Tagged health habits

Lightning, Thunder, Flash Floods…Drownings

“Obviously if you do more testing you’re gonna see more cases but the increases that we’re seeing are real increasing in cases, as also reflected by increasing in hospitalization and increasing in deaths.”

           Dr. Anthony Fauci, Congressional Hearing, July 31

“It’s very frustrating as an epidemiologist to see these cases at numbers continuing to rise without a national strategy, without adequate testing, without contact tracing as we need it—all of the things we’ve been talking about for months and months and these numbers are going to continue to go up until we do have these things in place.”

           Dr. Ann Remoin, UCLA, August 2

“What we are seeing today is different from March and April. It’s extraordinarily widespread.”

           Dr. Deborah Birx, White House task force, August 2

“It’s like a policy of mass human sacrifice.”

           Rep. Jamie Raskin, D-Maryland, Congressional Hearing, July 31

Dear Students,

At this writing, a tropical storm is progressing from the Caribbean up the east coast of Florida and will proceed north from there, affecting to some extent even the northeastern U.S. This is below hurricane status but still has hurricane-speed winds and has badly flooded some Caribbean islands. Storm surges will follow after the wind and rain die down. There have been drownings. They will be very sad and perhaps to some extent avoidable.

But as you know if you’ve been following my updates, the drownings in the title above are metaphoric—the deaths are all too real, but they do not involve storm waters. Americans are drowning and dying in the flash floods of viruses, being killed partly by the accumulation of fluid in their lungs as part of the crash of lung and heart function under viral attack. And the numbers of dead are hundreds to thousands of times higher than will be caused storm drownings.

So: our metaphor likens the features of a storm in weather to the features of the resurgent viral pandemic. You know I am not impressed by a surge in cases alone, if only because our mendacious political leaders falsely claim that more testing leads to more cases. For the record, once again: it is a lie that we do more testing than any other country, and it is a lie that 99 percent of the cases detected are benign. There are simple ways to use case records to refute these lies, such as rising or falling ratios of positive tests to total tests, but I decided not to get into an argument with unscrupulous men who have the most powerful megaphones in the world. I decided to wait for a measure that has no relation at all to the amount of testing: hospitalizations.

I suggested we think of the case surges as lightning and the hospitalizations following as thunder. As we began to see a month ago, the lightning strikes across the southern half of the nation were followed a few weeks later by rolling thunder. Hospitalizations surged, hospitals overflowed, health care workers were overwhelmed, and in general the southern states that had been feeling superior to New York followed exactly in New York’s path, in a way that was as predictable as it was completely unnecessary, since New York had blazed the path—both on the way up and on the way down.

I said at that time that I was not sure that deaths would follow hospitalizations, because the average age of victims was younger, and the treatments for advanced cases were better. I said that if the cases were lightning and the hospitalizations were thunder, the next stage could, but hopefully would not be, flash floods (overwhelmed lungs and hearts) and drownings (COVID-19 deaths).

This hope was dashed, and the surge in deaths is here. That is why Dr. Fauci told Congress on Thursday that the increase in cases is real, “as also reflected by increasing in hospitalization and increasing in deaths,” contradicting the lies of his boss and the leaders of several southern states.

 

Bad News

  1. The huge surge in America’s cases in June, which did not occur in any “advanced” country (or even in countries like Georgia, Rwanda, and Uruguay) was not a second wave, it was a devastating extension of the first wave. All advanced countries and some developing ones completed their first wave by reducing cases to tens or hundreds per day. The lowest we ever got was 20,000 a day, and now we have 67,000, more than double the mid-April maximum of around 31,000. Every day.
  2. Rep. James Clyburn, House Majority Whip, chairing Thursday’s congressional hearing on the coronavirus, showing the surge

    These cases are not caused by increased testing, and the U.S. does not have a good testing program. Our per capita testing is behind a number of other countries, who are testing more and finding fewer cases. Also, we are doing the wrong kind of testing, taking an average of four days and often much longer to get results. These results are useless for contact tracing. As Bill Gates said months ago, what are you supposed to do, send apology notes to the people you infected before you knew your own result?

  3. But then again, we do not have serious contact tracing, certainly not where the epidemic is worst. I and many others said months ago we would need an army of contact tracers, and we barely have any. It may be that with the numbers of cases we have now (at least 4.5 million), contact tracing is no longer a possible strategy for controlling the disease. Imagine contacting all the 67,000 new cases each day, finding all their contacts, testing them, and isolating those who (a week later) turn up positive, and then contacting their contacts, and—you get the idea.
  4. Nationally, hospitalizations are clearly up again, the “rolling thunder” I wrote about on July 9th. This, as I showed you, was especially true in 20 states, and now it is true in more. Even averaging in the big declines in the northeast, weekly hospitalizations per hundred thousand were around 10 in mid-April, 4 in mid-June, and back up to 7 in mid-July. Multiply each of those numbers by 3,300 to get the approximate totals. Further increases are likely.
  5. Daily deaths in the U.S., the best indicator of the progression of the pandemic, peaked in mid-April at around 2,300. They bottomed in late June at around 550. As of today they have been over 1,000 for the last few days. The increase in July was steady, large, and real. Bear in mind that these national figures average in an ongoing decline in deaths in the northeastern states, so much of the rest of the country is at an all-time high. Deaths are a lagging indicator, so they could go higher. Black, Latinx, and Native American people are affected much worse than whites. Prison inmates, nursing home residents, and workers forced into dangerous conditions in meat packing and other workplaces are most at risk.
  6. All the above statistics were coordinated, analyzed and reported by the Centers for Disease Control, a collection of 1700 scientists ideally suited to this task. It was taken away from them two weeks ago and placed in the hands of the much less experienced and much more political Department of Health and Human Services. The only reason I can see for this change is that the people in power in Washington were not satisfied with their efforts to muzzle the CDC and distort its work, so they just admitted what they were doing and made the collation of statistics purely political.

 

Good News

  1. The first vaccine to enter Phase 3 clinical trials is the one being jointly developed by the biotech company Moderna and the National Institutes of Health. This is a real-world trial in which 15,000 people will get vaccine and the same number placebo, which gives it sufficient power to see whether the vaccine protects people from community spread, and whether it is safe. It allows representation of age, sex, and minority populations. It is an mRNA vaccine of a type not approved for human use before. (For more on different vaccine types, see my update of June 20th.)
  2. The University of Oxford/AstraZeneca vaccine, based on a chimpanzee adenovirus carrying coronavirus genetic information, is expected to start Phase 3 in August, and the Pfizer/BioNTech one, like Moderna’s an mRNA vaccine, in September. This website monitors vaccine progress. “Experts estimate that a fast-tracked vaccine development process could speed a successful candidate to market in approximately 12-18 months – if the process goes smoothly,” the website says. I think that means 12-18 months from when they started earlier this year. Roughly 150 vaccine projects are under way worldwide, the above three being among the five prioritized in Operation Warp Speed (stupidly named because it will increase anti-vaxxer rejection).
  3. Dr. Anthony Fauci, the nation’s top infectious disease expert, did an amazing job Thursday testifying to Congress for almost four hours (with a little, actually very little help from two other officials, and a lot of speechifying from Representatives of both parties) before the House Select Subcommittee on the Coronavirus Crisis. He managed to thread the needle of telling the truth without saying anything that might get him fired, something no other government scientist or physician can do. But if you want to hear the real Dr. Fauci in a real conversation with other scientists, being himself and saying what he thinks and knows without pausing for many seconds before carefully answering, listen to the July 17th episode of This Week in Virology (TwiV-641).
  4. Treatments are also being sought throughout the world. The ones working now are: Remdesivir, an antiviral developed for Ebola; dexamethasone, a tried and true general-purpose anti-inflammatory; and convalescent plasma (probably). On the near horizon are monoclonal antibodies derived from convalescent plasma, other anti-virals, and combinations of anti-virals. Remember that a triple antiviral therapy changed HIV/AIDS from a deadly to a chronic disease, and plays a vital role in limiting spread. (Contrary to my own hopes, since I safely took it for malaria prevention, hydroxychloroquine doesn’t work. Also, ingesting or injecting bleach or other cleaning products will kill you.)
  5. The new recommendation of face shields or goggles along with mask wearing, social distancing, handwashing, and reversal of some of the most ill-advised state openings (bars, indoor rallies, packed houses of worship, etc.) all show promise of bending the curve downward again—cases first, then hospitalizations, then deaths—across the southern United States. Midwestern and North Central states have yet to be walloped by the two-by-four of COVID-19, and they are not learning from watching the suffering of others, so they are clearly next.
  6. The most exciting new development that I have heard about recently is a revolution in testing proposed by Michael Mina, a virologist and clinical pathologist at the Harvard School of Public Health. Rapid, less accurate testing is the key. (Abbott’s ID Now test, which I told you about on May 12th, is only one example.) The gold standard, PCR, is very accurate, but if it takes a week or more to analyze it is almost useless. Strips of cardboard mass-printed with molecules that detect virus in swab samples have not been widely deployed yet because they are not considered accurate enough. However: They are accurate enough if used when a person has enough virus to be infectious. At $1 a day, they can be used often by everyone, with results in minutes.

I want to say something about school and college openings, which are starting now. This is a mass experiment, with the lives of students, teachers, parents, and grandparents being put at risk, with conflicting guidelines about how to do it, and with low likelihood of compliance with guidelines anyway.

Major League Baseball is failing at safe reopening, even with their vast wealth and tight organization. More than 6,600 cases have been identified on college campuses that have mostly not yet opened for the fall semester. Young children (usually) do not become very sick from this virus, but they are quite effective transmitters of it to each other and to adults. Middle and high school kids are more effective spreaders. What has happened at summer camps and in the first school openings is not reassuring.

Rebekah Jones, a scientist fired by the governor of Florida for refusing to fudge the state’s statistics the way he wanted her to, said on July 8th, “If schools are opening next month, then we’re on a third wave of this first wave of catastrophe.”

Black leaders were in the news this week. Former President Barack Obama spoke brilliantly at the funeral of civil rights giant and “Conscience of Congress” John Lewis, whose last live appearance was at a Black Lives Matter protest. He died of pancreatic cancer. Rep. James Clyburn, Democrat of South Carolina and House Majority Whip, chaired the hearing of the Subcommittee on the Coronavirus Crisis, where he and Dr. Fauci told the truth. Herman Cain, a leading black Republican and former presidential candidate, died of COVID-19, which he probably caught while proudly attending a crowded Trump rally in Tulsa, Oklahoma, on June 20th.

Stay safe, you know how.

Dr. K

PS: Please don’t rely just on me. The best resource on what is happening specifically in the state of Georgia is Dr. Amber Schmidtke’s Daily Digest. More generally, I recommend the following: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; for the science of viruses, especially the new coronavirus, This Week in Virology (TWiV) podcast; Dr. Sanjay Gupta’s podcast, Coronavirus: Fact vs. Fiction; COVID-19 UpToDate for medical professionals; and for the current numbers: Johns Hopkins University (JHU); Institute for Health Metrics and Evaluation (IHME); Our World in Data (OWiD); The New York Times Coronavirus Resource Center (NYT).

 

 

Opening Gambits: Freedom Goes Viral

            “With your talents and industry, with science, and that stedfast honesty which eternally pursues right, regardless of consequences, you may promise yourself every thing—but health, without which there is no happiness. An attention to health then should take place of every other object.” 

                        Letter from Thomas Jefferson to Thomas Mann Randolph, Jr., July 6, 1787

Dear Students,

The letter that includes the above passage was written as part of a series to a young man of great promise. Randolph was 18 on the date above, which happened to be two days after the 11th anniversary of the Declaration of Independence. The Constitutional Convention was under way in Philadelphia, but Jefferson was still posted to Paris. (The federal government, still based in Philadelphia, was suspended several times during the 1790s yellow fever pandemic.) He began the letter by apologizing for his delay; he’d been traveling in southern France and northern Italy.

There is plenty of other advice in the letters, but young Thomas had been seriously ill a couple of years earlier, and the elder Thomas was concerned. The young man did take care of himself, and when the Jeffersons returned in 1789, he courted and married Jefferson’s eldest daughter Martha. They had 13 children together; 11 survived to adulthood. They eventually became estranged because his drinking interfered with his health and their life, although she was at his bedside when he died at age 59. But first he was a colonel in the War of 1812, served two terms in Congress, and became Governor of Virginia.

His future father-in-law’s advice kept him healthy for decades, and when he stopped following it he paid the price. I wonder what Thomas Jefferson, perhaps the greatest founder of early American freedoms, would have thought of the people risking their health and that of others to protest social distancing—while crowding together and refusing to wear masks—in the name of freedom.

All 50 states and many countries are easing or marching boldly out of their lockdown phases. It’s too soon to know the results; I predict they will be fine in some places and terrible in others. However, even “terrible” is in the eye of the beholder. Sweden has twice the population of Norway but around 16 times the number of COVID-19 deaths. Swedes regret that so many elderly and vulnerable people have died, but they defend their strategy of valuing individual autonomy and freedom; they think that other countries will have to follow their lead to the elusive goal of herd immunity.

Clearly a large minority of Americans agree. New York is opening slowly and carefully, but only after rigorous measures put its severe epidemic almost completely behind it. Texas and North Carolina are opening  boldly while cases continue to rise. The US as a whole gives a false impression of decreasing cases, but that is due to the huge decline in the worst-hit state, New York; most of the country is flat or rising.

The First Amendment to the Constitution, insisted on by Jefferson and drafted by James Madison, is now being used by leading legal authorities to justify anti-lockdown protests; they don’t mention the limits on my freedom to falsely yell “Fire!” in a crowded theater, or on my freedom to drive myself home from a party where I’ve been drinking. Protests are different as long as they’re non-violent. Apparently, wilfully spreading viruses more dangerous than bullets (bullets don’t keep jumping from person to person) is non-violent.

Good News

  1. The pharmaceutical company Moderna reports that of 45 patients who received their experimental vaccine, the 8 who got two specific doses (25 and 100mg), mustered antibodies to the virus more strongly than those found in people who have recovered from the disease. This vaccine uses messenger RNA (mRNA), which the viruses uses to make its proteins; this is a new approach that could be a game-changer for other viruses.
  2. Some states are opening slowly, carefully, and systematically. California is expanding its corps of contact-tracers from 1000 to 13,000. New York is deploying both viral and antibody testing, as well as contact tracing, and is poised to reimpose any restrictions it lifts if conditions warrant that. In Germany, this sequence from lockdown to partial opening, to small outbreaks, to selectively reimposed lockdown has already cycled through. When we have broadly available testing and contact tracing, as only a few places are approaching now, we can reopen more safely.
  3. Hospital systems are no longer overwhelmed in most of the U.S., and increasing numbers of elective procedures unrelated to COVID-19 are being done. Important exceptions are small community hospitals in areas surrounding meatpacking plants, prisons, and other hot spots, which may still be headed for disaster.
  4. Stay-at-home orders have worked. A multicity ongoing study conducted by the School of Public Health at Drexel University, estimates that the successful stay-at-home patterns prevented more than 2 million hospitalizations and 230,000 deaths. There is no vaccine and no treatment that has any prospect of making this much difference in the near future.
  5. We are understanding more and more about the course of illness (look at the excellent Medscape graph below; no, really look at it), modes of transmission (very numerous), and symptoms, especially those outside the lungs, also numerous.

Bad News

  1. Just as one swallow doesn’t make a summer, 8 people responding doesn’t make a vaccine. The Moderna study is a very early Phase 1 trial. Phase 2 will involve hundreds of people, Phase 3 thousands. About a hundred other vaccine candidates are under study. I wouldn’t want to be a premature adopter of any of them. Remember that uselessness in preventing the disease is certainly not the worst possible vaccine outcome.
  2. I believe that bad blunders are being made in some reopenings. Time will tell, and it will take time because some states and localities are doing it right, some are not, and people in many places are taking more or fewer risks than their governments advise. I get that everyone is tired of being locked down. Imagine how tired we will be of death if the second wave (almost certain to come in the fall, complicated by flu season) has, like the second wave of the 1918-19 flu, far more cases and deaths than the first wave. All the carpenters in America working full tilt could not make enough coffins.
  3. The small rural hospitals that may soon be overwhelmed are far less resilient, flexible, and resourceful than the big urban hospitals that expanded their ICU, ventilator, and to a lesser extent PPE capacity, in a matter of days to weeks in April. Community hospitals, even if they could somehow get the beds, ventilators, and other equipment, do not have the expertise to use them. Perhaps an army of doctors, nurses, respiratory therapists, and others from major medical centers will fan out to the rural hotspots overnight, but those people are literally sick and tired. How much damn heroism can we expect?
  4. Lockdowns have worked, but they are ending in haphazard ways, with hopelessly inadequate testing and tracing. We just have to see what happens, and continue building up (high-quality) viral testing, antibody testing, and contact tracing. Experts keep hammering away at this advice for a very simple reason: We are not there yet. Here’s your mnemonic: TETRIS: TEsting, TRacing, and ISolation.
  5. There is so much more about COVID-19 and SARS-CoV-2 that we don’t know. First, it was “Children don’t get it,” then, “They might be carriers,” then, “They’re definitely carriers but they don’t get sick,” to “Hundreds of children are showing up with a devastating post-viral hyperinflammatory syndrome and some of them have died horrible deaths.” The number with this, Multisystem Inflammatory Syndrome in Children may or may not remain small. Also, loss of smell and taste went from “Maybe in some cases” to “Maybe in a lot of cases” to “Often the only symptom.”

Your fellow student Caroline Yoon sent me a marvelous question the other day in a message called “Your take on positive retests?” She was concerned about the apparent reinfections in South Korea and on the aircraft carrier U.S.S. Theodore Roosevelt, and asked whether there might be reactivation of a long hidden infection as with HIV. It could be reinfection or reactivation or lousy tests, no one knows. But here’s my answer:

“The evidence of possible reinfection is very concerning in the two places you mention. The South Korea cases may be attributable to testing difficulties; the negative tests they had may have missed continuing infection (false negatives; there is a lot of evidence that this can linger for weeks to months). Or, the positive retests may be due to what some call “virus litter”—fragments hanging around after the infection is over (a type of false positive). The interpretation is complicated by post-infection symptoms due to viral damage during infection that takes a long time to heal, or to overactive and prolonged immune responses. The dreadful syndrome that has been hospitalizing and in some cases killing children (fortunately still a small number) is thought to be a post-viral hyper-inflammatory syndrome, perhaps a kind of autoimmune overreaction.

“The possible reinfection cases on the Roosevelt are more concerning to me than the South Korean ones, because conditions have been so controlled. The now 13 sailors who have retested positive did so after 14 days of quarantine and two consecutive negative tests. We haven’t been told whether any of the 13 have shown symptoms. Today it was announced that the Roosevelt will leave Guam and go back to sea—presumably, one hopes, without those 13. This will be an informative, I hope not dangerous, experiment, as the ship had over 1000 cases at one time not too long ago.

“I wish I had more definitive answers. Sometimes the best we can do is admit our ignorance, while pushing science forward to alleviate it.

“Stay safe, best wishes, and thanks again for your questions, Caroline.”

“Dr. K”

Eric A. Meyerowitz, MD; Aaron G. Richterman, MD, MPH,

A Quick Summary of the COVID-19 Literature So Far – Medscape – May 18, 2020.

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