COVID-19 A perfect storm

Did you know that 20,000,000 Americans don't know they have asymptomatic liver disease?

Did you know that disease called COVID-19 is caused by the virus SARS-CoV-2?

Did you know that COVID-19 or SARS-2 is more dangerous to society than SARS-1.0 which hit in 2003 and killed 9.6% of those infected?

Did you know that if you have advancing fatty liver disease without any symptoms your risk of death from SARS-2 is higher than average?

I have some concern about writing this.  When we face a crisis, panic and reactions driven by fear can do great harm.  I do not wish to contribute to that, however, as an advocate for people faced with chronic illness, such as liver disease, I feel compelled to inform my community about the details.

This is a new corona virus strain but since it causes Severe Acute Respiratory Syndrome it is officially a SARS type virus. It is not just a variation of the earlier one so this is a human pathogen to which we have no immunity.

A key difference between the original SARS and this virus is that while SARS was more deadly it didn’t spread easily. SARS-CoV-2 is a very efficient spreader so even though it isn’t as dangerous individually it is a far greater risk for society broadly and will kill far more people because it spreads very easily and will infect a large number of people.

Sadly, most potential victims may not know that they are part of a high-risk group. How high? We still have limited data but we know young people have a low mortality risk, but if you are over 50 the mortality accelerates rapidly with age.  If you have NASH, nonalcoholic steatohepatitis, your risk increases even more depending on your liver disease stage.

We have to think about any people whose health is compromised. Just as an example, let’s think about NASH and the fibrosis that is the result. This table is about the hazard ratio of different diseases compared to the four stages of NASH. Stage 4 is otherwise known as cirrhosis.

hazard-ratio-1.jpg

To keep this simple, the HR (Hazard Ratio) shows the probability of death from some disease compared to the general population. You can see that Fibrosis stage 1 at 1.88 is more likely to kill you than diabetes which is 1.61. This provides a frame of reference.

You might wonder how many people have Fibrosis stage 1 or higher. Might it surprise you that we don’t really know? The disease is usually symptom-free until well advanced but it is the hazardous form of nonalcoholic fatty liver disease or NAFLD. It is estimated that about 100 million Americans have NAFLD and about 20 million have NASH. The reason we don’t really know is because as a society we don’t screen for the disease. That is a topic for another time but it is a problem with our healthcare system. One other thing you might notice in the chart is that it is more dangerous to have fibrosis than it is to be old.

So why would this virus be particularly dangerous for someone with NASH? It is, after all, a cold virus that attacks the lungs and causes pneumonia. This is a normal pathway for a coronavirus. There may be several answers to that question but one of them is that this virus also attacks a receptor or gateway on the surface of some cells. Those cells are found in a variety of organs and the receptor is called ACE2. It gets complicated, but one location is in cells called cholangiocytes. Big word but the important fact is that these cells are in the lining of the bile ducts of the liver.

The liver is also an important part of the immune system so as the body fights its battle in the lungs the liver is also defending itself. If a person happens to have a damaged liver, as 20 million of us do, you might suspect that our risk from COVID-19 will be higher than that of a healthy person. Since age brings with it liver damage as part of aging, the idea that this virus would be a hazard for older people isn’t surprising. A challenge is that for most victims neither they nor their doctors know that they have NASH or any of the other mostly silent liver diseases.

The problem is that this new virus is about twice as infectious as the original SARS. Another fact that simply amplifies the danger is that unlike SARS this new virus can be spread by asymptomatic people and by people with very mild cases. It has the potential to simply explode where the earlier virus did not. 

We have about 100,000 critical care and ICU beds in the country. If this virus gets out of control we won’t be able to care for all the patients. If we infect 30% of the at-risk NASH patients, which is the potential, that is 2 million people and about 400,000 are likely to need critical care. The system can’t manage that and this doesn’t consider other patient populations. With that background, this message is directed to anyone who knows they have any kind of liver disease or its companions of diabetes or any of the comorbidities that plague the community. Do not take chances. This virus will spread throughout the country. We do not have the tools to stop it yet. Taking yourself out of the line of fire, for now, is the best defense.

We wish you the very best as we, as a community, cope with this rising tide of infection.

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