COVID-19 is has decided to stay and Americans need home treatments

After a brief reprieve, new cases of COVID-19 have been on the rise in the U.S. since June 9, and the slope of the seven-day average is moving up sharply, approaching the rate of the initial March 11 to April 5 runup. This time, greater numbers of Americans are becoming infected.

The U.S. curve resembles that of Sweden, but at much larger absolute numbers. Recall that Sweden was one of the few countries that did not put in place lockdowns or other extreme measures to stop community spread. The good news is that COVID-19 deaths are down and, despite the long lag between new cases and mortality, there are no signs that deaths will turn up with the same velocity as new cases in the U.S.

Thus, the viral pandemic is showing a new face: person-to-person spread among young people as social distances narrow and things return to normal in social and work life. While many people continue to work from home, some young people have returned to service work, dating, bars and restaurants and given the virus new opportunity.

The greatest concern for a second wave is an overrun of hospital beds in a beleaguered health care system. Most policy efforts and media reporting concerning this issue have angled towards stopping the spread after declaring victory too early. Understanding the Centers for Disease Control and Prevention (CDC) has estimated that nearly 20 million people have been infected, we should start to think about nearly all of us becoming infected. It’s time to change focus to treating the illness at home and avoiding hospitalization. 

There is a large effort under way to develop treatments for COVID-19. Most experimental protocols are designed for in-hospital intravenous administration to reduce the rates of mechanical ventilation and/or death. There are few novel, oral drugs being developed or tested for home use. While potential vaccines provide hope, the virus is mutating and becoming more infectious and, like many pathogenic viruses, is not likely to be amenable to a vaccine.

Current advice to COVID-19 patients who are ill at home is to contact their doctor. Little is said after that, and one may wonder what a doctor can do, given our current understanding. To be clear, there are no Food and Drug Administration (FDA)-approved outpatient treatments for COVID-19 and the few clinical trials in place for outpatients are likely not to deliver answers or provide the foundation for treatment guidelines for two years or more. As a result, many doctors simply do not treat COVID-19. For patients, this may mean survival of the fittest, explaining much of emergency room use, hospitalization and mortality data. 

Other doctors may take the view that doing something is better than nothing, even in the absence of medical evidence recognizing that hospitalization and death are among most serious outcomes for any acute illness. This more hopeful approach would operationalize the principles of what has been learned about COVID-19 in the past few months, leveraging medicine as both an art and a science.

The first principle is to reduce viral particle reloading. The dose of viral inoculum is probably related to the severity of illness. Because the virus forms a bioaerosol around the victim in exhaled air, it makes sense to open the windows and, better yet, go outside, keeping one’s distance from others, without a mask and “breath off the virus,” instead of inspiring it back down into the oropharynx and lungs. 

The second principle is to take drugs to slow the virus. Over-the-counter zinc lozenges have been shown to attenuate older coronavirus infections and are worth a try. The only two prescription agents suggested in the U.S. are azithromycin and hydroxychloroquine, which have weak off-target effects to slow viral damage to cells. Results are conflicting when given very late in the hospital; however, when given early at home, the outcomes may be more favorable. In Russia, the health ministry approved the oral drug favipiravir for outpatients based on antiviral effects and very limited human data in the spirit of doing something instead of nothing. This is similar to the current use of oseltamivir, a minimally effective medicine for influenza. 

The third principle is to prevent or treat “cytokine storm.” The bulk of the evidence now suggests that the severe damage to the lungs, heart, liver and kidneys in COVID-19 is not directly from the virus, but instead because internal cell-signaling pathways called cytokines go into deadly overdrive. The most tractable way of reducing cytokines and internal inflammation is the early use of corticosteroids.

The fourth principle is to prevent or treat microthrombosis. The virus causes small blood clots in the lungs and elsewhere that lead to some of the clinical findings, including respiratory failure and chest pain. Mild blood thinners such as aspirin can be used immediately, and prescription treatments such as enoxaparin injections or oral anticoagulant pills can be prescribed for home use.   

Lastly, there have been severe cases managed at home with supplemental oxygen, use of pulse oximeters and self-proning, which involves lying on the chest and abdomen to allow the lungs to be better aerated. While these approaches may seem radical, and a large departure from current  “do nothing” home standards, for many patients the specter of hospitalization, isolation from loved ones, and the sheer terror of dying alone build a strong case for an attempt at providing compassionate outpatient treatment. Keep in mind, the hospital can offer only one FDA-approved, minimally effective drug (remdesivir), given to fewer than 1 percent of cases but administered far too late. As a rule, treating an infection and its consequences early is always better than waiting until it gets worse and results in hospitalization.

It appears we are facing even a bigger battle this summer than we did this spring. It’s not just troublesome in Texas, Florida and Arizona — COVID-19 is more communicable and has found new friends who can spread it around far more quickly and broadly than occurred at the start. While younger patients may be less likely to die, hospitals still will be overwhelmed, perhaps on a much larger scale than they were in New York and Detroit. We need ambulatory clinical trials and practical support for doctors to treat patients at home with the goal of preventing hospitalization and death.

Peter A. McCullough, MD, MPH, is vice chairman of medicine at Baylor University Medical Center and a professor of medicine at Texas A&M College of Medicine in Dallas. An internist, cardiologist, and epidemiologist, he is the Editor-in-Chief of “Cardiorenal Medicine” and “Reviews in Cardiovascular Medicine.” He has authored over 500 cited works in the National Library of Medicine.