COVID-19: Who's At Risk & What's the Deal with Hydroxychlorquine?

by Ann Gerhardt, MD                        March 20, 2020
People at Risk: The first documented COVID-19 case in the U.S. was a  35 year-old Washington State man with no underlying disease , who had recently visited family in Wuhan, China. He had fever and cough, was hospitalized, developed complications and recovered after treatment with an experimental drug.  Anyone in any age group can and does get COVID-19.  Do not believe you are immune if you are young and have no predisposing conditions.

As of March 16, in the U.S.,  69 % of cases,  55 % of hospitalizations,  47 % of ICU admissions and  20 % of deaths occurred in patients aged  younger than 65 years . A huge percentage of those requiring support with a ventilator die regardless of age. Those aged under 20 years are least likely to die, but they still get relatively mild infections putting the parents and grandparents at risk. Anyone can get it and any who do can spread it to others. Hence, social distancing helps.

Urging older people, especially those with underlying disease, to isolate themselves is not because they are the only ones to get the disease, but because they are more likely to die from it. Italy may have more infections and a higher death rate because its population is one of the oldest in the world, second only to Japan.

Because our President has only recently authorized widespread testing, we still don't have good data about the characteristics of the many people with mild disease compared to those with severe disease. We know those with poor immune systems include the elderly, those with autoimmune disease or organ transplants who take immune suppressants, those with genetic immune deficiency or no spleen, and those who are malnourished or have chronic inflammatory disease or diabetes. Others carry excess risk, like those with heart disease, for unclear reasons.

Stories of groups who spend the day together, followed by one dying and one seriously ill from COVID-19 while the others remained well merely confirm that we can't predict who will fall ill.  We don't have good enough studies of people to be able to refine specific risk factors.

Right now, my guess is that those most likely to get sick are those who continue to congregate in groups and not compulsively wash their hands after exposure to public hard surfaces.

Don't demand hydroxychloroquine from your doctor. There is preliminary evidence that the drug might help those with COVID-19.  BUT, timing is everything. Hydroxychloroquine is an immune suppressant, meaning it puts people at risk of infections by dampening the immune system. If a person with no disease takes it, it might increase risk of SARS-CoV-2 infection and disease (COVID-19). When hydroxychloroquine might help is after symptoms develop. 

Virologists believe that after the virus attaches to and infects cells of the respiratory tract, it triggers the immune system to fight it off. That's a good thing unless the immune system overdoes it, with a "cytokine storm", which actually contributes to disease severity. Thus, hydroxychloroquine can be effective against the resulting inflammation, thereby minimizing lung damage. In summary,  we only need it after COVID-19 onset.


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