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, April 26, 2020: NYC vs. rest of USA; super-spreader events analyzed; reopening non-emergency care; cyclic lockdowns

(1) Bret Stephens in the NYT: lockdowns are good for NYC, but why should the rest of the USA have to play by the same rules as congested NYC? (archive version

As of Friday, there have been more Covid-19 fatalities on Long Island’s Nassau County (population 1.4 million) than in all of California (population 40 million). There have been more fatalities in Westchester County (989) than in Texas (611). The number of Covid deaths per 100,000 residents in New York City (132) is more than 16 times what it is in America’s next largest city, Los Angeles (8). If New York City proper were a state, it would have suffered more fatalities than 41 other states combined.

It isn’t hard to guess why. New York has, by far, the highest population density in the U.S. among cities of 100,000 or more. Commuters crowd trains, office workers crowd elevators, diners crowd restaurants. No other American city has the same kind of jammed pedestrian life as New York — Times Square alone gets 40 million visitors a year — or as many residents packed into high-rises. The city even has a neighborhood called Corona, which, it turns out, has among the highest rates of coronavirus infections.

Consider a thought experiment in which metropolitan New York weren’t just its own state, but its own country. What would the crisis for what remained of America look like, then? In this slightly smaller nation of a little more than 300 million people, the death toll would amount to about 7.5 per 100,000, slightly above Germany’s levels.

I also suspect that, if NYC were at the same latitude as Miami or Houston, it would have seen much lower mortality even with the same population density. Although the NYC subway still strikes me as “the mother of all super-spreaders”, and a study from MIT agrees.

(2) Speaking of super-spreader events: Quillette’s Canadian editor Jonathan Kay did some research of his own into 38 such events in 28 countries. (He restricted himself to documented events in languages he could read: the Purim super-spreader events in Israel he therefore dismissed, despite the extensive documentation I have seen in the Hebrew-language press and social media.) At any rate, let me (over?)summarize some of the patterns seen over and over:

  • mass events (at high density), not people going about normal day-to-day business (unless said business involves catering at crowded mass events, of course)
  • long duration
  • extremely close physical contact — kissing, hugging, or shouting into people’s faces or ears (e.g., because the music at the event was so loud).

Buying seeds or “nonessential” household items is not on this list, needless to say. (If of course said purchase requires queueing in tight quarters for hours, that’s another matter.)

(3) Rick Jackson, chairman and CEO of Jackson Healthcare, the 3rd largest health care staffing company in the USA, points out in an op-ed in Newsweek [!] that many hospitals are standing empty and face closure unless allowed to treat “non-urgent” non-COVID19 patients again — and urges authorities to permit this. He points out that no fewer than 1 in 8 [working] Americans work in healthcare…

(4) The group of systems biologist Uri Alon at the Weizmann Institute developed this “Adaptive cyclic exit strategies” simulator

Their idea in a nutshell: work x days on, y days off (their recommendation is x=4 and y=10), for example by alternating shifts. I think the easiest to implement in practice would be x=5 and y=9, two shifts (i.e., alternating working weeks). The 9-10 days at home would mean anybody who got infected at work would either be showing symptoms or asymptomatically test positive by the time they’d have to go back to work.

Their simulations show that this is a way to achieve most of the benefit of a full lockdown, while still permitting about 50% economic activity in non-telecommutable sectors (so probably 70%+ overall).  The active case load, rather than a monotonic decay as in a full lockdown, would get a damped oscillation superimposed on it. Below is an example:

Anyway, have a look at the simulator. The key is to keep the effective reproductive number Rt (in their notation) below 1 so the epidemic will die out eventually. A number of larger Israeli companies have adopted this strategy, with two staggered shifts.

(5) As a final reflection: the more I think about COVID19, the more it sounds that, if we had a reliable way to prevent cytokine storm, or nip it in the bud if it appears, we would be following a drastically different strategy. I talked to a source in the drug design community, and it sounds like more and more immunosuppressant/immunomodulator drugs are being repurposed for clinical trials (or compassionate use) in severe COVID19.