COVID19 update, April 9, 2020: Passover quick takes

Happy Passover to my Jewish readers! Some quick takes on the holiday:

(1) Germany’s Minister of Health Jens Spahn is looking at reopening the country, reports DIE WELT (in German). He sees two main preconditions: (a) numbers keep evolving in the right direction; (b) businesses will be compliant with hygiene and distance requirements 

Spahn on video: “The Easter Weekend will be a fork in the road.” Paraphrasing: If we remain compliant, we may soon be on the road to renormalization. If we become lax and complacent, we may be stuck with this for a long time.

DIE WELT also reports that Chancellor Angela Merkel is reluctant to open early, as she is afraid that a flare-up following a hasty reopening will instead lead to a much longer shutdown

(2) A European Union think tank is drafting a “European roadmap for an exit from the COVID-19 epidemic” , and Die Welt obtained a copy. Their recommendations echo some of what the German decision makers are mulling, but urge a coordinated response of all European countries. At the same time, they recommend that specific lockdown relaxation decisions be taken at a local (district or province, not national) level — such that if a flare-up does occur, the affected district can be separately placed in renewed lockdown, rather than the entire country.

Also, enough time should be left between relaxation steps to assess their impact. 

Fundamentally, blanket “one size fits all” measures should give way to targeted measures

(3) De Standaard (in Dutch) reports hopeful signs from Belgium where total COVID19 hospitalization keeps dropping. 

(4) Via Instapundit, a peculiar result from a French cancer research team, where of a group of 2,500 high-risk cancer patients that were administered the antioxidant methylene blue as part of their therapy (for reasons unrelated to COVID19), allegedly not a single patient got infected by COVID19. The researchers hypothesize that the changes in cellular pH induced by methylene blue impede the replication of the virus, in the same manner as they hypothesize (hydroxy)chloroquine work

This particular institute seems to be exploring the controversial theory of Otto Warburg (Nobel Prize in Medicine 1931 for “discovery of the nature and mode of action of the respiratory enzyme”)  that cancer is primarily a metabolic disease. (Mainstream oncology considers the metabolic peculiarities of cancer cells an effect, rather than a cause.)

(5) Some New York physicians, who look at the terrifying death rate among adults placed on “ventilators” (read: lung intubation), now favor keeping patients off invasive respiration as long as possible, as they suspect that long-term intubation is itself a stressor.

(6) CDC director Robert Redfield says actual mortality will be much lower than models predicted.

(7) As Zoom has become so popular during this epidemic, and contains a number of cyber vulnerabilities, here are some cyber security recommendations from CheckPoint Software 

(8) Roger Seheult MD, host of the YouTube channel MedCram, has an update on ivermectin and COVID-19 that makes its possible mechanism quite clear to people other than molecular biologists.

COVID19 update, Eve of Passover edition: eyeing the long road to normality

Ezekiel Emanuel (brother of Rahm Emanuel) — whose ‘peculiar’ views on medical ethics would require a separate blog to fisk them — now calls for a 12-to-18-month lockdown. Bill Gates, not a doctor but somebody I’d expect to at least understand supply chains, argues for a 6-month lockdown until a fast-tracked vaccine would be available.

Only somebody who is completely divorced from any economic and social reality outside medicine would present such extended lockdowns as anything other than “in an ideal world, we’d wish we’d be able to do this. In the real world, this would kill the patient while curing the disease”. Sarah Hoyt has been expressing her fear of the latter repeatedly and stridently on her blog.

Even now, the economic fallout from lockdowns is immense, although perhaps less felt in some countries than in others. France, for instance, routinely goes on a nearly month-long collective vacation in August, and Israel nearly shuts down twice a year around Passover and around the High Holidays. But these are scheduled, cyclical events that these economies have been working around for decades.

There are already the first signs of food supply chain disturbances in the US. (With “just in time delivery” chains, that happens faster perhaps.) In this small country here (Israel), agriculture is more or less business as usual, though the shutdown of cafés and restaurants has meant that some farmers primarily selling to that sector now are having to dump vegetables and dairy products at a loss. Some have gotten creative and have branched out into home delivery.

Instapundit says, “we can keep this up for another two weeks at most, and then we have to start reopening things”. Considering hopeful signs that the epidemic has reached plateau phase in its US epicenters, this may actually be realistic. Austria, where active cases are past the hump, has committed to a phased reopening of the economy. Belgium, where the infection is peaking, is looking at doing the same, as is Denmark. Israel’s initial contingency planning was for reopening in stages after the week-long Passover holiday; it’s not clear whether that is still in the cards, but planning is going on, and the planners openly discuss the trade-offs involved. As one put it: “we might have world-class epidemiological statistics” (Israel’s IFR is well below 1%) “but wreak irreparable damage to our economy that may cause more mortality in the elderly than the virus”.

Some advocates of sustained strident measures quote Tomas Pueyo’s “The Hammer And The Dance” essay without context. Actually, Pueyo argues precisely for an alternative to extended lockdowns. What he called for were:

1) In the “Hammer” phase, carry out as stringent a lockdown as possible, as early as possible, such that the period required for breaking the back of the epidemic is as short as possible (ideally, get effective reproductive number down into the 0.35 range).

2) In the “Dance” phase, reopen things with social distancing & hygiene restrictions in order to keep the effective reproductive number R from exceeding 1.0. Ideally, with abundant statistical data (which he admits may not be available) one would be able to establish a kind of “menu” of R-reduction options, and be able to assemble a combo of the options that give the most benefit for the least economic cost.

What does the latter mean in practice? Just by way of illustration: frequent hand-washing and wearing masks may be nuisances, but do not significantly interfere with economic activity. (Again, the primary benefit of wearing masks is to your fellow person, not to yourself. It will stop you from projecting aerosols of the virus unto others if you are in the asymptomatic phase.) Respecting the personal space of others may seem annoying to Spaniards or Italians (or Israelis, for that matter), but is a way of life to many people elsewhere. I was astonished when last year I visited various stores in Norway where people routinely stayed a meter apart from each other in line, without pushing or becoming impatient. Likewise, many Americans who haven’t been conditioned to dense urban areas like NYC respect personal distance better than most others.

And some aspects of the world economy may change forever, and not necessarily for the worse. Some jobs that can be done just fine by video link or other electronic communications may never return to one-on-one. And conversely, many countries and large corporations will be reconsidering the wisdom of being overly dependent on a single supplier for anything crucial. The diversification process had already started, but will go much further. The PRC is sure to feel the economic repercussions of this — at a level that may jeopardize the survival of its totalitarian regime.

DE STANDAARD (in Dutch) looks at six possible strategies for “back to normal” in Belgium, which I will briefly summarize

https://www.standaard.be/cnt/dmf20200407_04916238

1. Test and trace. Main downside, aside from required testing capacity, is privacy invasion through phone app. (South Koreans don’t GAF)

2. Gradually opening schools and businesses, while continuing distance learning and telecommuting in such sectors where this is feasible. Mass events (concerts etc.) remain off the menu

3. Immunity testing and immunity passes — those who have them can go back to work. Main downsides: antibody tests not yet reliable enough; not proven that one cannot get reinfected after getting cured; probably fewer people have immunity than many advocates think.

4. Masks for everyone. Main downsides: not enough masks for everybody; false sense of security; people not used to using them start futzing with them and touching their faces, which (if hands contaminated) makes it worse

5. Variolation [they call it instead “Hotel Corona”] of younger people to build up “herd immunity”. Main downside: not clear if this is really as safe for young people as generally thought. Erika Vlieghe, head of the Infectious Diseases Dept. at U. Of Antwerp, mentions genetic predisposition to overreacting immune system (“cytokine storm”) in some people.

6. Miscellaneous “out of the box” approaches, such as staggered lockdowns (alternating odd and even ID numbers, alternating male and female, alternating odd and even DOBs) to ensure fewer people in public spaces at any one time; release one region/province at a time while keeping the remainder on lockdown, keeping excess hospital capacity available in the other regions in case of a flare-up in the opened region;…

Meanwhile, the observation that China is trying to rewrite the history of the virus is not just the province of “les déplorables” in the US: the center-right German daily Die Welt — as “establishment” as you can get — has an article arguing exactly that https://www.welt.de/politik/ausland/plus207092013/Ende-des-Lockdowns-in-Wuhan-China-will-die-Geschichte-des-Virus-umschreiben.html (Alas, they have plenty of Полезные идиоты in the mediatainment complex.)

To my fellow Jews, have a wonderful Passover, with or without electronic means of distance participation in the Seder.

And to all, my best wishes for health, well-being, safety, and may we soon see the light at the end of the tunnel.

COVID19 update, March 28, 2020: South Korea’s experience in more detail

Stephen Park, who runs the YouTube channel “Asian Boss”, managed to secure an interview with Dr. Kim Woo-Ju of the Transgovernmental Enterprise for Pandemic Influenza in Korea. How did the country manage to nip the epidemic in the bud, so to speak? Or, using a different metaphor (see below), skip the “hammer” phase and move straight to the “dance” phase?
https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56

Here is the full video (in Korean with English subtitles) follows at the end of the post (due to a WordPress glitch). The URL is:
https://www.youtube.com/watch?v=gAk7aX5hksU

Below follow my notes from the video:

* Koreans learned from 2009 H1N1 swine flu and 2015 MERS outbreak
Mask discipline, rapid PCR testing capability. Massive investment in R&D of PCR kits
* * MERS: 186 patients, 38 dead. Only country outside Middle East that had an outbreak
* status as of March 24 in South Korea: 8.961 cases, of which 20% asymptomatic. 111 dead.
Case fatality rate by age:
11.6% over 80
6.3% in seventies
1.5% in sixties
0.4% in fifties
0.1% in thirties and forties [but stats of small numbers, since only one fatality of each]
no fatalities (yet) below 40
* reason for age dependence: (a) immunosenescence, natural decay of immune system with age; (b) pre-existing conditions [that become more frequent with age]
* reactivation cases: have seen some cases that were discharged as cured, then came back 5-7 days later
* in South Korea, anyone can get tested on demand for pay: if found positive, gov’t refunds test. Should get tested if feel any of sore throat, fatigue, fever,…
* masks ARE definitely useful, though should go to healthcare personnel in 1st priority[, general public in 2nd priority]. Proved their worth during SARS and MERS outbreaks. Eyeglasses are useful! Infection occurs through mucous membranes (mouth, inside nose, eyes): virus needs ACE2 receptors, none to be had on epidermis of regular skin.
* main vectors: 1st: droplets from cough, sneeze on mucous membranes (can travel up to 2m in Earth’s gravity field); 2nd hands after wiping nose; 3rd droplets falling on keyboard, table,…
* risky locations: isolated gathering places, e.g. places of worship (he hinted at shouting preacher reaching further than 2m)
* presently, 20% of new cases arrive at airport from aborad. Everybody is now tested on arrival, held overnight at a temporary facility. Turnaround time for PCR testing is 6h, but can be overnight due to overload. If found positive, sent to hospital if moderate or severe symptoms, to special treatment clinic for mild cases. If found negative, tracking app installed on cell phone and sent to 14-day (?) home quarantine
* from 20 March, strongly recommended to close bars, churches, gyms, clubs (in “Gangnam” district), and cram schools (after-school college admission prep schools) for 2 weeks. Least successful with cram schools: 90% still open
* How long does he think this will last? Best-case scenario would be like SARS. (November 2002 outbreak killed 776 people out of about 8000 worldwide, fatality rate of 9.6%. Then just… disappeared basically). If all countries work together to whip this, could be gone by July-August; 2nd scenario: sputters out in Northern hemisphere in summer and but flares up “Down Under” during their winter, then comes back to North during winter, and becomes part of seasonal infection cycle; 3rd scenario: develop a vaccine and vaccinate the whole human races. If all goes well, should have vaccine in 18 months.
* drug repurposing: gives Viagra as best-known example. Originally developed for pulmonary arterial hypertension. [Note added: there are many other examples. The ADD drug Ritalin was originally developed as a remedy for hypotension; Antabus was originally a drug for tropical parasites]
* Kaletra and chloroquine somewhat effective
Convalescent plasma: antibodies from blood of patients who have recovered
*Best advice to young people: wash hands carefully, wear masks, practice social distancing

So what options do countries have that missed the bus for early clampdown South Korean style? This is probably best illustrated by a metaphor from Tomas Pueyo, “The Hammer And The Dance

The basic strategy outlined in that long essay is:
PHASE 1: very tight lockdown for a brief(ish) period to “starve the virus of hosts”: the goal is to get the reproductive number R well below 1, so the infection sputters out over a period of 3-7 weeks. (His guesstimate for R under tight lockdown conditions is 0.35.)
PHASE 2: “the dance”, relax lockdown in combination with intensive tracking and monitoring efforts, targeted quarantine, to keep R from exceeding 1 again

Full interview with Dr. Kim Woo-Ju