COVID 6
Rick Hodes, MD, MACP JDC-Ethiopia
EthiopianSpines@gmail.com
15 May, 2020
-EMRAP Important Free Announcement -World Update
-Treatment Update
-Hidar Beshita
Articles – Lancet: Kawasaki Disease -New York Times – strokes
-Wall Street Journal - ventilators
To my Ethiopian colleagues:
Greetings! I am writing to give you an update on coronavirus in the US and the world.
First, an important announcement: 1) EMRAP:
There is an emergency medicine website called EMRAP, located at:
https://www.emrap.org/
It is an excellent, online site with live webcasts, an online textbook, and talks by expert academics and clinicians. Normally it costs $495 USD to subscribe for 1 year. For example, most recently they have an 18 minute video on COVID-19 news, higher-risk clinicians, and Kawasaki’s Disease and COVID-19. If any Ethiopians are interested in a subscription at no cost, please contact me.
2) World Situation:
As I write this, according to the Johns Hopkins Coronavirus Map there are about
< https://coronavirus.jhu.edu/map.html>
4.4 million cases of COVID-19 in the world, with just over 300,000 deaths. America is hardest hit with 1.4 million cases, and about 85,000 dead. Looking at Africa: West Africa is being hit more severely than East Africa. Ghana (pop 30 million) has 5400 cases, Nigeria (pop 200 million) nearly 5000 cases, and Guinea (pop 13 million) nearly 2400 cases. They are hit far worse than Ethiopia (pop 110 million), 272 cases, Kenya (52 million) 758 cases, and Tanzania (60 million) 509 cases. Notably Djibouti (1 million) has 1284 cases, and S. Africa (pop 58 million) has nearly 13,000 cases.
Some countries like Israel and Italy have done a good job “flattening their curve,” while other countries like Brazil and Ethiopia still seem to have increasing cases daily.
3) Treatment update:
There has been no breakthrough in the past week. Hydroxychloroquine is no better than previously shown. Remdesivir data is promising, and a combination of lopinovir+ritonavir + ribavirin + interferon was superior to the Lop+Rit (control) in eliminating the virus. We await data on famotidine, which computational chemists find promising.
4) Hidar Beshita: 1918 flu in Ethiopia and worldwide.
The victims in Addis Ababa died like flies” –
British Traveler Sir Charles Rey, published in London, 1923.
As we work our way though the coronavirus pandemic, it is useful to take an historical perspective.
Despite the ongoing COVID-19 epidemic, we can’t equally compare the present catastrophe with the 1918 influenza. Historian John Barry puts its origins in the US state of Kansas. 102 years ago, beginning in spring, 1918 in the USA and lasting for over 12 months, it infected 500 million people, 1/3 of the world’s population, and killed somewhere between 17 million and 50 million. 50 million = 3% of the world population. Perhaps 100 million! There was a W-shaped mortality curve, with highest mortality at age 27. Most of the deaths took place in a 12 week period. (1)
On July 21, 2018 the Italian governor of Eritrea, De Martino, telegraphed his headquarters in Rome describing a “fierce variolic epidemic” raging in Addis Ababa. Variola is the technical word for smallpox. An Italian physician travelled to Ethiopia via Djibouti with 100,000 doses of smallpox vaccine. This was useless. What was happening was actually the 1918 flu pandemic, often called the “Spanish flu.”
There were 2 distinct waves in Ethiopia, the first was quite mild and never properly diagnosed, in April, 2018. Later it hit in full force.
One of the earliest hit in the main wave, on 27 August, 1918, was Ras Tafari Mekonnen (the future Haile Selassie). 4 days later he contacted a French missionary in Harar and asked him to pray for him. An Armenian physician, Dr. Devletian, arrived to treat him. On 2 Sept, Major JH Dodds of the British Legation telegraphed his Foreign Office in London that Ras Tafari was “suffering a form of typhoid prevalent in Addis Ababa.” Others called it typhus.
It was later reported that Ras Tafari was hovering between life and death, and that he had been “touched in 1 lung.” On Sept 8, 1918 (Pagume 3), Ras Tafari deteriorated and hovered between life and death for some days. He was so ill that he was given holy communion. He remained critical but slowly recovered, treated by the French physician Dr. Le Pape.
But he was rumored to have died, and his staff wanted him to appear on the balcony to show the Ethiopian people he was alive. He appeared in public on September 30, 1918. After that, he retreated, to avoid contact with others.
The disease spread. Among Somalis, it was reported that 50% suffered, and mortality was about 7%. Most deaths were due to secondary pneumonia.
The disease is believed to have reached Ethiopia via Berbera, brought by a steamer from Aden. From Berbera it spread rapidly. In early November, the number of influenza cases spiked. And in Djibouti, there were visits of French vessels. The disease appeared a week later.
Within a week, it has reached Addis Ababa. There were mysterious deaths between 10- 15 October of Arabs, Indians, and “faranje.” It struck hard, starting Hidar 1 (November 10, 1918). Aleka Kenfa stated “It advanced like a forest fire.” Ras Tafari’s Armenian physician, Dr. Devletian, died on Nov 11, followed by a British physician. Dr. Assad Chaiban, a Lebanese physician, died. He had been in perfect health, and died in 3 days. 4 physicians died, half the doctors in the country. Swedish missionary Cederzvist noted “God first took the doctors, then swept away the people.” Only 2 doctors worked through the epidemic, the French Dr. d’Antoine de Bosas and Dr. Hamid Nia, an Indian.
The British Consul General and minister plenipotentiary to Ethiopia, Wilfred Thesiger, was told not to return to Addis Ababa.
It was believed that the incubation was only 24 hours. Reported symptoms: fever, headache, sore throat, cough, back pain. Many took to bed, taking 7-10 days to recover to weakness.
Pharmacies closed. There was “no medicine, no aspirin, absolutely nothing.” People desired aspirin, pyramidon (a painkiller), and eucalyptus oil. Those who could, turned to alcohol – wine, whiskey, and cognac. For prophylaxis, Ethiopians were eating garlic and boiling eucalyptus.
Many people fled from Addis Ababa, especially the laborers. Farmers did not bring in food into the city, and existing food became very expensive. Shops closed.
Armenian resident Terzian remarked “The whole town was dead. Shops were closed, some of them even without a lock for even the thieves were not around. The market
was dead. Nobody came to town, there were no “Gallas” or farmers bringing in supplies. It looked like a dead city. Everyone was isolated.”*
Another observer: There was no supplying, everything was closed. There was no bread. And I remember I was eating injera – the servants always had enough teff at home, but we couldn’t get any vegetables or butter.” A paralysis gripped the city. Telegraph was suspended. There were no police. There was nightly looting.
There were 10 Orthodox churches in Addis Ababa, each had 100-150 burials/day. Mortality was highest in younger people.
There was nobody to dig graves, and people could not bury their dead. Dogs and vultures ate corpses by day, hyenas by night. Pretense of burial stopped, bodies were left in deserted tukuls. The cost of coffins skyrocketed. Some bodies were buried a few inches under the soil, and there was fear of a cholera epidemic. When people talked about AA they said “Hulum Sew Alkuwal,” everyone is finished.
Thesiger estimated 10,000 died out of 50,000 in the city. Some felt this was too low.
One account states that the disease stopped on Hidar 21, the feast of St. Mary. Aleka Kenfa claims “Our Lady intervened, and all patients recovered.” At the end of November, the disease moved north to Tigrai. Normal life soon resumed.
Neighboring parts of Ethiopia were affected in spring, 1919, probably the 3rd wave, which was notedly milder. Within a year this was known as the Hidar beshita (2-4).
Even now we are left without accurate treatment and no anti-viral drugs.
What was the “best treatment” in 1918? The “bible” of medicine, Osler’s textbook of medicine, recommended:
Aspirin / bedrest/ gargles /dovers powders – ipecac for vomiting + opium Then standard treatment for influenza was:
Pain – aspirin or morphine Cough: codeine and heroin Stimulants: Atropine
Digitalis Strychnine Epinephrine
Oxygen
May people published their own home remedies with “guaranties” of success. One doctor wrote in JAMA (Journal of the American Medical Association) that blowing
irritating chemicals into the respiratory tract stimulated mucus production and was 100% protective. Another claimed that turning the entire body alkaline with potassium citrate and sodium bicarbonate was effective. (The pH of the body is tightly regulated). Others recommended typhoid vaccine for general immune stimulation. There is some scientific basis for this. Others suggested quinine, hydrogen peroxide, the plant gelsemium, mustard plasters, mercury injections, rubbing creosote (chemicals responsible for the flavor of smoked meat) into the axilla, and enemas of warm milk and creosote.
Old time remedies used in many conditions were applied: cupping, venisection, gargling, and camphor balls around the neck were common. Nothing really worked, and even the standard treatment would not have had much effect.
The only highly effective intervention was was isolation. American Samoa was isolated, and had no cases. A few miles away was Western Samoa, seized by New Zealand from Germany. On September 30, 1918, the population was 38,302. A steamer arrived. The epidemic ran through, and the population decreased to 29,802, a 22% decrease.
Some strains of the flu were more virulent than others. And when the flu struck a city, it decreased in virulence over several weeks. In the first 5 army bases hit, they found 20% of those with flu developed pneumonia, of those, 37.3% died. But in Camp Sherman in Ohio – 36% of cases developed pneumonia, of those, 61% died. 3 weeks later, 7.1% developed pneumonia, and 17% of those died (1).
There was some work with convalescent serum in 1919, which showed that it was effective in decreasing mortality. Redden analyzed 8 studies involving 1703 patients, selected due to the severity of their illness. Crude mortality was 16% among treated, 37% among controls.
There were several sequelae: A form of schizophrenia has reported (7). Survivors had a higher risk of Parkinson’s Disease, including my grandfather (8).
Bibliography:
1) Barry J: The Great Influenza: story of the greatest pandemic in history. Penguin Books, (USA), 2005
2) Pankhurst R: The Hedar Basheta of 1918 Journal of Ethiopian Studies 1973, 13(2):1030131.
3) Yahehrad Kitaw, Mirgissa Kaba: A century after Yehedar Beshita (The Spanish Flu in Ethiopia): Are we prepared for the next pandemic? Ethiopian Journal of Health Development, 2018;32(1).
4) Pankhurst R: A historical note on influenza in Ethiopia. Medical History 1977;21:195- 200.
5) Redden:boston – using Convalescent serum published on December 11, 1919Boston Med Surg J 1919; 181:688-691 (later renamed New England Journal of Medicine) DOI: 10.1056/NEJM191912111812406
6) Luke TC, Kilbane EM, Jackson JL, Hoffman SL: Meta-analysis: Convalescent blood 6) products for Spanish Influenza pneumonia: a future H5N1 treatment?
Annals Int Med 2006, 17 October
7) Kepinska, Iyegbe CO, Vernon AC et al: Schizophrenia and influenza at the Centenary of the 1918-1919 Spanish influenza pandemic: mechanisms of psychosis risk.
8) Henry J, Smeyne RJ, Jang H, Miller B, Okun M: Parkinsonism and neurological manifestations of influenza throughout the 20th and 21st centuries. Parkinsonism Relat Disorders 2010 Nov;16(9): 566-71
*Note: I realize this is pejorative, but chose to quote this correctly for historical accuracy.
I can provide the Ethiopian history papers to anyone interested. They are fascinating.