COVID19 update, July 8, 2020: by CDC criteria about to fall below “epidemic” threshold in the USA?; Israel public health chief resigns, citing “frivolous” decision making process; Dr. Campbell on knowns and “known unknowns” of COVID19

(1) Instapundit reports that the death rate from COVID19 has fallen far enough that by CDC criteria it’s about to fall below the “epidemic” threshold. He comments:

WE CAN HOPE: Is The Pandemic Coming To An End At Last? “Well, firstly, it’s not actually us saying this. It’s the Centers for Disease Control, which reported that the death rate has fallen so far it’s now roughly equal to the threshold for even qualifying as an epidemic, which isn’t as severe as a pandemic.”

Death rates aren’t following case numbers up, at least not yet. In my area we had our first Covid deaths in two months last week, as case numbers climb — but we’ve had a total of 9 deaths in a county of over 400,000 people since the beginning of the pandemic. We’ve almost certainly lost more people to flu in the same period.

But case numbers are climbing, and death is a lagging indicator. Even so, though, if the disease is as fatal as it was in, say, March, deaths should be climbing much faster than they are. Some of that is no doubt because we don’t have the nursing home outbreaks we had back when Grandma-Killer Cuomo and other governors were sending infected patients into nursing homes, and some of it may be because Vitamin D levels are higher this time of year, and coronavirus fatalities seem closely tied to very low Vitamin D levels. Also, thanks to the marches and the general laxity that followed them, more of the infected are younger people, who typically don’t get as sick. That’s good, because it’s moving us toward herd immunity with as few fatalities as possible. But stay tuned; it’s still too early to know what’s really going on.

(2) Despite that, Israel is seeing a second wave of the same magnitude as the first, but again (tellingly) with much lower mortality than the first. Still, our country’s head of public health, Prof. Siegal Sadetski (on leave from Tel-Aviv U.’s medical school) suddenly resigned, and left a blistering public resignation letter.

In the letter sent to Health Ministry director-general Chezy Levy, she accused the government of “making frivolous and unsubstantiated decisions, without considering their widespread and long-term public health implications.” 

“Infinite time” is spent “calming the spirits” and “managing partnerships,” while the work that needs to be done in the field is relegated, Sadetsky said.

“Too much time is invested in debates, discussions, consultations and forums… while the operations and details required for the success of the various operations do not receive the proper attention,” she said, stressing that the work environment at the Health Ministry has become wrought with personal interests. 
“The [coronavirus] is a deadly, cunning and agile epidemic,” she added. “I feel with a high-level of certainty… that the coming months will be difficult and even tragic.”

[…] “Opening the education system first in a limited way and two weeks later in a sweeping way… led to widespread reinfection in Israel,” Sadetsky said. “Maintaining educational frameworks plays a major role in the ability to safeguard the economy and their importance to our children. However, in the absence of conformity to corona regulations, schools and kindergartens become fertile grounds for infection. 
“Israel opened the education system too quickly compared with most countries in the world. Without compatible conditions, education systems cannot be opened.”

“In the first phase, Israel’s achievements were reflected in the flattening of the morbidity curve, and the measures taken were inspirational and praised by other countries dealing with the plague. In contrast, the second phase was characterized by a vital but rapid and sweeping opening of the economy […] The atmosphere of illness treatment and decision-making has changed fundamentally, and the results are evident in the morbidity curve,” Sadetsky said. 
The government broke its promise of opening progressively and reviewing the impact of its decisions, continually moving forward even though the morbidity graph indicated the situation was getting worse, she said.

“The global experience in dealing with epidemics shows that actions and moves that are avoided due to the fear of difficult and painful decisions subsequently cost twice as much as making those difficult decisions,” Sadetsky wrote. “It was only last weekend that [the government] decided it was ready to return to preventative measures, which in my estimation is too little and too late.”

Another article in the Jerusalem Post (which sadly has gone downhill under its new editor) uses the term “ship without a rudder” and contrasts the clear voice with which authorities spoke during the first wave with the chaotic mess currently pertaining. 

The decision-making process is actually more complicated than the public is aware: Some decisions fall into the hands of the Health Ministry, some are the government’s and still others the Knesset’s, which means that even though the new directives were announced together, only some of them went into effect. 
“Sometimes, the directives are in the news, but they are not yet enforceable,” clarified Prof. Hagai Levine, a Hebrew University epidemiologist and chairman of the Israeli Association of Public Health Physicians.

But whether the directives are enforceable or not should not be a question for the public, he said, adding: “If the risk of attending a mass wedding is high, then regardless of the law, you should not organize such a wedding.” 
Nonetheless, Levine admitted that when it is unclear to the public that the decisions made by the government are based on science, rather than pressure by the loudest interest groups, it harms public trust and makes it harder for the people to follow them.

The current national unity government with its proliferation of redundant ministerial portfolios created explicitly for coalition reasons, led to the quip “we have more ministers than patients on respirators”.

In other Israel-related COVID news, El Al, Israel’s national airline which was privatized 15 years ago, is being renationalized. The company was struggling to begin with, but now was brought to its knees like many national airlines.

(3) I’ve been wanting to do a “Known knowns, known unknowns, and unknown unknowns about COVID-19” post for a while. This just-released video by Dr. John Campbell is a good starting point though.

For the impatient, there are some keyword-style talking points in the description of the video, which also links to two articles:

https://www.nature.com/articles/d41586-020-01315-7

https://www.nature.com/articles/d41586-020-01989-z

Watch the whole video (on high-speed if need be — I often run such videos at 1.25 or 1.50 speed) but I just want to highlight one aspect I haven’t ever discussed here. 

(a) viral load (around 11 minutes into the video). Paraphrasing: Ten viral particles or so might be enough to get to the throat, but are likely to be cleared by the mucociliary system. By the time viruses from the throat infection can make it down to the lungs, the innate immune system, the rapid-response part of the body’s immune system, has mobilized. For such people, it would end with a mild case.

In contrast, you get a hundred viral particles or so, and some may make it past the mucociliary system down to the lungs before immunity has had a chance to mobilize — setting you up for pneumonia and a severe case. 

(b) genetics (about 21 minutes into the video): 4,000 people in Northern Italy who got particularly bad seem to belong to two particular gene variants. There are precedents for this in, e.g., the bacterial disease tuberculosis and the viral disease Epstein-Barr. 

BEFORE I FORGET: This other video by Dr. Campbell, which is mainly about face coverings, also has a cute memory trick for the different kinds of immunoglobulins:

IgM for iMMediate action

IgG for aGGlutinating

IgA for sAlivA, sweAt, and teArs (or mucous membrAnes)

IgE in type 1 hypersEnsitivity

COVID19 update, May 7, 2020: risk of severe case presentation increases with age too; meat processing plants; fraying lockdowns; Georgia (the country)

Busy day at work, so just some quick updates:

(1) There is a commonly quoted rule of thumb that 80-85% of COVID19 cases are mild, and the rest severe and life-threatening. But how constant is that ratio really?

I was emailed a copy of a report (in Hebrew) by a group that was consulted for our national COVID19 planning. In the section on expected hospital load was a table with a breakdown of hospital and ICU admissions by age bracket, apparently taken from a CDC Morbidity and Mortality Weekly Report, http://dx.doi.org/10.15585/mmwr.mm6912e2. Screenshotting the table here:

* Lower bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group; upper bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group with known hospitalization status, ICU admission status, or death.

Needless to say, these are data early in the epidemic (when the group had to make its recommendations). But if we use ICU admissions as a proxy for the number of severe cases, then we see a clear increase with age, the way it is seen for mortality.

(2) Elsewhere on the CDC site, one finds a report about the conditions and challenges at meat processing plants https://dx.doi.org/10.15585/mmwr.mm6918e3
Some quotes:

During April 9–27, aggregate data on COVID-19 cases among 115 meat or poultry processing facilities in 19 states were reported to CDC. Among these facilities, COVID-19 was diagnosed in 4,913 (approximately 3%) workers, and 20 COVID-19–related deaths were reported. Facility barriers to effective prevention and control of COVID-19 included difficulty distancing workers at least 6 feet (2 meters) from one another (2) and in implementing COVID-19-specific disinfection guidelines.* Among workers, socioeconomic challenges might contribute to working while feeling ill, particularly if there are management practices such as bonuses that incentivize attendance. 

 Facility challenges included structural and operational practices that made it difficult to maintain a 6-foot (2-meter) distance while working, especially on production lines, and in nonproduction settings during breaks and while entering and exiting facilities. The pace and physical demands of processing work made adherence to face covering recommendations difficult, with some workers observed covering only their mouths and frequently readjusting their face coverings while working. Some sites were also observed to have difficulty adhering to the heightened cleaning and disinfection guidance recommended for all worksites to reduce SARS-CoV-2 transmission.

Solutions to structural and operational challenges that some facilities adopted included adjusting start and stop times of shifts and breaks to increase physical distance between workers. Outdoor break areas were added at some facilities to decrease contact between workers. Some facilities installed physical (e.g., plexiglass) barriers between workers; however, this was not practical for all worker functions. Symptom and temperature screening of workers was newly instituted in some facilities and improved in others.

Sociocultural and economic challenges to COVID-19 prevention in meat and poultry processing facilities (Table 2) include accommodating the needs of workers from diverse backgrounds who speak different primary languages; one facility reported a workforce with 40 primary languages. This necessitates innovative approaches to educating and training employees and supervisors on safety and health information. In addition, some employees were incentivized to work while ill as a result of medical leave and disability policies and attendance bonuses that could encourage working while experiencing symptoms. Finally, many workers live in crowded, multigenerational settings and sometimes share transportation to and from work, contributing to increased risk for transmission of COVID-19 outside the facility itself. Changing transportation to and from the facilities to increase the number of vehicles and reduce the number of passengers per vehicle helped maintain physical distancing in some facilities.

(3) Lockdowns — useful as they undeniably are in densely populated urban regions — are not something that can be maintained forever. In the “hammer and dance” strategy of Tomas Pueyo, the “hammer” — the lockdown to break the epidemic’s back — is supposed to be hard and short, followed by a maintenance phase — the “dance” — that favors such social distance measures as yield the maximum reduction for minimal economic cost. (Face masks are one example.)
There are increasing signs that lockdowns in the US are fraying. Bethany Mandel, who lives in New York, speaks for many who express a sense that politicians of a certain stripe now keep “moving the goalposts” way beyond the original justification for lockdowns, and that they are completely oblivious to the staggering and still mounting economic costs for those who do not have guaranteed government paychecks. “We are tired of being treated like children,” one reads numerous times in the comments.[*]

Days ago, a hairdresser in Texas who had reopened her business made a tearful plea that she not be punished for wanting to feed her children. She was convicted to seven days in prison and a $7K fine. Now in a dramatic turn of events, not only have both the state Attorney-General and the Governor criticized the “excessive” punishment (the lockdown over hardressing salons ends Friday anyhow), but the state’s Lt.-Gov. donated the money from his own pocket and offered to serve the 7-day sentence himself as a proxy for the woman.

(4) DIE WELT looks at what it calls the “Coronavirus Model Pupil,” Georgia (the country, not the US state). The country, knowing it could ill afford such a calamity, locked down proactively rather than reactively, and is now exiting. (Possibly the most prescient thing it did was cut air links to China before they even saw their first case.) Now, despite a social culture much like Italy, it got a sum total of 610 cases, with just 9 (nine) dead.

(5) Finally, hard-hit Belgium is reopening after a few false starts. Summarizing the report from De Standaard (in Dutch):

  • starting May 10, every household can receive and host four designated people (a fixed list of four). Recommended to sit outdoors. No travel distance limitation
  • May 11, shops will open. One customer per 10m^2 (110 sq.ft.) floor area. Wearing a mask is recommended but not mandatory; generally recommended in situations where 1.5m (5ft) distance cannot be maintained (e.g. on public transit). If lines develop, elderly, handicapped, and care workers get priority
  • public transit in principle reserved for people who have no private means of transportation (cars, motorcycles). In practice, this will not be enforced
  • restaurants, cafés, cultural centers remain closed for now
  • public sports events are put off until July 31

[*] Without engaging in partisan political rhetoric: one reason the lockdown in Israel was largely successful, and saw a compliance well above what one might expect of our garrulous nation, was that we were treated like adults. Economic trade-offs were honestly discussed, including the limits to how long we could lock down before irreparable damage to our economy would ensue — and we were given a realistic time horizon from the start. At no point was there a sense of “bait and switch”.

UPDATE: via the Jerusalem Post, this interesting paper in the Journal of Medical Virology has an interesting theory about why the SARS-nCoV-2 coronavirus may elicit potentially fatal “cytokine storm” so much more often than seasonal influenzaviruses: https://doi.org/10.1002/jmv.25866

We have applied mathematical modeling to investigate the infections of the ongoing COVID‐19 pandemic caused by SARS‐CoV‐2 virus. We first validated our model using the well‐studied influenza viruses and then compared the pathogenesis processes between the two viruses. The interaction between host innate and adaptive immune responses was found to be a potential cause for the higher severity and mortality in COVID‐19 patients. Specifically the timing mismatch between the two immune responses has a major impact on the disease progression. The adaptive immune response of the COVID‐19 patients are more likely to come before the peak of viral load, while the opposite is true for influenza patients. This difference in timing causes delayed depletion of vulnerable epithelial cells in the lungs in COVID‐19 patients while enhancing the viral clearance in influenza patients. Stronger adaptive immunity in COVID‐19 patients can potentially lead to longer recovery time and more severe secondary complications. Based on our analysis, delaying the onset of adaptive immune responses during early phase of infections may be a potential treatment option for high risk COVID‐19 patients. Suppressing the adaptive immune response temporarily and avoiding its interference with the innate immune response may allow the innate immunity to more efficiently clear the virus.