So here are my annual recommendations.

These were formulated for the flu but may pertain to the Coronavirus.   Influenza vaccines are ineffective.  Anti-virals such as Tamiflu and Relenza have immediate value if taken within the first 48 hours.

My recommendations each year are effective.  [Although the usual FDA disclaimers for advocating treatment therapies are acknowledged.]

At the first sign of the flu or any viral syndrome:

  • 50,000 units of vitamin D daily for 5 days.
  • Astragalus 1000 mg daily for 5 days.
  • Thymic protein A (ProBoost) 1-2 packets 3 times daily for 5 days.

The effectiveness of vitamin D against viral syndromes is well demonstrated.  Similarly should there be any doubt of high dose vitamin effectiveness, the only known cure for severe life-threatening measles is – vitamin A.

Wash your hands.  As Ignaz Semmelweis demonstrated in the mid 19th century, washing the hands prevents dissemination of disease.  He was able to decrease the rate of postpartum death  (Puerperal Sepsis)  from 40% to 1% simply by washing hands (in carbolic acid).

Stay calm. Get plenty of rest and sleep.  Don’t panic.

Let me know your own observations.

 

Philip Lee Miller, MD

Carmel CA

March 3, 2020

2018-2019 Flu Vaccine, Prevention and Treatment

2018-2019 Flu Vaccine, Prevention and Treatment

This is my seasonal flu post.  One that I update each year.  Here are current recommendations and controversies regarding influenza vaccinations, prevention and treatment.  I am going to give you a slightly expanded version this year related to last year’s flu vaccine post.  In short, I have never been a proponent of flu vaccinations.  I am middle of road on vaccinations.  You really want polio, measles and mumps and tetanus every 10 years.  For high risk exposures you want Hepatitis B vaccination. But we are over vaccinating our children and even pets.

Influenza is a seasonal epidemic viral syndrome that usually starts in December and lasts until approximately February or March.  In the past, I would begin to see large number of acutely ill patients pouring into my Urgent Care clinics in October and November. I eventually termed this the “pre-flu” syndrome.  Something approximating the flu but not the full-blown symptom complex.  The true flu is manifest as fever, shaking chills, severe achiness (myalgias), and malaise.  You feel really sick.  This is more than a common cold.

Now the problem with flu vaccination recommendations is dependent on who makes the recommendation and for what population.  I am going to make a recommendation for you specifically.  This is in contradistinction to a public health official who epidemiologically makes decisions for large populations.   They are concerned about “herd immunity.”  Higher rates of immunized people decreases the spread.  At least that is the theory.

There is no universal flu vaccine

The challenge has always been how to formulate this year’s flu vaccination.  There is no universal flu vaccination.  That is the basic dilemma.  Influenza A is the more virulent strain mainly affecting adults.  Influenza B affects mainly children.  Influenza mutates by “antigenic drift” from year to year.  It can even mutate during incubation. In most years, there is a “minor antigenic drift.”  In some years there is a “major antigenic drift,” in which case far more people fall ill because they have not never been exposed to the current strain.   And thus it is more virulent. A pandemic.

Flu Strains

Epidemiologists classify influenza with two attributes.  H attribute (hemaglutinin).  And N attribute (neuraminidase).  H1N1 and H3N2 are targeted this year.  So the recommended quadravalent (4 strains) flu vaccine being manufactured this year targets:

  • A/Michigan/H1N1
  • A/Singapore/H3N2
  • B/Colorado 2017 B/Victoria 87
  • B/Phuket 2013 B/Yamagata 88

Because we do not know the precise strain that will prevails this 2018-2019 season, it becomes our best educated guess.  What is the most likely strain based on recent world wide observations.  The selection process may begin in February of the current year.  This gives enough lead time for sufficient vaccination stocks to be replenished each year.  This takes time.  It is all the guess.  Again, the primary dilemma is – there is no universal flu vaccine.  That is the holy grail.  Research scientists are busy trying to develop this.

Vaccine Effectiveness Rates

CDC Seasonal Flu Vaccine effectiveness
Seasonal Influenza Vaccine Effectiveness, 2004-2018

Last year it was said that the flu vaccine was only 10% effective.  In retrospect, the CDC published an average for all age groups of 40%.  Here are the reported rates of effectiveness for the last 14 years [link is no longer available].  A more detailed breakdown by age for 2016-2017 shows even more variability.  All these statistics are somewhat irrelevant.  What is more relevant is the flu vaccination most often less than 40% effective.  So the recommendation is based on, “well, it’s better than nothing.”  I can’t think of hardly any other medication in use today were the rationale is, “well, it’s better than nothing.”  Surely there must be a stronger argument and rationale to the widespread public campaign to “get your flu shot now.”

Recalling my days in Urgent Care once again in the early 1990s, it was common knowledge that “there is no medical treatment for the flu.”  So you must get a flu vaccination.  This always puzzled me because there was indeed a medication that treated the flu.  Symmetrel (Amatidine).  This was discovered by happen stance when so many Parkinson’s patients who were treated with Symmetrel for “the shakes” had a much lower incidence of the flu.  I began using Symmetrel with rewarding success.

Anti-Virals now available

Today, we have a developing stable of anti-influenza virals.  That is Tamiflu, Relenza, Rapivab and the newest Xofluza (Baloxavir).  So you have a choice.  You can have the flu vaccine in various forms.  You can defer any vaccination and be treated with any of a number of antiviral drugs.  Or there is a natural routine that I have developed over the years.  Empirically quite effective.

My recommendation for a natural approach

Miller Anti-Viral Regimen ™

  • Vitamin D 50,000 daily x 5 days
  • Astragalus 1000 mg daily x 5 days
  • Thymic Protein A (TPA) 1-2 packets 3 times daily x 5 days

So what do I recommend?  I have been a proponent of aggressive doses of vitamin D which is known to prevent seasonal flu syndromes.  At the first sign of any viral illness or especially the flu, start taking vitamin D 50,000 units for 5 days.  Yes that is high dose.  Astragalus 1000 mg daily for 5 days and a proprietary product called Thymic Protein A (ProBoost).  One packet 2-3 times daily for 5 days.  This is a highly effective routine.  And most effective when started in the first 48 hours.  Sometimes this routine is so effective that after one or day, you may feel totally resolved and stop the routine.  2 to 3 days later, the virus is even stronger.  So a 5 day routine is highly recommended.

Now let me know your thoughts and experiences.

Philip Lee Miller, MD
Carmel, CA 93923
Nov 2018

Vitamin D and Osteoporosis Prevention

Vitamin D and Osteoporosis Prevention

Vitamin D is back in the news again.

You may have seen recent news claiming vitamin D supplementation fails to prevent osteoporosis, fractures or falls.  Published in the Lancet — a Systematic Review and Meta Analysis paper dated October 04, 2018 from the Department of Medicine, University of Auckland, New Zealand and the Health Services Research Unit, University of Aberdeen, Scotland, UK.  They conclude and state at the end of a complex meta-analysis

“we believe there is no justification for more trials of vitamin D supplements with musculoskeletal outcomes because there is no longer equipoise about the effects of vitamin D on these outcomes.”

Rather strong conclusion designed to forestall any further investigation or discussion.  Really?

Now personally, I owe my interest in vitamin D supplementation to my good friend Dr. William Grant of SunArc.  And work that has been done by Dr. John Cannell, who founded the Vitamin D Council headquartered in Marina del Rey, California.  Both are superb sources of ongoing vitamin D research.

A meta-analysis is a literature review of all relevant resource papers.  It suffers from specificity and accuracy of database key words, capture and design.  It is limited by various assumptions, and highly intricate statistical conventions.  Studies are excluded or included based on assumptions of the authors.

One of my current criticisms of all these citations is failure of a popular news article to actually cite the source.  So we cite here.  Effects of Vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis and trial sequential analysis.  You will have to pay to actually read this paper.  So, I will summarize for you.

The paper is exhaustively written and detailed.  But suffers from a number of limitations and dubious pharmacologic assumptions.

First, it is stated that there was no difference between high-dose vitamin D and low dose vitamin D.  What defines high-dose and low dose?  Low dose was <800 units per day.  High-dose was >800 units per day.  I always have issue with “greater than” or “less than” because of a lack of specificity.   >800 could be 801, 1000, 5000 or 50,000.  You don’t know.  <800 could be 799, 700 or 100.  To be somewhat facetious.  But it is highly important because we don’t know from their study.  What would be the ideal dose of vitamin D?   Who decided on this magical 800 units number?

In fact, that is where 80% of all medical and scientific studies fail.  Who chooses the ideal dose?  On what basis is an ideal dose determined?

I often use a facetious example of Lipitor.  Lipitor will lower your cholesterol.  More specifically, your LDL values.  I could design an experiment using 1 mg of Lipitor for one year.  You will see no benefit.  It is too low.  A study using 1 mg would conclude Lipitor is a worthless drug.  In the other hand, let’s use an arbitrary dose of 100 mg of Lipitor for a study.  After one year I would conclude this is a highly toxic drug causing muscle pains, memory losses and liver abnormalities.  A drug that is too dangerous.  So at some point, scientists determined that the ideal dose of Lipitor is 10 to 40 mg.  With a certain segment of the cardiology community is using extremely high doses of 80 mg.

Dose-response.    A fundamental tenant of good pharmacologic design and use.

Now back to vitamin D.  We are told that the levels achieved were were either >50 nmol/l or >75 nmol/l.  Again we have the problem with the specificity of “greater than.”

Furthermore, most commercial clinical labs report in ng/ml not nanomoles/l.  So  >50 nmol/l  =  >20 ng/mL and >75 nmol/l = >30 ng/mL.  What does this mean?

Vitamin D testing (using GC/MS/MS) is one of the lab tests that that is rationally graded on a continuum. Not simply high or low cutoffs. <15 ng/ml is (severely) deficient.  15 to 30 ng/ml is insufficient.  30 ng/ml to 100 ng/ml is sufficient.  > 100 ng/ml is excess.  And >150 is considered toxic.  Never mind, that it is not toxic.

So that this meta-analysis using a “high value” of >75 nmol/ml  ( >30 ng/mL ) is not high.  It is barely therapeutic.  Just barely at the very lower limits of therapeutic.  Like driving a car with a 1/4 tank of gas.

Personally, and in the Anti-aging / Nutritional Medicine community a consensus seems to be a daily dose of 5000 units is the average starting dose for the overwhelming majority of our patients.  Aiming for 60-80 ng/ml blood values.  That seems to be the ideal dose and value.  There are individual variations so that some of our patients will require 10,000 and 15,000 or as high as 20,000 units daily to achieve good therapeutic levels.  In rare cases patients only need 3000 units.   But clearly 800 units is nearly useless.

So this meta-analysis suffers from so many shortcomings.  A meta-analysis is a poorly controlled study because it is a retrospective look at a host of studies all probably suffering from experimental design weakness.  Then there is the highly intricate retrospective statistical conventions excluding and including various studies for capricious reasons.  Starting with a completely capricious and arbitrary dose and level.  And finally, we have no idea whether blood levels were drawn at one time during a study or weekly or monthly or the beginning or the end.  Most likely levels were drawn very infrequently and then assumed to be constant through the study.   Probably None of these studies were carried longer than one year.

Finally, Vitamin D alone is probably insufficient to enhance bone integrity and prevent osteoporosis.  Empirically, I have observed osteoporosis is prevented by a combination of estrogen or testosterone vigor, vitamin D3, vitamin K2, the right balance of calcium and magnesium, and light weight bearing exercises.  A study simply looking at the efficacy and levels in potency vitamin D will never prove the assertion that osteoporosis cannot be prevented by vitamin D.

There are some political considerations.  The US Preventive Services Taskforce specifically recommended against Vitamin D supplementation to prevent fractures or falls.  They intentionally excluded all of the known experts in vitamin D.  Of which there are only 4 or 5 notable vitamin D researchers in the world.

So beware.  This meta-analysis or study does not prove that vitamin D is either inadequate or useless.  I personally  recommend vitamin D at least 5000 units daily,  Vitamin K2 15 mg,  800-1000 mg calcium 200-600 magnesium, weight-bearing exercises and evaluation of your hormonal status.  This is simply a starting point.  There is considerable variation from patient to patient.  That is why you need expert advice and counsel.   Reference my earlier blogs on Osteoporosis Prevention.   And the importance of Vitamin K2.

Reader beware.

Philip Lee Miller, MD

Carmel CA

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