COVID19 update, May 19, 2020: scaling up drug production; super-spreading events; reopening churches and synagogues; Matt Ridley on vitamin D

(1) OK, so you have an experimental coronavirus drug and suppose it actually works — what next? NATURE has an article on the challenges involved in scaling up production to massive quantities. For instance, Gilead, having donated its entire supply of drug on hand, has now licensed production to five generics manufacturers.
And like with other manufactured products, the switch to “lean” “just in time” manufacturing and the outsourcing of critical components to cheap specialized suppliers abroad creates vulnerabilities. (The article gives a non-Chinese example: following the Fukushima earthquake and tsunami, the pharmaceutical industry faced a shortage of polyethylene glycol, as all major suppliers of this chemical were in Japan.)

(2) According to an analysis by the London School for Hygiene and Tropical Medicine, super-spreader events may be responsible for 80 percent of more of COVID19 cases, reports The Daily Telegraph.

“As most infected individuals do not contribute to the expansion of an epidemic, the effective reproduction number could be drastically reduced by preventing relatively rare superspreading events”[…] Hospitals, nursing homes, large dormitories, food processing plan[t]s and food markets have all been associated with major outbreaks of Covid-19.

Vigorous physical activity in an indoor space without adequate ventilation is one risk factor, as a South Korean analysis of outbreaks at intense workout classes at gyms found. Less strenuous classes, such as yoga, were not associated with such outbreaks, nor were outdoor sports.

Singing at high volume, and the attendant voice projection[*], is another factor associated with super-spreading events:

In Washington State on the west coast of America, a church choir went ahead with its weekly rehearsal in early March even as Covid-19 was sweeping through Seattle, an hour to the south. Dozens of its members went on to catch the virus and two died. [par] The Washington singers were not the only choristers to be hit. Fifty members of the Berlin Cathedral Choir contracted the virus after a March rehearsal, and in England many members of the Voices of Yorkshire choir came down with a Covid-like disease earlier this year. [par] A choir in Amsterdam also fell victim to the virus, with 102 of its 130 members becoming infected after a performance. One died, as did three of the chorister’s partners.

I’ve already mentioned carnival celebrations in Germany, with everybody kissing everybody and hollering at each other in packed beer halls to be understood over the loud ‘music’. (Outdoor beer gardens are probably safe, if you don’t share steins.) And then there are the apres-ski parties that have become a by-word:

Hundreds of infections in Germany, Iceland, Norway, Denmark and Britain have been traced back to the resort of Ischgl in the Tyrolean Alps. Many had visited the Kitzloch, a bar known for its après-ski parties. [par] The bar is tightly packed and famous for “beer pong” – a drinking game in which revellers take turns to spit the same ping-pong ball into a beer glass. [par] Earlier this year The Telegraph obtained a video from inside the Kitzloch. It may yet come to define the perfect superspreader event, with attendees all singing along to AC/DC’s Highway to Hell

Had I written the latter detail in a novel, an editor would consider it a particularly cheesy foreshadowing technique.

But here is the good news from all of the above: none of it is representative of how one goes about one’s normal daily business.

(3) Prayer without singing returns to synagogues in Germany and Israel (h/t: Mrs. Arbel). Church services in Germany actually reopened a couple of weeks ago: aside from social distancing similar to what is described below for synagogues, no singing.
I had a look at the website of the Zentralrat der Juden in Deutschland (Central Council of Jews in Germany): they actually have a section with COVID19 guidelines. My abridged translation:

* public prayer and Torah reading are allowed again
* people with even mild symptoms should stay away
* maintain a distance of 1.5m (read: 5ft), preferably 2m (6.5ft)
* it is recommended to keep attendance lists in case contacts need to be traced
* if need be to maintain distance, use the largest hall or sanctuary available rather than a small chapel (as many congregations use for regular services)
* no handshakes, hugs, kisses
* worshipers are urged to wear masks (regular day-to-day nonsurgical masks OK)
* recommended to bring your own siddur (prayer book) and, on the Sabbath, chumash (book with the Torah and commentaries)
* using only one’s personal kippa/yarmulke/skullcap and tallit/prayer shawl (and, for weekday morning minyan, tefillin/phylacteries)
* doorknobs etc. are to be disinfected frequently
* disinfectant should be on hand
* no kissing of religious objects (e.g., mezuzah, Torah scroll) — therefore, usual Torah scroll procession before the reading off the menu
* no touching the Torah scroll when called up for a reading[NB: these behaviors are customs and not Jewish law]

(4) Matt Ridley Ph.D., veteran popular science writer and editor[**], lays out the evidence on vitamin D. As usual, his writing is a paragon of clarity.

[M]any people are deficient in vitamin D, especially at the end of winter. That is because, uniquely, vitamin D is a substance manufactured by ultraviolet light falling on your skin. You can get some from fish and other foods, but not usually enough. So most people’s vitamin D levels fall to a low point in February or March when the sun has been weak and its UV output especially so. Public health bodies have long advised people to supplement vitamin D in winter anyway. The level falls especially low in people who stay indoors a lot, including the elderly, and in those who have darker skin. Whereas the safe level of vitamin D is generally agreed to be above 10 nanograms per millilitre, one recent study of South Asians living in Manchester found average levels of 5.8 in winter and 9 in summer: too low at all times of the year. Darker skin reduces the impact of sunlight; so does the cultural habit of veiling; and so does a reluctance among some Muslims to take supplements that might have pork-derived gelatin in them.Vitamin D deficiency has long been known to coincide with a greater frequency or severity of upper-respiratory tract infections, or colds. That this is a causal effect is supported by some studies showing that vitamin D supplements do reduce the risk of such infections. These studies are not without their statistical flaws, so cannot yet be regarded as certain, but they are not quackery like a lot of the stuff coming out of the supplements industry: they come from reputable medical scientists.

What about vitamin D and Covid in particular? Results are coming in from various settings and the main message seems to be that vitamin D deficiency may or may not help to prevent you catching the virus, but it does affect whether you get very ill from it. One recent study in Chicago concluded that its result ‘argues strongly for a role of vitamin D deficiency in COVID-19 risk and for expanded population-level vitamin D treatment and testing and assessment of the effects of those interventions.’ The bottom line is that an elderly, overweight, dark-skinned person living in the north of England, in March, and sheltering indoors most of the time is almost certain to be significantly vitamin D deficient. If not taking supplements, he or she should be anyway, regardless of the protective effect against the Covid virus. Given that it might be helpful against the virus, should not this advice now be shouted from the rooftops? A new article by a long list of medical experts in the BMJ cautiously agrees, confirming that many people in northern latitudes have poor vitamin D status, especially in winter or if confined indoors, and that low vitamin D status ‘may be exacerbated during this COVID-19 crisis by indoor living and reduced sun exposure’.

Read the whole thing. I’ve been taking vitamin D and zinc supplements since the beginning of the crisis, even though I live in sunny Israel and have a very light skin type.

(5) This cartoon from Die Welt probably does not require translation:

[*] full disclosure: I am married to a classical soprano. She can easily fill a hall with sound without a microphone — and one does not achieve that feat without some serious air pressure.

[**] and member of the House of Lords, as the 5th Viscount Ridley

5 thoughts on “COVID19 update, May 19, 2020: scaling up drug production; super-spreading events; reopening churches and synagogues; Matt Ridley on vitamin D

  1. I wonder if the lack of vitamin D in northern climes was mitigated in Scandinavia by the propensity for those folks to be outside, even in winter? Would it have been worse with a less “Snow’s Fun!” population? (Assuming they didn’t spread it in the pub afterward.)

    • Presumably, when Scandinavians go cross-country skiing or ice-skating or whatever, they wear long-sleeved shirts, and pants that come down to their ankles, and gloves, and possibly a scarf or balaclava that partly covers the face. So the amount of skin exposed to sunlight is definitely minimized.

  2. I’m interested to hear there have been other cases somewhat similar to the Mount Vernon group– although I’m still skeptical about it, based on the way it just didn’t fit with any other patterns, and early local reports mentioning the singing-around-the-pianos after social distancing for practice, while broader news reports didn’t.
    (At least one ‘study’ I ran into, which no I don’t know where I put it, was based on national news reports.)

    Be interesting to see what kind of information comes out of this, assuming folks don’t just keep building on assumptions.

  3. This is advice I sent to my kids about a month ago. It follows advice in early March based on epidemiologic findings that respiratory infections, including common corona virus infections, were fewer if vitamin D serum levels were higher.

    We now have some new information that comes from Indonesia. This was a study of 780 diagnosed coronavirus cases in whom 25 hydroxy vitamin D levels were measured.

    The mortality rate in those patients who had a vitamin D level less than 30 ng/mL was from 10 to 17 times worse than those with a level above that number. The difference between a factor of 10 and a factor of 17 is because of the uncertainty surrounding correction for confounding factors like age and pre-existing conditions. This is much better direct evidence than the general expectation of a reduction in sickness by up to 70% for generic pulmonary infections.

    Also, the annual benign coronavirus infections peak at the same time vitamin D levels reach their low point. That is the same as the behavior of influenza infections. The reason is probably that both of these viruses have lipid membranes that will be disrupted by an intact innate immune system. That part of the innate immune system is dependent on adequate levels of vitamin D in the blood.

    Laura pointed out one possible factor that might increase the need for the quantity of vitamin D supplementation necessary for some of you to get to an optimal level.

    The two factors that are well-known to increase the requirement for vitamin D3 are degree of adiposity, and hyperinsulinemia ( metabolic dysfunction). In either case, a dose that will give a person a human optimal level of vitamin D may be two or three times the 5000 units per day I quoted in the first email. That would be 10- 15,000 units ( 250- 375 micrograms) daily.

    There is one other complicating factor, if a person begins with an insufficient level, as at least 70% of the American population has right now, and there are no other complicating factors, it will take between four and six weeks to achieve a human optimal level of 40 to 60 ng/mL at a dose of 5,000 units per day. I expect that doubling or tripling the dose would shorten that time considerably.

    Vitamin D toxicity: this is a very rare condition. In caring for nearly a quarter of 1 million patients over the last 45 years I have not yet seen a case. There have been no cases ever reported at a dose level less than 50,000 units per day for months. It has been well established that doses of 30,000 units per day do not ever result in vitamin D toxicity.

    Additionally, you cannot get vitamin D intoxication from sun exposure despite being able to synthesize tens of thousands of units per hour in midday sun.

    So, here are my new recommendations:

    if you know your vitamin D level and it is between 40 and 60 ng/mL, continue to do what you’re doing.

    if you don’t know your vitamin D level and you haven’t been taking any, I would recommend at least 15,000 units per day of vitamin D3, especially if you are carrying some extra adipose tissue.

  4. […] the whole issue of aerosol transmission of COVID-19 started coming to the fore, and reports of super-spreader events at choir rehearsals (notably this well-studied one in Washington state) and religious services with singing […]

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