COVID19 update, July 12, 2020: Sweden redux and immunity; inhaled steroids; BCG vaccine redux

UnHerd interviews a Swedish medical researcher and practicing physician about what things are like there now. It seems the epidemic is winding down there now. Let me start up with Worldometers:

And a Swedish journalist fisks the NYT’s article about the Swedish response, which isn’t isn\t quite the horror show the NYT is making it out to be. Also, it “didn\’t do nothing” — it just relied more on persuasion and voluntary recommendations rather than mandates. (Good luck with THAT when dealing with Belgians, Israelis, or New Yorkers ;))
Maybe Sweden spared itself a 2nd wave by not locking down so tight in the 1st wave? 

(2) Dr. Seheult on inhaled steroids:

(3) I’ve mentioned earlier speculation that past TB vaccination with the BCG (bacille Calmette-Guérin) vaccine may impart a degree of protection against COVID19. Now a story affirming this got published in the prestigious Proceedings of the National Academy of Sciences: https://doi.org/10.1073/pnas.2008410117

The COVID-19 pandemic is one of the most devastating in recent history. The bacillus Calmette−Guérin (BCG) vaccine against tuberculosis also confers broad protection against other infectious diseases, and it has been proposed that it could reduce the severity of COVID-19. This epidemiological study assessed the global linkage between BCG vaccination and COVID-19 mortality. Signals of BCG vaccination effect on COVID-19 mortality are influenced by social, economic, and demographic differences between countries. After mitigating multiple confounding factors, several significant associations between BCG vaccination and reduced COVID-19 deaths were observed. This study highlights the need for mechanistic studies behind the effect of BCG vaccination on COVID-19, and for clinical evaluation of the effectiveness of BCG vaccination to protect from severe COVID-19.

Finally, “Five Foot of Lutheran Fury” Mollie Ziegler Hemingway, while acknowledging the seriousness of the epidemic, tells her fellow Americans to react rationally rather than the “h” word she uses.

COVID19 update, July 10, 2020: aerosol transmission; empirical studies on choir rehearsals and office buildings; some neighborhoods of NYC at herd immunity?; deaths in British care homes linked to contract labor

(1) Dr. John Campbell on airborne aerosol transmission

The article he refers to is this one:

https://doi.org/10.1093/cid/ciaa939

In a nutshell: while a 1-2 meter “social distance” is useful against larger droplets (which fall to the earth), this does not apply to aerosols (made up of droplets of 5 micron or smaller) which can spread dozens of meters through the air and keep hanging for quite a whole. Your typical cloth or surgical mask will not be very helpful against aerosols either. (A true N95 mask, that conforms to the NIOSH N95 standard, is supposed to block 95% or more of particulate matter at  0.3 micron size.)

So what can you do? In a word: refresh the air. Outside activities are safest from an aerosol perspective (especially if there is at least some breeze), and small or tightly packed enclosed spaces with no air refreshment from outside are the worst. (I used to think planes would be the very worst, but Air Canada, in a recent mailing to me, claims that not only do they turn over all cabin air at a rate of one full refresh every three minutes, but they filter the air through HEPA filters.)

(2) Aerosol transmission: how dangerous is singing, really? A reporter from Die Welt (herself a member of the Berlin philharmonic chorus) discusses (in German)  a study by engineers from the Technical University of Berlin. 

The people involved are professionally mostly interested in the design of ventilation systems for large office buildings and residential complexes. As 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 kept coming up, they asked themselves the question: can we empirically test and quantify this? Do singers spread more aerosol droplets than people speaking or going about their daily activities?

So they recruited eight volunteers from the RIAS Chamber Choir in Berlin and had them, inside a “cleanroom” breathe,  then speak, then sing at a range of volumes into funnels connected to a special apparatus in which a laser particle counter measures and counts aerosol droplets. A preliminary report (in German) is available  here on the university’s preprint server. The English abstract (some “Gerglish” corrections for clarity in square parentheses):

n this study, emission rates of aerosols emitted during singing are presented for professional singers. The results, measured with a laser particle counter, are compared with published data for breathing and speaking. In the investigated cohort of eight volunteers, the particle source strengths during singing are between 753.4 and 6093.14 [articles per second]. The [increase factor in emission] rates [when] singing [compared to] speaking [is] between 3.98 and 99.54. The present study contributes to a more precise assessment of a possible spread of SARS-CoV-2-viruses during singing. It should support the efforts to improve the risk management, especially for choir singing.

From Figure 4 of the whole report, we see also that the aerosol particle concentration (particles of 5 micron and smaller) was statistically well correlated (R**2 = 0.824) with the volume in decibels: Log10 (concentration) = 0.07 (volume in dB) – 2.41.

The researchers then carried out a second study (preliminary report here) in which they tried to see under which circumstances choir rehearsals could be made no more dangerous (from the point of view of aerosol exposure) than an ordinary office building. In their simulation, they achieved this for a given rehearsal room (the auditorium of a local school) by spacing the participants at 2m distance and, instead of having them sing for 2h at a stretch, sing for half an hour at a time with 15=-minute breaks during which all windows of the hall were opened wide.

Perhaps the most counterintuitive conclusion was that the audience and orchestral musicians at classical music performances in large halls, like those of the Berlin Philharmonic and its Dresden counterpart, are surprisingly safe, thanks to the very large and high-ceilinged halls and the efficient forced-ventilation system. (This was in place for very different reasons: reduce accumulation of CO2.)

Graph address: https://img.welt.de/img/gesundheit/mobile211378363/5007931917-coriginal-w780/DWO-WS-Corona-Chor-js.jpg

This graphs shows the concentration of potentially infectious aerosol particles per square meter in different spaces. Lowest are the large, high-ceilinged  concert halls of the Dresden and Berlin philharmonics; above that is an office with forced ventilation, about the same as a choir rehearsal room with a single infected person; higher (in blue) is an office with just window air (presumably different if you sit by the window); and at the top is a choir rehearsal room with three infected participants. The descending segment in the middle represents the effect of a 15-minute “airing out” after 30 minutes. 

(3) The Daily Telegraph reports that some neighborhoods of New York have shown up unprecedentedly high percentages of positive antibody tests — reaching 1st-order herd immunity levels. 

Areas of New York have recorded a nearly 70 per cent rate of immunity to Covid-19, in what scientists have described as “stunning” findings that suggest they could be protected from any second wave.

Some 68 per cent of people who took antibody tests at a clinic in the Corona [you can’t make this up! — Ed.] neighbourhood of Queens received positive results, while at another clinic in Jackson Heights, 56 per cent tested positive. 

The results, shared by healthcare company CityMD with the New York Times, appear to show a higher antibody rate than anywhere in the world, based on publicly released data.

The next closest is the Italian province of Bergamo, which recorded 57 per cent, followed by Alpine ski resort Ischgl, the site of Austria’s biggest coronavirus outbreak, which reported 47 per cent.

[…]

Wealthier areas recorded much lower rates, according to CityMD data. For example, at a clinic in Cobble Hill, a mostly white and wealthy neighbourhood in Brooklyn, only 13 per cent of people tested positive for antibodies.

The results suggest higher-income neighbourhoods may bear the brunt of any second wave to hit the city.

CityMD administered about 314,000 antibody tests in New York City, as of June 26. Citywide, 26 per cent of the tests came back positive.

Tangentially related, Dr. Seheult here discusses immunity testing and survey data for Spain

The paper is here: https://doi.org/10.1016/S0140-6736(20)31483-5 They retained a sample of over 61,000 (the largest of its kind so far), and used two different antibody tests on each. For Spain as a whole, the seroprevalence is only 5%, but larger towns (and especially the Madrid area) have higher figures, as do health care and nursing home workers, and — interestingly — the top 5% earners (presumably because many such people travel a lot for work). At least one-third of people who has antibodies had never had any symptoms. 

(4) Also in the Telegraph, the story of deaths in British care homes seems more complicated than meets the eye.

It has been the same, awful story everywhere. Sweden didn’t lock down and has still had fewer deaths per capita than Britain (while taking a far smaller economic hit). But a failure to protect care homes led to most of Sweden’s Covid deaths. The figures here are quite striking: care homes look after three per cent of Britain’s elderly population but accounted for 41 per cent of our Covid deaths. Similar ratios can be found in Spain, France, Denmark, Israel and Portugal.

As a result, most of Europe is now asking what went wrong in care homes – and moving to a similar conclusion. It took ages to realise how many people are barely affected by Covid, carrying (and spreading) the virus without knowing it. Asking people to isolate if they had symptoms didn’t offer much protection. The more people coming in and out of the care homes, the greater the risk of infection. If those care homes don’t offer sick pay, the risk is greater.

Hong Kong banned care home visits pretty early on: it had learned from Sars. But British care homes were taking visitors for weeks after lockdown and, even after that stopped, agency workers drifted in and out, some working in multiple homes. The Government (belatedly) advised against this “where possible”. But for most homes it is not possible: they have no staff backup. Yet again, we see the problem in the British care home industry: a refusal to pay decent wages, a dependence on casual staff and a reliance on agencies that can provide low-cost workers.

Care homes that did things differently saw very different results. In France, a home near Lyon put its staff and residents into complete isolation for seven weeks, taking no one from outside. They had no Covid deaths. Valerie Martin, its director, said she went to such lengths because “my residents still have so much to live for”. She also had carers paid enough that they didn’t need a second job and were willing to be quarantined.

It has been a very different story here. An Isle of Skye care home found that 30 of its 36 residents ended up with the virus, six of whom died. It turned out to be shipping in workers, including one from Kent. [That’s literally the other end of the UK — Ed.] A study published last week tried to explain the huge differences in how homes in England were affected. Residents looked after by agency workers were 58 per cent more likely to contract Covid. Those working in multiple care homes were more than twice as likely to carry the virus.

It might be shocking. But it’s not really surprising – given that this is the same problem we saw during the spread of superbugs like MRSA. Those lessons weren’t learned. Care homes argue, still, that their business model depends on being able to pay people less than supermarkets do. Their complaint about Brexit, even now, is that it makes it harder for them to import cheap labour and keep wages down. Their bigger concern should be what the Covid crisis has shown about their ability to protect those in their care.

(5) The WHO discontinues the hospital arms of both hydroxychloroquine and lopinavir/ritonavir trials, on the grounds that they statistically are no better than standard of case.

Contrary to the misleading headline in the original, however, it seems that the shutdown only affects the hospital arm, and that the prophylaxis and outpatient arms of the trials are continuing. I would indeed not expect antivirals like lopinavir/ritonavir (and, indirectly, HOcq) to be very effective in the severe disease stage, at which point immune overresponse is your biggest threat, not the virus per se anymore.

ADDENDUM: David Friedman on the recent increase in verified cases not being accompanied by an increase in deaths.

COVID19 update, July 6, 2020: mortality lower than generally perceived; easier to synthetize alternative to remdesivir? Tightened restrictions in Israel

(1) “Masgramondou” sent me the following:

https://www.wfae.org/post/wake-forest-covid-study-death-rate-severity-symptoms-lower-first-thought

A study by Wake Forest Baptist Health has found that between 12-14% of people tested in North Carolina have antibodies for the coronavirus — meaning they have been exposed to the virus — with most of them showing little or no symptoms. 

The majority of the study participants are in the Triad area. 

The findings suggest that COVID-19 is less deadly than originally thought and that the death rate for the disease could be in the range of 0.1%.

But the study also shows that there is significant community spread and that efforts so far to curtail COVID-19 are faltering. 

“It’s a double-edged sword,” said John Sanders, the chief of infectious diseases at Wake Forest Baptist. “We are clearly seeing a rapid increase in the number of people that we have antibody evidence who have been infected.”

But he said “the vast majority of these people have very few or no symptoms.”

“We can look at it and say the death rate is lower than we have estimated,” Sanders said. “The severity of symptoms is lower than we estimated and the vast majority of people who were infected are going to do fine.”

[…]

There are about 10.5 million people in North Carolina. If 14% of the population has been infected with the coronavirus, that would translate into about 1.47 million people.

The state has more than 66,000 confirmed cases as of Wednesday and 1,373 confirmed COVID-19 deaths.

Stanford U. Professor John Ioannides, a medical doctor and statistician best known for his research Into the reliability and reproducibility of the medical literature, points out that mortality for those below 45 is “almost zero”, and slams statewide lockdowns. (I approve of lockdowns as a targeted measure in densely populated areas, but don’t believe in their use as blunt instruments.)

“The death rate in a given country depends a lot on the age structure, who are the people infected, and how they are managed,” Ioannidis said. “For people younger than 45, the infection fatality rate is almost 0%. For 45 to 70, it is probably about 0.05%-0.3%. For those above 70, it escalates substantially.”

[…]

Several states have seen spikes in cases, especially in the southeastern part of the country, where lockdown measures were lifted earlier than in other states.

The mortality rate nationwide appears to be tapering, however, a trend U.S. health officials attribute to a younger age bracket in terms of infection. The national single-day death rate from the virus fell to a three-month low last month. Additionally, Massachusetts reported zero new deaths from the coronavirus on Tuesday for the first time since March.

(2) From an ACS virtual issue of COVID-19 related articles across its journal family, this one caught my eye:

https://doi.org/10.1021/acsmedchemlett.0c00316

Advantages of the Parent Nucleoside GS-441524 over Remdesivir for Covid-19 Treatment
Victoria C. Yan* and Florian L. Muller

While remdesivir has garnered much hope for its moderate anti-Covid-19 effects, its parent nucleoside, GS-441524, has been overlooked. Pharmacokinetic analysis of remdesivir evidences premature serum hydrolysis to GS-441524; GS-441524 is the predominant metabolite reaching the lungs. With its synthetic simplicity and in vivo efficacy in the veterinary setting, we contend that GS-441524 is superior to remdesivir for Covid-19 treatment.

(3) Was the lockdown worth it? The Daily Telegraph has a long piece in which twelve experts and writers of the paper make their cases pro and con.

(4) Israel, with escalating COVID-19 infections in what is probably the one pronounced second wave at the moment, announced tightened restrictions. Prof. Eli Waxman, head of the Coronavirus ad hoc committee, speaks out in this interview. This needs to be seen in the context of a tug-of-war between public health authorities fiercely defending their own turf, and perceived “upstarts” with “no background in medicine” (never mind what they can bring to the table in terms of logistics, tracing, and testing knowhow). A somewhat similar situation pertained in the US at least at the beginning of the outbreak, where it often seemed the CDC was excessively preoccupied with protecting its own backyard — particularly on testing, whic Germany wisely decentralized from the beginning.

COVID19 update, July 5, 2020: new large, successful hydroxychloroquine trial; China did not actually notify WHO of outbreak on 31 December 2019; vascular dementia sequelae in elderly survivors; aerosol transmission and why risk much less outdoors

Happy Fourth of July weekend to my American readers, and belated happy Canada Day to my Canadian ones.

(1)  (via Matt Margolis): New large-scale (over 2,500 patients) hydroxychloroquine (HOcq) trial in Henry Ford Health System (in the Detroit area) finds definite benefit to HOCQ. The paper was just published online, following peer review but prior to copy-editing, in the International Journal of Infectious Diseases.

https://doi.org/10.1016/j.ijid.2020.06.099

In a nutshell, 13% of patients who received HOcq alone died, compared to 20% of those who received the HOcq-azithromycin combo, 22% of those who received azithromycin alone and 26% of patients who received neither drug. The researchers then carried outr “propensity matching”  — that is, the creation of equal-sized “HOcq” and “non-HOcq” subsamples designed to be similar in terms of age distribution, race, pre-existing conditions, … to  create an “all else being equal” comparison. (This is known in the medical statistics lingo as “eliminating confounding factors”.) They then obtained  the following Kaplan-Meier  survival curve (Figure 2 of the paper):

Quoting from the article text:

“The benefits of hydroxychloroquine in our cohort as compared to previous studies may be related to its use early in the disease course with standardized, and safe dosing, inclusion criteria, comorbidities, or larger cohort. The postulated pathophysiology of COVID-19 of the initial viral infection phase followed by the hyperimmune response suggest potential benefit of early administration of hydroxychloroquine for its antiviral and antithrombotic properties. Later therapy in patients that have already experienced hyperimmune response or critical illness is less likely to be of benefit. […]
Limitations to our analysis include the retrospective, non-randomized, non-blinded study design. Also, information on duration of symptoms prior to hospitalization was not available for analysis. However, our study is notable for use of a cohort of consecutive patients from a multi-hospital institution, regularly updated and standardized institutional clinical treatment guidelines and a QTc interval-based algorithm specifically designed to ensure the safe use of hydroxychloroquine. To mitigate potential limitations associated with missing or inaccurate documentation in electronic medical records, we manually reviewed all deaths to confirm the primary mortality outcome and ascertain the cause of death. A review of our COVID-19 mortality data demonstrated no major cardiac arrhythmias; specifically, no torsades de pointes that has been observed with hydroxychloroquine treatment. This finding may be explained in two ways. First, our patient population received aggressive early medical intervention, and were less prone to development of myocarditis, and cardiac inflammation commonly seen in later stages of COVID-19 disease. Second, and importantly, inpatient telemetry with established electrolyte protocols were stringently applied to our population and monitoring for cardiac dysrhythmias was effective in controlling for adverse events. Additional strengths were the inclusion of a multi-racial patient composition, confirmation of all patients for infection with PCR, and control for various confounding factors including patient characteristics such as severity of illness by propensity matching.”

(2) Laura R. A geriatric nurse, messaged the following:

Mortality of COVID-19 is not my biggest worry. I’m a long-term and skilled care nurse, and hold a CDP (Certified Dementia Professional, which indicates some training, but much more experience). All indications show that COVID-19 can cause brain damage in survivors. Non-severe disease with simple anosmia may not cause long-term sequelae, but I fully expect there to be a huge wave for demand for memory care for people with vascular dementia in the next five years, as home caregivers become overwhelmed.

https://www.washingtonpost.com/health/2020/07/01/coronavirus-autopsies-findings/

https://doi.org/10.1016/S2215-0366(20)30287-X

“Neurobiology of COVID-19”, Journal of Alzheimer’s Disease, 76,(1), 3-19, (2020) http://doi.org/10.3233/JAD-200581

(3) (Via Instapundit) WHO Quietly Changes COVID Timeline following Republican Questioning. “The World Health Organization quietly changed its timeline of the coronavirus pandemic’s first days on Tuesday, clarifying that the Chinese Communist Party never informed the organization of the pandemic on December 31, despite previous claims to the contrary.” 

“In the new timeline, which the WHO says has been updated “in light of evolving events and new information,” the organization reveals that its Chinese Office “picked up” an online statement — which has since been deleted — made by the Wuhan Municipal Health Commission describing cases of “viral pneumonia.” The WHO says it also received open-source intelligence suggesting there was “pneumonia of unknown cause” in Wuhan.

The additions clarify the WHO’s previous timeline, which simply stated that on December 31, “Wuhan Municipal Health Commission, China, reported a cluster of cases of pneumonia in Wuhan” — implying the report was made to the WHO. In its initial report on the outbreak, the WHO said its China office “was informed” of the unknown pneumonia cases, without clarifying that the information was not provided by the Chinese Communist Party.

The lack of clarity led multiple outlets — including Axios, the Washington Post, and the BBC — to report that Chinese authorities told the WHO’s China office about the outbreak on December 31. ” 

Quite erroneously, as it turned out. 

(4) My Belgian correspondent “Y.” sent me this Dutch informational video from the advocacy group SmartExit.nu. (The top level domain for Niue also happens to mean “now” in Dutch.)

(English translation: https://www.youtube.com/watch?v=asjKXK44fN4  )

In brief: it discusses the main ways for the virus to spread, and places most of the blame on aerosols. Garden-variety masks are not terribly useful against aerosols, and neither is keeping a 1.5m distance, but… good air circulation and vigorous air refreshing help a lot. Best of all is to be outside.

Y. comments: “This explains why various mass outdoor parties and events in Brussels, as well as massive demonstrations, did not trigger renewed outbreaks here. And the whole ‘climate’ push for ‘passive buildings’ with almost zero ventilation turns out to be a bad idea.”

(Apropos the Washington State choir rehearsal that became a super spreader event, a (critical) commenter to the video adds this CDC link.)

Related, this just in via Instapundit: 239 experts with 1 big claim: the virus is airborne

(5) https://www.jpost.com/health-science/how-to-avoid-catching-coronavirus-633952

The Coronavirus National Information and Knowledge Center, which is overseen by the IDF Intelligence Corps in cooperation with the Health Ministry, released a report Sunday that reviews international recommendations for the kinds of activities that are high- to low-risk. The punch line is to “avoid the ‘three Cs,’” as a poster in Japan offers: closed spaces with poor ventilation, crowded places with many people nearby and close-contact settings such as close-range conversations.
 
The Jerusalem Post has put together a priority list of “safe” and “less safe” activities based on lists published by international health networks and publications that were used by the IDF to compile Sunday’s report.

The full report is here (in Hebrew). The following infographic taken from  it might be useful

(6) Naftali Bennett, former Minister of Defense, leader of the Yamina party and a successful hitech executive before entering politics, published an open letter with a 15-point plan to revamp Israel’s coronavirus response.

Happy Fourth of July: story segment, “To Look For America”

As fans of Sarah A. Hoyt (the Beautiful but Evil Space Mistress) know, her Darkship series of novels is set in a future in which most of Earth’s landmass has become uninhabitable following biological warfare. A remnant of humanity survives in “Seacities”, artificial islands. These were originally supposed to have been under the “enlightened” rule of genetically engineered technocrats, but as has happened time after time when people let themselves be ruled by their betters “for their own good”, things took a darkly dystopian turn.
A remnant among the remnant passes along, from generation to generation, secret knowledge of a place where there were no “betters” ruling you, and where government was but with consent of the governed. Some believed this place called “America” was a myth, other that it had actually once existed, yet others that it still existed somewhere. The believers call themselves “USAians”.

The following is an Independence Day excerpt from a story I wrote in that universe, for a forthcoming anthology edited by the BbESM herself. As often happened, the inspiration came from a song — video embedded at the end

Happy Fourth Of July!

Illegitimi non carborundum!


New Rotterdam
Somewhere in the North Sea
A distant future.

[…] We gather in a hidden back room of one of the entertainment complexes. The ceramacrete floor had been painted in a black and white tile pattern. Two pillars mark the eastern wall of the room. A tattered flag with red and white stripes, and stars on a blue field, hangs between them.

“Is the Lodge covered?” our Master of Ceremonies asks.

The Tiler makes a show of checking the locks and ritually answers, “the Lodge is covered.”

“Then let us start our Work.”

Some ten years ago, a new religious movement had started here. I’m told there are “USAian” groups in many other Seacities, no two of them fully alike in their rituals. Here in the Seacity of New RotterdamSome of ours are supposedly borrowed from a secret society that used to exist since about the 18th Century.

A few groups clinging to pre-Biowar faiths are frowned upon but authorized. We aren’t, but the Overclass and the Lawkeepers tolerate us as long as we’re quiet and don’t openly recruit new members. My guess is they’d rather have us discreet and be able to monitor us, than go underground completely.

Our Scriptures, “The Words that Make People Free”, are passed in secret from one group to the next—hand-carried by broomers between Seacities. I can barely believe that before the Biowars, there was a worldwide network that allowed everyone to share information with whoever they wanted, worldwide and indeed beyond. Not anymore.

Our services are short and to the point—mostly we recite The Words that has been handed down through the centuries. We don’t carry individual copies but memorize the texts through recitation. 

The Speaker intones, and we repeat:

“When in the course of Human Events…” and the text goes on to explain how, and why, the people oppressed by an ancient empire had decided to declare their independence and start a new Land of the Free.

“…that all men are created equal & independent, that from that equal creation they derive rights inherent & inalienable, among which are the preservation of life, and liberty, and the pursuit of happiness…”

The preservation of life… The preservation of life… As was our custom, we meditated on the meaning of those words.

What do we really have of those “inalienable rights”? The pursuit of happiness? Of course, the needs of keeping a Seacity going means not everyone can ‘pursue happiness’ at work. But when not working, we can ‘pursue’ what some call ‘happiness’ by having sex in every anatomically possible configuration, and we can even use some designer drugs. Just don’t do or say anything that inconveniences the Overclass too much—then you end up in the Lawkeepers’ cellars, or worse.

And life? The preservation of life?

What exactly was [my superior] doing?

***

The formal service is now over. Some members have brought some refreshments—they also mean we have a cover. In case the Lawkeepers raid us, we were celebrating a birthday.

One of us brings out a bootleg media player and makes it play back a recording of a song called “America”. I have heard it many times before — two men singing wistfully about somebody hiking for days from a mysterious place called Saginaw to look for America, but never finding it. They even mention spies wearing cameras concealed in various archaic pieces of clothing — that bit could have been talking about New Rotterdam itself.

But the version we are hearing now is by a different group. Three men sing in harmony, the lead singer naturally and warmly in a register that most men can only scream in, or sing in falsetto.   The guitar player tinkles exuberantly and virtuosically. And the bass, with  a bright, half-electronic half-organic sound, goes back and forth between a deep, bombastic strut and high, playful countermelodies. There is a joyfulness, a sense of purpose about this version that is missing from the other one.

It then hits me. The mythical America, freedom, and natural rights must ever be searched for. The search will never fully end, but it must begin with each of us.
[…]


COVID19 update, July 2, 2020: Joel Kotkin and “neo-feudal” tech oligarchy; masks in the OR; the COVID age/risk calculator; Dr. Hansen on what he learned working in COVID ICU

(1) “One man’s meat is another man’s poison” (or, in Dutch, “The death of one is the bread of another”). Certain tech companies that either supply work-from-home infrastructure, or are easily adaptable to WFH themselves, did very well for themselves during the crisis. Demographer Joel Kotkin fears this will exacerbate trends already in progress: the triumph of the [tech] oligarchs. His article plays off his most recent book, “The Coming of Neo-Feudalism: A Warning to the Global Middle Class” — a must-read that I will review in a separate article.

(2) Erik Wingren (thanks!) drew my attention to a 10-year old paper on mask use in the operating room  (cited here)

Use of Face Masks by Non-Scrubbed Operating Room Staff: A Randomized Controlled Trial

https://doi.org/10.1111/j.1445-2197.2009.05200.x


Background: Ambiguity remains about the effectiveness of wearing surgical face masks. The purpose of this study was to assess the impact on surgical site infections (SSIs) when non-scrubbed operating room staff did not wear surgical face masks.

Results: Overall, 83 (10.2%) surgical site infections were recorded; 46/401 (11.5%) in the Masked group and 37/410 (9.0%) in the No Mask group; odds ratio (OR) 0.77 (95% confidence interval (CI) 0.49 to 1.21), p = 0.151. Independent risk factors for surgical site infection included: any pre-operative stay (adjusted odds ratio [aOR], 0.43 (95% CI, 0.20; 0.95), high BMI aOR, 0.38 (95% CI, 0.17; 0.87), and any previous surgical site infection aOR, 0.40 (95% CI, 0.17; 0.89).

The article elicited a comment back in the day that not all surgeries are the same: in particular, orthopedic surgery (except for laparoscopic procedures) needs a much higher level of bacterial safety than the usual soft-tissue surgery, in part because infections in the bone are very hard to treat with antibiotics. https://doi.org/10.1111/j.1445-2197.2010.05412.x

(3) Dr. Seheult on Remdesivir availability

After R&D, and after giving away its supply on hand, it is now producing for resale. A 5-day course for a patient will cost a bit over $3,000. 

He also mentions the Covid-age calculator here, developed by an insurance company. The web app estimates your “COVID-Age”  based on your chronological age, your body mass index, your HbA1C reading (a measure for the health of you sugar metabolism), whether M or F, how much you smoke per day,… cholesterol levels, blood pressure,… and yes/no to several pre-existing conditions.  Whichever item you don’t know, you can leave blank. (Interestingly, Mrs. Arbel pointed out, blood group is not an input item, despite the fairly well-established difference between blood groups A and O.)

And based on this “COVID-Age”, the app then tells you your risk of needing hospitalization, of ending up in the ICU, or of dying. I entered some data for a random 25-year old female in excellent health, and got as output:
Hospitalization1.6%. ICU Admission0.21%. Mortality0.03%

Just manipulating the age, while leaving everything else constant, got
Age 50 Hosp. 4.5%  ICU 1.2%. Mort. 0.17%
Age 70, Hosp. 7.4% ICU 2.9% Mort. 0.63%
Age 80, Hosp. 8.9% ICU 4.1% Mort. 1.2%

Related, reader “Tullius Cicero” sent me this infographic:

(4) Dr. John Campbell, while generally apolitical, doesn’t have kind things to say about the WHO

(5) And this sort of thing makes one wonder why the American public has started tuning out experts. As Insta, linking this op-ed, points out, “TRUST IS PUBLIC HEALTH’S MOST IMPORTANT ASSET, AND THEY SQUANDERED IT WITHOUT A THOUGHT IN THE NAME OF EXPEDIENCY.”

(6) Dr. Mike Hansen on what he learned treating COVID-19 in the ER:

Today was a bit of a bumper crop for COVID-19 news: tomorrow I will likely skip a day unless events require otherwise.

COVID19 update, July 1, 2020: skipping phase 3 trial, China vaccinates entire army; Hong Kong loses autonomy; Israeli volunteer for “vaccine challenge trial”; how to recondition N95 masks

(1) I had somehow missed this bombshell: China skipped the Phase 3 clinical trial for its vaccine altogether and is now vaccinating its entire “People’s Liberation Army”, reports the Daily Telegraph. Dr. Campbell comments in his daily update. Epoch Times commentator Joshua Philipp (at 4:00 into the video) notes that, in parallel, it will be tested on 9,000 volunteers in Brazil: if these trials are successful, the vaccine will be manufactured in Sao Paulo and distributed free of charge. Free? Timeo DanaosSinos et dona ferentes. Keep watching for some insight on ChiCom influence operations in Brazil from, admittedly, a stridently anti-CCP commentator.

(2) While everybody was preoccupied with COVID19 and with the US riots, China’s sham parliament rubber-stamped the extension of China’s national security law to the Hong Kong Special Administrative Region, de facto (if not de jure) abrogating the “One Country, Two Systems” agreement. The UK is extending an offer of residence, with a path to citizenship, to the 3 million Hong Kongers with “British National Overseas” status.

(3) “Infect me”. The Times of Israel has an interview with Keren P., a US-born army veteran who just graduated as a mechanical engineer from the Technion. She is one of 61 Israelis who have volunteered to be “guinea pigs” in a vaccine challenge trial through the 1daysooner nonprofit. In a “challenge trial”, people are first vaccinated, then deliberately exposed to the pathogen under controlled circumstances.

(4) Following the sharp rise in new infections in Israel, the relevant Knesset committee has greenlighted the renewal of “track and trace” by Israel’s domestic security service, the Shin Bet.

(5) Can you recondition an N95 mask? An article in ACS Nano studies the question experimentally. https://pubs.acs.org/doi/10.1021/acsnano.0c03597

Quoting from the abstract:

We investigated multiple commonly used disinfection schemes on media with particle filtration efficiency of 95%. Heating was recently found to inactivate the virus in solution within 5 min at 70 °C and is among the most scalable, user-friendly methods for viral disinfection. We found that heat (≤85 °C) under various humidities (≤100% relative humidity, RH) was the most promising, nondestructive method for the preservation of filtration properties in meltblown fabrics as well as N95-grade respirators. At 85 °C, 30% RH, we were able to perform 50 cycles of heat treatment without significant changes in the filtration efficiency. At low humidity or dry conditions, temperatures up to 100 °C were not found to alter the filtration efficiency significantly within 20 cycles of treatment. Ultraviolet (UV) irradiation was a secondary choice, which was able to withstand 10 cycles of treatment and showed small degradation by 20 cycles. However, UV can potentially impact the material strength and subsequent sealing of respirators. Finally, treatments involving liquids and vapors require caution, as steam, alcohol, and household bleach all may lead to degradation of the filtration efficiency, leaving the user vulnerable to the viral aerosols.

ADDENDUM: CovidAGE risk calculator by Sanford Health (via Dr. Seheult)

COVID19 update, June 30, 2020: droplet and aerosol transmission; herd immunity requires as little as 20%?

Been a very busy day at work, but let me just share with you two things:

(a) a long essay that Jeff Duntemann drew my attention to:

Aerosols, Droplets, and Airborne Spread: Everything you could possibly want to know by Justin Morgenstern MD, an emergency physician located in the greater Toronto area.

The essay is long but very much worth your while.

(b) Coronavirus: could it be burning out after 20% of a population is infected? We pointed earlier to a preprint that showed that, if susceptibility to the infection isn’t assumed to be all or nothing, that this leads to a second-order mathematical model that predicts much lower herd immunity thresholds than the common first-order model. See also (h/t: masgramondou): https://judithcurry.com/2020/05/10/why-herd-immunity-to-covid-19-is-reached-much-earlier-than-thought/ 

But it is unlikely that lockdowns alone can explain the fact that infections have fallen in many regions after 20% of a population has been infected – something that, after all, happened in Stockholm and on cruise ships. 

That said, the fact that more than 20% of people have been infected in other places means that the T-cell hypothesis is unlikely to be the sole explanation either. Indeed, if a 20% threshold does exist, it applies to only some communities, depending on interactions between many genetic, immunological, behavioural and environmental factors, as well as the prevalence of pre-existing diseases. 

Understanding these complex interactions is going to be necessary if one is to meaningfully estimate when SARS-CoV-2 will burn itself out. Ascribing any apparent public health successes or failures to a single factor is appealing – but it is unlikely to provide sufficient insight into how COVID-19, or whatever comes next, can be defeated.

COVID19 update, May 31, 2020: which patients benefit most from Remdesivir; asymptomatic infection rate; the post-lockdown economy; miscellaneous updates

(1) Dr. Seheult discusses remdesivir for different categories of patients, and suggests that the drug is most beneficial (in terms of quicker recovery) for patients sick enough to require oxygen, but not so sick as to require mechanical ventilation or ECMOs (“heart-lung machines”). In this latter group, the virus has already done so much damage that remdesivir amounts to “closing the barn door after the horses have fled”, while mild cases will resolve on their own.

The conventional division of patients is (averaged across age groups):

  • 80% self-limiting, self-resolving disease
  • 15% get more severely ill
  • 5% critically ill

So it would be the 15% where the drug can make most of the difference, probably by keeping patients from moving into the 5% critical group. 

(2) Dr. John Campbell’s video looks at the asymptomatic infection rate, which he frustratingly places “between 5% and 80%”, and briefly highlights different studies that arrive at wildly different rates. My working assumption all along has been “about 50%”. 

(3) The Economist has a somewhat pessimistic take on the post-lockdown economy. Note that at least some of the economic effects of the pandemic are also felt in countries that never locked down, like Sweden.

Relatedly, Die Welt (in German) looks at how in reopened Germany, spending habits have changed to the extent that some retailers say they don’t see the point of reopening. The main shopping streets have seen foot traffic dwindle by 30 to 75% (Berlin’s famous Kurfürstendamm was hardest hit). Stores with an online presence, who kept in touch with customers during the crisis, have weathered the storm better, while some with a primarily online business model have seen revenue rise (including a new online grocery shopping chain).

(3) Miscellaneous updates:

Moderna’s COVID-19 vaccines now moves into Phase 2 clinical trials, reports the Jerusalem Post, who also note that the chief scientific officer of Moderna is an expat Israeli. (Like in information technology, tiny Israel punches well above its weight in biotech.)

Forbes highlights what it calls the most important COVID-19 statistic: 42% of US deaths occur in a group that is just 0.6% pf the US population, namely care home residents.

Oddly enough: Monkeys steal COVID-19 testing samples in India. 

Tangentially related, the Daily Telegraph looks at what awaits Hong Kong under full ChiCom rule. The UK has offered asylum to Hong Kongers who still hold BNO (British National Overseas) passports. (This unusual type of passport does not come with automatic “right of abode” in the UK.)

COVID19 update, March 21, 2020: Dr. Matt Shelton on vitamin D; Harvard historian Niall Ferguson on how the pandemic exposed the “dysfunctional administrative state”; 2005 CDC paper touting chloroquine for SARS

(1) Dr. Matt Shelton, interviewed by Dr. John Campbell, tells us much more about vitamin D. Amusing statement: “Stay in the sun until you’re halfway to sunburned for your skin type, and you’ve had enough.”

(2) Niall Ferguson, about 10 minutes into this video from the Hoover Institute:

“The pandemic has revealed a terrible pathology at the heart of American political life, and it’s not the one you think. While the media endlessly pore over every utterance of President Trump, the real pathology that the pandemic has exposed is that we have a completely dysfunctional administrative state that is extremely good at generating PowerPoints and multiple-page reports, but when it comes to actually dealing with an emergency, is completely useless.”

Here’s another good one:

(3) My Facebook friend Jeff D. reminds me of a 2005 paper published by a group from CDC in the Virology Journal entitled: “Chloroquine is a potent inhibitor of SARS coronavirus infection and spread”.
http://doi.org/10.1186/1743-422X-2-69

And yes, that’s the old SARS-CoV-1, not the current SARS-nCoV-2 — but some of the people now doing all they can to “prove” HOcq doesn’t work would be quite embarrassed at this article.

(4) Meanwhile, Standard & Poor maintains Israel’s AA- sovereign credit rating, and predicts a “V-shaped recovery“.

Finally, another good one from Unherd: Prof. Karol Sikora, former head of The Who cancer program and Dean of the U. of Buckingham medical school, sounds a largely optimistic note.

 

COVID19 update, May 20, 2020: reinfection unlikely; correlation between HbA1C and vulnerability to severe disease; German RKI recommendations on masks

Just a quick update today, as workday has been pretty intense.

(1) Dr. John Campbell’s vlog has a special edition on a new report from the South Korean CDC. There have been a number of worrying reports that people tested positive again after recovering, fueling speculation that this could become a chronic disease, like HIV or Hepatitis B. (As he explains, these viruses slip into the cell nucleus and insinuate themselves into the human genome.[*]) Worse, that people could be infectious for life.

However, as it turns out, the tests were false positives. The RT-PCR test detects the presence of a short fragment of RNA that’s specific to the virus, but cannot tell whether this is a remnant of long-destroyed virus, or belongs to a viable virus particle. So when cured patients cough up worn-out lung cells in their sputum, such remnants will trigger a false positive test. This appears to have been the case here.

Just as I was typing today’s update, Dr. Seheult posted a video on the exact same study. He has the link to the English version of the Korean CDC report in the description. (Dr. Campbell had to go off second-hand reports, as only the Korean-language version had been released at the time.) Dr. Seheult’s video adds much more detail.

I believe this is the great COVID19 news of the day.

(2) Yesterday, the good doctor posted another video with a couple of different segments. One is about a recently published evaluation of four new antibody tests using arrays of known positive and negative samples. http://doi.org/10.1016/j.jcv.2020.104394 “Comparison of Four New Commercial Serologic Assays for Determination of SARS-CoV-2 IgG”

The second is about a paper in the Journal of Diabetes Research, showing a clear link between high levels of glycosylated hemoglobin (high HbA1C values) and severe COVID19. http://doi.org/10.1016/j.diabres.2020.108214 “Glycosylated Hemoglobin Is Associated With Systemic Inflammation, Hypercoagulability, and Prognosis of COVID-19 Patients”

Those of you who are struggling with diabetes (or are trying to avoid going there, as I am) will recognize HbA1C — while blood glucose gives an immediate picture, HbA1C gives an “integral”, as it were, of your blood sugar picture over the last few months, and is less prone to fluctuation due to exertion or recent food or drink intake. [**]

(3) Recently, the topic of face masks has generated extreme passions on both sides, at least in the US. (In Israel, the mask mandate came about as a compromise between the Ministry of Economics, which pushed for accelerated reopening of stores, and the Ministry of Health which wasn’t keen on that. The latter acquiesced in exchange for getting its way on masks. As far as I can tell in my Tel-Aviv borough, the mandate is not being enforced visibly, and indeed in some places is honored more in the breach than the observance.)
Now I would like to think that both sides in the US debate would agree that Germany doesn’t mess around in such matters. (Besides, its statistics in the epidemic speak for themselves.) So what does the Robert Koch Institute (RKI) — their infectious diseases authority — have to say on the matter? Here is their position paper on the subject, which may surprise both the “no masks!” and “must wear masks, because science!” sides. Summarizing in translation:

  • most important are good hand hygiene, sneeze-cough hygiene, and maintaining an effective distance of 1.5m (5ft)
  • high-grade multilayer masks are foreseen for healthcare workers
  • we recommend keeping a simple textile mask handy to wear in specific situation in public, namely where no 1.5m distance can be maintained (e.g., on public transit). [***]
  • that said, some people are unable to wear masks at all due to health conditions
  • links to “proper wear and care” recommendations for different mask types
  • notably absent: any recommendation, let alone requirement, that people need to wear masks in public at all times


[*] What Dr. Campbell skips over is that the RNA is first copied to a double strand of DNA using an enzyme called reverse transcriptase — yes, the RT of RT-PCR testing.

[**] Our red blood cells don’t last much longer getting pumped around our bodies, and hence are continuously replaced by newly manufactured ones, with an average turnover of about 4 months.

[***] I feel compelled to belabor the point that momentary passing-by at closer distance does not mean you are suddenly at risk of infection. Our own Ministry of Health, which recommends 2m (6ft6), only counts exposure as ‘closer than the safe distance for 15 minutes or longer.

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

COVID19 update, May 18, 2020: preliminary human vaccine trial results; new BCG study rules out COVID protective effect; the Swedish road alone; more YouTube censorship

Been a crazy-busy day at work, so a few quick updates:

(1) Derek Lowe at Corante reports on the first preliminary results of human trials of the Moderna vaccine. At this point, healthy volunteers were injected with three different doses of the vaccine: 25 µg, 100 µg, and 250 µg. The goal was both to see if antibodies developed (they did, even at the lowest dose) and to establish a safe dosage range. At the highest dose, three volunteers had significant adverse reactions, so that will be off the menu for further testing.

Also from Derek Lowe (hat tip, “Laura R.”) some good news on the human immune response to SARS-nCoV-2.

(2) Miscellaneous updates:

(3) Via Instapundit, YouTube again covers itself in free speech “glory” (sarcasm tag needed)? An epidemiologist who used to be head of Rockefeller U.’s department of epidemiology and biostatistic is the latest to be declared “doubleplusungood” — essentially for stridently advocating the Swedish model as an alternative to lockdowns. I vehemently disagree with him, but why not debate him in the marketplace of ideas rather than place him on the Index Librorum Prohibitorum?

(4) Instapundit’s feed is full of examples of further protracted lockdown measures being openly defied even in Manhattan (!). He calls this “Irish democracy”. I believe, and continue to believe, that short and intense lockdowns work in densely populated countries like my own — but what is currently going on in some US states amounts to perpetual moving of goalposts, and increasingly looks like a flag of convenience for agendas unrelated to epidemiology. The “Irish democracy” response then sooner or later became inevitable. As I have pointed out earlier, the active cases graphs in European countries (+Israel) that have reopened have yet to show any signs of resurgence.

(5) Finally, as a long-time admirer of Richard Fernandez’s work, I was rather amused to see him use the Cytokine Storm metaphor for blunt-instrument lockdowns that you might have seen here.

COVID19 update, May 17, 2020: Exposé on decision making timeline in Germany; YouTube censorship asininity of the day

(1) DIE WELT AM SONTAG, the Sunday supplement of the German daily, has a very long article detailing the timeline of Germany’s response to the pandemic. I will try to put up a translation somewhere, but the bottom line is: decision makers — both in the government and in the Robert Koch Institute (RKI), Germany’s infectious diseases authority — were lulled into a false sense of security by the misinformation spread by the Chinese regime. The article concludes that if these precious weeks had not been lost, Germany likely would have been able to contain the epidemic without a lockdown, and at a much lower cost in lives (not to mention the ruinous economic cost).

A virologist named Alexander Kekulé [a great-grandson of the Kekulé who first discovered the ring structure of benzene] acted as a Cassandra — saying “this isn’t your garden variety flu, but SARS all over again”— but found little resonance at first. A continuous tension existed between the Minister Jens Spahn and the Interior Minister Horst Seehofer (a former head of the CSU, the Bavarian sister party of Angela Merkel’s CDU). Seehofer favored more restrictive measures than his colleague.

Even as the duplicity and manipulations of the Xi regime became clear, Spahn tried to defend the WHO chief, saying he was in an impossible position since he was wholly dependent on the Chinese for information.


Then a number of things happened in quick succession:

  • 100 Germans came in on an evacuation flught from Wuhan. Two tested positive.
  • Diamond Princess ship, first major spread outside China
  • Examination of the first cases in Bavaria revealed that, unlike the 2002-3 SARS, this virus did not confine itself to the lower lungs but also sat in the throat and upper respiratory system , and therefore could spread much more easily.
  • News from Italy came in about the outbreak in the North
  • Following carnival celebrations, the first major “community spread” outbreak in Germany
  • a German dealer in medical PPE (personal protective equipment) sold out of his entire stock (good for about 5 months of normal sales volume) in a single day, and realized something was up.
  • Angela Merkel, in a goodwill gesture, sent 5.5 tons of PPE to China — and in order to do so, had to dig into Germany’s own emergency stockpile, as China was stripping the world market bare
  • at an intelligence briefing, the BND (Bundesnachrichtendienst or Federal Intelligence Service, Germany’s CIA) showed satellite footage of mass graves in Iran that indicated the epidemic there was much more severe than they were communicating outside

Once the powers that be finally became convinced they were dealing with a potentially cataclysmic event, Germany appears to have gotten its act together quite rapidly.

(2) A commenter alerted me that Roger Seheult MD’s youtube video about the zinc-hydroxychloroquine combination, which I linked yesterday, had been deleted by YT for “violating community standards”. To call this asinine would be an insult to donkeys. Dr. Seheult is not your garden-variety crank poster pushing quack remedies, but a pulmonologist who actually deals with COVID19 patients and lectures in medical school, and who has been running an excellent medical school tutoring channel named MedCram on YouTube for some time. Whichever self-appointed medical authority at YT decided that we must be protected from “doubleplusungoodthink” ought to be ashamed of themselves.

Let me repeat once again a quote from the French mathematician, theoretical physicist, and pioneering philosopher of science Henri Poincaré that is something of a creed for French (and Belgian) secular humanists, but is a rallying cry for anyone who takes the pursuit of science and truth seriously:

Liberty is for science what air is for an animal: when deprived of liberty, it dies of suffocation like a bird deprived of oxygen. […] Thought must never submit — neither to dogma, nor to party, nor to passion, nor to special interest, nor to preconceptions, nor to anything but the facts themselves — for when thought submits, that means it ceases to be.

Quote from: Henri Poincaré, Le libre examen en matière scientifique [free inquiry in scientific matters], lecture Nov 20, 1909, on the 75th anniversary of the Université Libre de Bruxelles, http://doi.org/10.1007/978-3-0348-8112-8_12

ADDENDUM: Mike Hansen MD on results from autopsies (the paper in the Annals of Internal Medicine being discussed is here: https://www.acpjournals.org/doi/10.7326/M20-2003 )

COVID19 update, May 16, 2020: evidence hydroxychloroquine works better with zinc added; how Taiwan succeeded; Niall Ferguson on his disgraced namesake

(1) When I reported on the failed hydroxychloroquine (HOcq) trial, a number of commenters asked “what about zinc?” It is indeed so that the early reports of success by both Didier Raoult [director of IHU-Méditerranée in Marseille, France] and by Williamsburg, NY community doctor Zev Zelenko included zinc supplementation.
Now the latest video of Roger Seheult MD highlights a retrospective study with zinc+HOcq (plus azithromycin) about which a preprint just was published. And guess what: results there look a good deal more promising if administered early in the disease. That is strongly suggestive of HOcq’s role being that of a zinc ionophore (and, at least in vitro, Zn2+ inhibits with the RdRp, a.k.a. replicase, that copies the viral RNA) https://www.medrxiv.org/conte…/10.1101/2020.05.02.20080036v1  https://www.youtube.com/watch?v=WZq-K1wpur8

(2) Two COVID19-related videos worth watching from the Hoover Institute

(2a) Vice President Chen Chien-jen, Taiwan, himself a reputed epidemiology professor, describes Taiwan’s response, and how they quickly contained the epidemic without lockdowns.


https://www.youtube.com/watch?v=-3Ry6eiKvvw

(2b) Niall Ferguson, the British-born Harvard University historian, discusses the British and American responses to the epidemic, the economic falloutk, and his now-disgraced near-namesake of the “2 million will die” model.

Neil Ferguson (the modeler) reminds me of the Talmudic maxim:

Scholars, be careful with your words, lest you [lead your pupils] to a place of bitter waters, and they drink from it and die — and thus the Name of Heaven will be desecrated.

Pirkei Avot 1:11

ADDENDUM: Quillette has an article from Paulina Neuding, who lives in Stockholm: “Sweden Has Resisted a Lockdown. But That Doesn’t Make it a Bastion of Liberty” [This is aside from issues with its healthcare system reported on earlier.]

In reality, Sweden’s response to the pandemic has less to do with freedom and individual responsibility, and more to do with the country’s tradition of consensus and social control. Its choice of a uniquely lax approach to the pandemic should not be mistaken for a sudden turn toward individual freedom.

The Swedish strategy, devised by a team of government experts headed by chief epidemiologist Anders Tegnell, rests on the assumption that [(a)] COVID-19 cannot be contained, and that [(b)] other international experts are overestimating its fatality rates. Herd immunity is viewed as the inevitable end point, and it is assumed that such immunity can be achieved relatively quickly and at a cost in human lives that will not be too high.

“We have been a bit careful [about] the words [herd immunity] because it can give the impression that you have given up, and that is not at all what this is about… We will not gain control of this in any other way,” Tegnell explained in an interview in March.

[…] Though polls show that most Swedes trust the state consensus, a minority would prefer to have their families self-isolate, but cannot because they risk intervention from social services. Imagine being a Swedish parent who belongs to a high-risk group, and to face the choice between possibly contracting the virus through your child’s school, and that of being reported to the authorities for the offence of homeschooling.

Sweden’s COVID-19 death rate hovers high above that of other Nordic countries, which have chosen a more restrictive strategy. As of this writing, Sweden has 22 deaths per 100,000 citizens—more than five times as many as Norway (four per 100,000) and three times as many as Denmark (seven per 100,000), even though all three countries saw their first fatalities on roughly the same date. But collectivism is deeply ingrained in Swedish culture—for good and ill—and many view it as bad form to question the authorities in the midst of a crisis.

Even though Sweden has taken a path that is extreme compared to virtually all other EU countries, there is limited overt political opposition, and scientists who have criticized the strategy have been victims of vicious attacks on their characters, and are rejected at public events. The rector at a leading Swedish university even saw it necessary to declare in a blog post (available in English) that employees who had publicly criticized the government’s COVID-19 response would not be censored for doing so. That he even saw a need for such a public statement is telling of the current mood in the country.

COVID19 update, May 15, 2020: interview about German meat processing plants; Santa Clara County immunology study redux

(1) Die Welt (in German) interviewed a Polish guest worker at a German meat processing plant on condition of anonymity. (The interview was conducted in Polish.)
My summary in bullet points:

  • almost all line workers are Polish, Romanian, and Bulgarian guest workers hired via subcontractors. No German wants to do that work [and definitely not at that salary]
  • we get paid net EUR 6.50 to 9.50 per hour, depending on position. We typically work 12 hours a day, 6 days a week. No bonuses for overtime or weekend work—don’t understand my work contract so I don’t know if I’m entitled. [I’m reminded of the Israeli situation where direct employees of a large enterprise — especially long-standing ones — have lavish benefits, but outsourced subcontractor employees often have none at all.]
  • we work as many hours as we can so we can send more money home
  • we typically live 2 or even 4 to a room in houses or apartments, typically arranged via the subcontractor. I paid EUR 150/mo. for effectively half a room; meanwhile I learned two bits of German so I was able to rent a place for just myself. We kept our place clean, but some of the Bulgarians and Romanians are withheld EUR 250/mo. from their wages for 4-to-a-room pigsties.
  • [He claims] some of the Romanians and Bulgarians can’t read or write in any language, and are hence taken advantage of by the middlemen.
  • “we could never in our lives keep 1.5m/5ft distance on the assembly line.” (Title of the article.) “Our stations are 60cm/2ft apart.” They would have to make the line 2.5 times as long for the same productivity.
  • Contrary to claims in the media, general hygiene in the plant is good; otherwise, there are disinfectant stations at toilets, cloakrooms, entrances.
  • we get fresh cloaks every day, with an RFID tracking chip inside. We ourselves have to carry RFID on our persons. Cloak not returned on end of shift — 30 Euro docked from pay
  • masks are mandatory inside now; they used to be optional, but most were wearing them anyhow
  • German foremen are generally polite and reasonable, since previous incidents of brutality led to walkouts
  • Poland just exempted cross-border commuters from 14-day quarantine, so I’m looking forward to visiting my family for the first time in 8 weeks.

(2) (Hat tip: Cedar Sanderson). Interview with Prof. John Ioannides about the revised version of the Santa Clara County [read: Silicon Valley] immunity study [below: Bendavid et al.]. You can read the paper for yourself here (note the “v2” for Version Two at the end of the URL: the original is still available by substituting “v1”. These kinds of preprint servers keep full version history to avoid “Oceania has always been at war with Eastasia” rewriting of history):
https://www.medrxiv.org/content/10.1101/2020.04.14.20062463v2

I think pretty much every serious epidemiologist assumes there is a substantial “Dunkelziffer”/stealth infection rate — the debate is about how big. Truly asymptomatic infection proportions? 22% was reported by German virologist Prof. Hendrik Streeck on his all-community test in a German village; Ref.8 of Bendavid et al. reaches 17.9±2.4% from Diamond Princess data. But this excludes “eh, just a seasonal cough/cold” minimally symptomatic cases, which I suspect are the majority of the Dunkelziffer.

In the current manuscript, they arrive at 1.2% seroprevalence after weighing test performance, and 2.8% (95CI 1.3-4.7%) after adjusting for population demographics.


These prevalence point estimates imply that 54,000 (95CI 25,000 to 91,000 using weighted prevalence; 23,000 with 95CI 14,000-35,000 using unweighted prevalence) people were infected in Santa Clara County by early April, many more than the approximately 1,000 confirmed cases at the time of the survey.

In plain English: the original manuscript claimed there were 50 to 85 “stealth” infections for every documented one, while in the revised version, it may be as low as 14 or as high as 91. OK, let’s apply a simple “Streeck sanity check” here: he proposed using the ratio between the reported case fatality rate (CFR) and his whole-population IFR (infection fatality rate) of about 0.36±0.12% as a crude estimate of how many “stealth” infections are out there for every documented one. From Worldometers data today, I get a 4.1% apparent CFR for California, and 5.6% CFR for Santa Clara County. 5.6 divided by 0.36 leads to about 16:1, though it could be as high as 24:1, consistent with Ioannides’s “unweighted prevalence” data and at the lower end of the 95% confidence interval for weighted prevalence.

(3) Via Erik Wingren, nutritionist Dr. Rhonda Patrick on the wildly popular Joe Rogan Show, speaking on how to boost one’s immune system against infections in general (and thus also COVID19). A commenter summatized the segment as “vitamin D, sauna, sauna,…” Here is a more useful table of contents of the 3-hour podcast.

(4) Israel Hayom, lying around in our condo complex’s lobby, had a headline where outgoing Economics minister Moshe Kaḥlon was quoted as saying: “We sacrificed the economy on the altar of health”. It reminds me of the debate in the US about who is right, Anthony Fauci MD or Senator Rand Paul (R-KY; himself an MD ophthalmologist and a COVID19 survivor). My personal answer: both. They just emphasize opposite scales of the balance. There is no perfect solution here—only a trade-off between different sources of mortality, and the best you can do is try to minimize their sum. Because make no mistake: even the now-disgraced Neil Ferguson (he of the “2 million dead” model that ) acknowledged that continued hard lockdown would engender collateral mortality exceeding any reduction in COVID19 mortality.

(5) Lagniappe: Roger Seheult MD on glutathione deficiency, which brings us back to our previous items on N-acetylcysteine, a.k.a. “NAC”.

ADDENDUM: Israel Institute for Biological Research files for patents on 8 SARS-nCoV-2 antibodies

Antibody tests of two Snohomish County, WA residents push back COVID19 timeline in the USA to probably mid-December.

Marta Hernandez on the ChiCom propaganda machine being turned up to 11. But Peter Zeihan has an interesting out-of-the-box theory about that.

COVID19 update, May 6, 2020: Dr. Hansen on what we learn from autopsies of COVID19 patients; infection fatality rate; Neil Ferguson’s downfall

(1) In a previous episode, I partly translated an interview with a German pathoogy professor and his assistant about what they learned from autopsies on COVID19 patients pathology professor discusses what can be learned about COVID19 from autopsies

Now Mike Hansen MD discusses the same in English

Blood clots, endothelial inflammation, and in general the immune system trying to kill you in order to save you. The blood clots account for much if not all of the damage to all sorts of organs. If only we could reliably stop this from happening, COVID19 would be a nuisance, not an emergency.

And Roger Seheult MD just posted this video on the exact same subject.

The rule of thumb is that 80-85% of symptomatic cases get the mild version that affects the upper respiratory tract but not the lower lungs. These patients, seemingly without exception, get better on their own — it’s the remaining 15-20% that get lower pneumonia who may be fighting for their lives against bad odds. The sooner such cases are recognized, the better to start administering oxygen and anticoagulants, and perhaps remdesivir if available.

(2) But is this “80% rule” constant across all age brackets? A breakdown of case fatality rates by age cohort makes this seem quite implausible. The figures below are taken from the daily report of the Korean CDC for South Korea, from the RKI’s daily report for Germany, and from an informally shared report for Israel.

Age groupIsraelSouth KoreaGermany
Average1.462.364.18
80+13.023.918.4 average 70+
70-796.310.3
60-691.82.61.65 average 30-69
50-590.50.8
40-490.10.2
30-390.10.2
20-290.1nil0.01
10-19nilnil0.01
0-9nilnil0.01
case fatality rates (%) per age bracket

It is pretty obvious with the low mortalities in the lower age brackets that severe cases cannot account for 15-20% of the age bracket. (I would love to lay my grubby hands on statistics of ICU admissions in Germany as a proxy for severe cases.)

Note also, by the way, that Israel’s mortality seems to be lower across the board than South Korea’s and especially Germany’s. While Israel’s medical system punches above its weight, it would be silly to claim it is that much better than Germany’s or South Korea’s. I also can’t think of any genetic reason, and in terms of vaccination schedules, Israel is similar to the other two countries. Now it is quite possible that despite pretty aggressive testing, Germany’s denominator is too low; South Korea had meticulous test & tracking from the beginning (one reason why they were able to weather the storm without hard lockdowns). Adjusting for population pyramid (Israel’s is by far the youngest of the three) accounts for much of the difference between Israel and South Korea. What remains with Germany?

It couldn’t possibly have anything to do with this fireball in the sky, 150 million kilometer away, could it? Israel of course enjoys a much warmer and sunnier climate — its largest population centers are near the 32nd parallel, compared to the 52nd parallel for Berlin. Lots of sun means more vitamin D and a stronger immune system; warmer and especially sunnier weather means virus survives less time on surfaces, clothes,…

(3) And as long as we’re crunching numbers:

German virologist Prof Hendrik Streeck, from community-wide testing in Gangelt in North Rhine-Westphalia, derives 0.36% as the infection fatality rate, but allows it might be as low as 0.24%. He suggests the ratio between his IFR estimate and the official CFR as an estimate for the Dunkelziffer or stealth infection rate.

The small country that tested the highest percentage of it s population is, of course, Iceland, which according to  http://www.covid.is/data now has tested over 14% of their entire population (of about 360K). With ten (10) dead out of 1,799 confirmed infections, this suggests an upper limit of 0.56% to the infection fatality rate (IFR). German virologist Prof. Hendrik Streeck derived 0.36% from nearly whole-population testing of a single hard-hit village (Gangelt), but in an interview on Unherd I’m now watching, he allows it might be overestimated and be closer to 0.24%.

(Streeck also talks about the initial outbreak in Gangelt through mass spreading at a carnival celebration: packed indoors, loud singing, loud shouting over the “music”, traditional kissing on the mouth [UGH],… None of this is representative of going about regular business of life in a country where people keep each other at arm’s length, like the US.)

The infamous “two million will die” prediction of Neil Ferguson was based, among other assumption we now know to be incorrect, on an IFR of 0.9% Swedish epidemiologist Johan Giesecke [sp?] speaks of 0.1%, a number similar to what some of the community testing studies in California imply. I am leaning toward 0.3±0.2% as a rule of thumb.

(4) Speaking of Neil Ferguson: despite his vocal advocacy of social distancing and lockdown, he was forced to resign after being caught meeting with his lover , a younger woman in an allegedly “open” marriage to someone else. Toby Young in the Spectator cannot suppress a degree of Schadenfreude.

COVID19 update, May 5, 2020 edition: protective effect of MMR vaccination? strokes, vitamin D; ACE inhibitors and ARBs

Some quick updates, as today is very busy at work:

(1) Intriguing preprint from Cambridge U., via Yves [not Cohen]:
http://doi.org/10.1101/2020.04.10.20053207https://www.medrxiv.org/content/10.1101/2020.04.10.20053207v1.full.pdf+html

Franklin, R.; Young, A.; Neumann, B.; Fernandez, R.; Joannides, A.; Reyahi, A.; Modis, Y. Homologous Protein Domains in SARS-CoV-2 and Measles, Mumps and Rubella Viruses: Preliminary Evidence That MMR Vaccine Might Provide Protection against COVID-19. medRxiv 2020, 2020.04.10.20053207.

The COVID-19 disease is one of worst pandemics to sweep the globe in recent times. It is noteworthy that the disease has its greatest impact on the elderly. Herein, we investigated the potential of childhood vaccination, specifically against measles, mumps and rubella (MMR), to identify if this could potentially confer acquired protection over SARS-CoV-2. We identified sequence homology between the fusion proteins of SARS-CoV-2 and measles and mumps viruses. Moreover, we also identified a 29% amino acid sequence homology between the Macro (ADP-ribose-1’’-phosphatase) domains of SARS-CoV-2 and rubella virus. The rubella Macro domain has surface-exposed conserved residues and is present in the attenuated rubella virus in MMR. Hence, we hypothesize that MMR could protect against poor outcome in COVID-19 infection. As an initial test of this hypothesis, we identified that 1) age groups that most likely lack of MMR vaccine-induced immunity had the poorest outcome in COVID-19, and 2) COVID-19 disease burden correlates with rubella antibody titres, potentially induced by SARS-CoV2 homologous sequences. We therefore propose that vaccination of ‘at risk’ age groups with an MMR vaccination merits further consideration as a time appropriate and safe intervention.

Excerpt from Figure 4 of the paper:

(2) John Campbell has more on strokes as a complication of excessive blood clotting in severe COVID19,

https://www.nejm.org/doi/full/10.1056/NEJMc200978

as well as on a preprint from Indonesia that appears to show a very strong link between vitamin D deficiency and COVID19 mortality:

(3) Good news for people who are on ACE inhibitors and ARBs (angiotensin release blockers):

COVID19 update, Yom HaAtzma’ut edition: “Coronahotels” for mild cases in Israel; pathology professor discusses what can be learned about COVID19 from autopsies

Happy Independence Day/Yom Atzmaut Sameach to my fellow citizens of Israel

(1) In the video below, you see an interview with IDF soldiers staffing a “CoronaHotel”. As our hotels are basically shutdown anyhow, the government requisitioned a number of them to create a third option for people not sick enough to need hospital care, yet whose living conditions do not permit safe home isolation (e.g., because they might infect family members or roommates): the “CoronaHotels”. 

These places are operated by (mostly female) IDF soldiers in their mandatory service: here is a video interview with one of them

No, the hotel is not on a dark, deserted highway 😉 — the one in the video is the Dan Panorama in Jerusalem, normally an upscale tourist and business hotel.

But can you check out? This is not in the hands of the IDF but of doctors, under the overall authority of the Health Ministry.

As I scraped together from different sources:

  • if you tested positive but never showed symptoms, you get retested after two weeks, and if you are negative for the virus then you can go home. If you still test positive, you are retested a week or so later.
  • If you did get a mild flu-like illness, you are tested after you get better.
  • Of course, if your condition worsens, you are transferred to a hospital. In this manner, hospital beds are only used for COVID19 patients who actually need hospital care.

According to the latest Ministry of Health update, https://govextra.gov.il/ministry-of-health/corona/corona-virus/

1,726 people are currently in CoronaHotels, 4,540 mild or suspected cases are in home isolation, and just 352 people are in hospital. Of the latter, 120 are in grave condition (91 of them on artificial respiration), 85 in moderate condition,  and the remainder currently in mild condition (presumably convalescent after more severe episodes). 212 people have died, 7,929 have officially recovered. Out of 15,782 documented infections, that leaves 7,641 active cases, down from their peak of 9,808 on April 15.

(2) Moving from Israel to Germany, DIE WELT has a long (and for me enlightening!) interview with two pathologists at the U. Of Hannover medical school, one of them a lung pathology professor. They perform numerous autopsies on patients deceased from COVID19. Normally they spend 5% of their time doing autopsies and 95% analyzing tissue samples from living patients, mostly for suspected tumors or to help establish optimal cancer treatment plans for confirmed tumors. Nowadays — mostly COVID19 dead. Below follows a mixture of paraphrased summaries and (in quotation marks) hand-corrected machine translations from the original German.

The pathologists broadly hint that invasive respiration (“ventilators”) does more harm than good, and exposes the patients to all sorts of secondary infections [by antibiotic-resistant “hospital bugs”]. 

Primary infection is via nose and throat. 80% of cases are mild [and get better without treatment]. Of the remaining 20%, one-third end up in intensive care with severe lung involvement.

“Jonigk: Blood clotting occurs in the lung [capillaries], which are in the walls of the lung alveoli that serve to absorb oxygen and remove CO2. The damage causes protein to escape from the blood into the alveoli. Oxygen must somehow be transported from the air we breathe into the capillary network. That’s how we breathe. Anything that lengthens that route ensures that the patient can no longer supply himself with sufficient oxygen. It’s like playing soccer when you’ve skinned your knee: First a brown-red crust of protein and blood develops. We have a similar situation in the air bubbles. And breathing through them is massively difficult. The patient has a feeling of breathlessness, too little oxygen gets into the organism. It is more likely to be secondary to an inflammatory reaction. A downward spiral begins, which ends in a so-called shock lung. The lung and with it the patient fight for their lives.[…]”

Q: [which pre-existing conditions?]

A: “Older people with previous damage to the lungs. Patients who are dependent on medication that diminishes the immune system. And smokers, for example. Or people who live in an area with high particulate matter pollution and therefore already have pre-damaged lungs. So they are already not well before that. If an acute infection such as SARS-CoV-2 is then added, this can be enough to put the already sick patient’s life in danger.”

“Classic pneumonia is a bacterial infection with purulent sputum. The pus is yellow because it is made up of fatty granulocytes. Their task is to fight the enemy, the pathogen, in the body. But SARS-CoV-2 is a virus. It attacks cells directly and reprograms them. After an initial unspecific reaction, the response to this infection consists of specific T-lymphocytes, a subtype of white blood cells. These can recognize and attack virus-infected cells. We now have a large number of lymphocytes in the basic structure of the lung, which collect in the walls of the alveoli and develop their inflammatory activity there.”

Q: [what about other organs?]

“Up to 25 percent of intensive care patients have disorders of liver and kidney functions. In addition, blood coagulation often appears to be permanently disturbed. Small, local blood clots form at many sites because the inflammatory cells beat around to destroy the virus-infected cells, which include vascular cells. No matter where this occurs, it always has considerable consequences for the organ — strokes occur and sometimes extremities have to be amputated. In many organs, the occlusion of a blood vessel can be compensated. But if you have many occlusions, the blood does not flow properly, organ damage occurs, inflammatory cells do not get where they actually want to go, and the heart is also put under strain.”

Q: [is this just a COVID19-thing?]

“When you have a nasty cold with a fever, there’s always the recommendation: “Don’t go to the gym.” The basic idea behind this is that any virus can, in principle, infect any organ. Normally you have a resting heart rate of 65 or 70, but if you want to be a tough guy and go to the gym and treadmill and give it all you’ve got, you have a pulse of 150, so your heart is pumping properly. The chance of the virus infecting the heart suddenly increases dramatically. When you are infected, the body fights most viral infections with lymphocytes that go to the heart muscles and kill the infected cells. And this heart muscle inflammation is the most common reason for heart transplants in people under the age of 25.”

“At the moment when [the blood flow in] small vessels in the lungs is disturbed, the heart has to apply increased pressure to pump the blood through the lungs at all. This places an enormous strain on the right ventricle, which is normally only responsible for a low pressure. If the pressure requirements increase, it is quickly overtaxed, resulting in acute right heart failure. The left ventricle does not pump the blood into the lungs, but into the rest of the organism. It is capable of producing a pressure four to ten times greater than the pulmonary circulation. Regardless of whether it is caused by Covid or some other infection: as soon as the pressure in the pulmonary circulation is increased and the right heart is put under pressure, the patient can quickly die. […] So when the lungs are infected, the right heart has to run at full throttle for 1.5–2 weeks and is stressed far beyond normal levels. A young, fit person is more likely to cope with this than someone who already has a previous injury. But the virus is apparently also able to damage the heart itself. And the blood clots can of course also appear in vessels in the heart. So you have a heart that is pumping strongly, and suddenly the blood supply to the heart itself goes down. Then you have two hard strains, which can already be too much for the damaged heart.”

Q: [what about pre-existing conditions?]

“There is the old saying: A healthy patient is only a patient who has not been examined well enough. For example, high blood pressure is a classic disease of old age. In Germany, this will be about 35 percent of the total population. Up to now, mainly elderly people in Germany have died of Covid-19, which means that most Covid-19 deaths have had hypertension. Us being Germans, we also drink a lot of alcohol, so many citizens are overweight and have a fatty liver. The patient over 60 who has no previous illness – statistically there are only few. The important thing is not that there are pre-existing conditions, but which ones. And in what context do these have an influence on the probability of survival in the case of Covid-19 disease? It’s not enough to say, “This patient had something.” Rather, the previous illnesses must be systematically uncovered in relation to the population.”

You have to separate whether someone died of, or with, a Covid-19 infection. It’s already affecting statistics. As far as we know, in Italy a corona test was carried out on every person who died and everyone who was found to have the virus was considered to have died of corona. In the case of pre-existing conditions, a distinction must also be made between diseases that generally shorten life expectancy and diseases that specifically increase the risk of corona infection and possible complications. This is somewhat muddled in the public discussion.”

Q: [brain involvement]
A [paraphrased]: we cannot conclusively rule out direct virus involvement, but the brain is so sensitive to disturbances in blood flow that blood clots quickly lead to headaches, then strokes.

[Paraphrased] “Overall, we know a lot about what happens at the cellular level with the virus, but relatively little about what happens at the organ level. Cell cultures can only tell you so much. So here is where autopsies come in.”