Tag Archives: Covid-19

Is the end of the pandemic at hand?

6 days ago I published my brother’s idea, that the pandemic may be nearing an end.  That post can be found below the ****

Here is some startling evidence that he might be right.  Today’s (12 August) Nature pp. 175 – 176, notes that new ‘cases’ in the UK defined as a positive test for the viral genome dropped in half from 17 July to 2 August 54,674 to 22,287. That could just be due to fewer people being tested (the total number tested isn’t given in the article).  More to the point, hospitalizations dropped from 836 25 July to 645 1 August.  It isn’t clear if all these numbers are daily or weekly.  Regardless, it is worth noting just how few cases are actually hospitalized ( 836/54674 = 1.5%)

These numbers are those persons deciding or required to be tested.  A random population survey is in order to see how many people now have antibodies to the virus.  Clearly SARS-Cov-2 can spread widely without making most people sick.

It is worth noting that the article doesn’t consider my brother’s idea as a possibility, so it likely originated with him.  If so, Bravo ! ! !

Addendum 19 August — from Nature vol. 596 p. 326 “In a nationwide survey of about 28,000 people (two-thirds of whom were unvaccinated and had therefore acquired immunity from infection) in June and July this year, researchers found that 68% had SARS-CoV-2 antibodies in their blood. This represented a huge increase from the 21% with antibodies, recorded in a similar survey in December 2020 to January 2021, before the second wave.”  This is exactly what my brother was talking about — vaccination by infection. It shows that most infections are survivable — with a population of 1.3 billion, the vast majority of those coming in contact with the pandemic virus are still here.

****

Sibling rivalry aside, my younger brother thinks that we’re currently in a mass vaccination situation with the pandemic virus.  He does not mean that people are willingly signing up for vaccinations. He says that the Delta virus is so infectious and spreading so quickly, and that most cases are asymptomatic that  the populace is being vaccinated by infection.  If so, those who will die because they weren’t vaccinated will die and those unvaccinated who have been infected but not sick will be immune, so that the populace will achieve herd immunity in a month or two and the pandemic will be over.Fantastic if true.

My kid brother’s brilliant idea

Sibling rivalry aside, my younger brother thinks that we’re currently in a mass vaccination situation with the pandemic virus.  He does not mean that people are willingly signing up for vaccinations. He says that the Delta virus is so infectious and spreading so quickly, and that most cases are asymptomatic that  the populace is being vaccinated by infection.  If so, those who will die because they weren’t vaccinated will die and those unvaccinated who have been infected but not sick will be immune, so that the populace will achieve herd immunity in a month or two and the pandemic will be over.Fantastic if true.

How a doctor must learn to think

The previous post (found just below) is a textbook example of how a doctor (e.g. me) thinks about medical issues.

“A steady rise in COVID-19 is continuing this week as the state reported 208 new cases Wednesday.

Updated data from the Massachusetts Department of Public Health shows that new cases last week rose 46% over the previous week. The updated percentage includes cases from last week that were reported Wednesday. It’s the second week in a row that cases rose after more than two months of decline that hit a pandemic low the week of June 20.”

Well those are the first two paragraphs of https://www.masslive.com/coronavirus/2021/07/just-one-month-aver-hitting-pandemic-lows-new-covid-cases-in-massachusetts-continue-to-rise-as-delta-variant-spreads.html

Which led to the post

Here are the next two paragraphs

“Deaths continue to remain low, however, with one new COVID death being reported on Wednesday. A total of 17,648 Massachusetts residents have died from the virus since the start of the pandemic.

Hospitalizations ticked back up to 102 after hitting a low of 80 on July 4. They have slowly been trending back up since then. Of the hospitalizations, 37 are in intensive care and 17 are intubated.”

 

If they led with the second two paragraphs no one would have read the article.
This is typical in several ways of the medical literature

 

l. Make the most spectacular claim you can first off to grab the readers attention — we’re in another wave of the epidemic

2. The actual data don’t seem to support the lead (things just aren’t that bad).

Eventually I’d read each medical paper wondering how the authors were lying to me — for a horrible example (from Johns Hopkins yet — please see   https://luysii.wordpress.com/2009/10/05/low-socioeconomic-status-in-the-first-5-years-of-life-doubles-your-chance-of-coronary-artery-disease-at-50-even-if-you-became-a-doc-or-why-i-hated-reading-the-medical-literature-when-i-had-to/

So now the doc has to deal with two conflicting pieces of information.  This never happens in math (which is why I love reading it in retirement).  You can prove anything from assuming a statement and its negation are both true.  Here’s how Bertrand Russell proved that he was the Pope starting with 1 = 2. “Either the Pope and I are one person or we are two people. If 1=21=2 then in either case we are one person. Therefore, I am the Pope.”

 

So the doc has to reach into his/her store of knowledge to figure it out.  Well, he/she knows that most COVID-19 stay in the hospital for longer than a day.  Clearly not all the 208 cases wound up in the hospital as there were only 102 COVID-19 cases in the hospital.  I’m guessing that the median (not average) length of hospital stay for COVID-19 is two weeks.

 

But it’s more complicated than that (https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-how-long-do-covid-19-patients-spend-in-hospital) as in England the median length of stay ranged from 5 to 10 in the past year.

 

So how many ‘cases’ of COVID-19 were there in Massachusetts — the excellent statistics of the Department of Health says about 1,000 in the past two weeks.
So if there are only 100 in hospital and the average stay is 10 days (I couldn’t find data for Massachusetts — again this is typical of medical practice — you can’t find the data you really want), 90% of the COVID-19 cases aren’t severe enough to be hospitalized.

 

This led to the conclusion in the first part of the post “What does the rise in COVID-19 cases mean?  NOT MUCH.”

 

The data is quite similar to that from Los Angeles — http://publichealth.lacounty.gov/media/coronavirus/data/index.html
1,827 cases on the 17th, 500 COVID-19 cases in the hospital.  Assume that cases are rising and figure 1,000 cases/day over the past 10 days, and you get to 95% of ‘cases’ not sick enough to be hospitalized.

 

When the normal person thinks of a ‘case’ of a disease, they think of someone who is physically ill.  Not so with COVID-19, and this is incredibly dishonest reporting by the press, various health departments etc. etc.

 

My post ends with “Presently nearly all the deaths from COVID-19 are in people who were not vaccinated, so to lower your odds further please get vaccinated.”

I couldn’t track this down to any sort of hard data.  It certainly is plausible, but how may plausible medical ideas have I seen crash and burn.  The Associated Press quotes a former official in the Obama administration making this claim.  At least they identify him Andrew Slavitt — a former investment banker — rather than an anonymous source.

Addendum 21 July

“There’s a common theme among those behind the worsening COVID-19 numbers, said Dr. Rochelle Walensky, director of the US Centers for Disease Control and Prevention:

“This is becoming a pandemic of the unvaccinated,” Walensky said at a COVID-19 briefing Friday.”

More than 97% of people getting hospitalized with COVID-19 now are unvaccinated, Walensky said. And 99.5% of deaths are among the unvaccinated, US Surgeon General Dr. Vivek Murthy said Sunday.”

Even more reason to get vaccinated.

*****

What is a ‘case’ of COVID-19

What does the rise in COVID-19 cases mean?  NOT MUCH.  Here’s how the local paper played it — https://www.masslive.com/coronavirus/2021/07/just-one-month-aver-hitting-pandemic-lows-new-covid-cases-in-massachusetts-continue-to-rise-as-delta-variant-spreads.html

There were 208 ‘cases’ today 14 July 2021   in Massachusetts, which is a rate 46% higher than last week. In the past two weeks there have been about 1,000 cases according to the Massachusetts department of health. https://www.mass.gov/info-details/covid-19-response-reporting#covid-19-interactive-data-dashboard-

So the hospitals must be packed and deaths must be soaring.  Right?

Wrong — the same article tells us that there are currently 100 people in Massachusetts hospitals with COVID-19 and that there was one death today

This means that what they are calling a case of COVID-19 is not enough to put 90% of people with it in the hospital.  Most of the ‘cases’ of COVID-19 in Massachusetts are either asymptomatic or mild.

It’s hard to find comparable statistics from states with lower vaccination rates (e.g. the south) but deaths are also lower there.

Well what about the Delta variant?  It is definitely more infectious, and the disease it causes is more severe.  We should be in big trouble if Delta takes over in the USA.  Right?

Wrong.  Delta has taken over.  According to the CDC, Delta accounts for 58% of all new cases of COVID-19 in the USA — https://abcnews.go.com/Health/delta-variant-now-accounts-58-covid-19-cases/story?id=78834579.   Deaths have not spiked.  The vaccines are working.

Presently nearly all the deaths from COVID-19 are in people who were not vaccinated, so to lower your odds further please get vaccinated.

My friends and I did — https://luysii.wordpress.com/2021/05/19/anti-vaxers-what-is-it-that-you-know-that-we-dont/

What is a ‘case’ of COVID-19

What does the rise in COVID-19 cases mean?  NOT MUCH.  Here’s how the local paper played it — https://www.masslive.com/coronavirus/2021/07/just-one-month-aver-hitting-pandemic-lows-new-covid-cases-in-massachusetts-continue-to-rise-as-delta-variant-spreads.html

There were 208 ‘cases’ today 14 July 2021   in Massachusetts, which is a rate 46% higher than last week. In the past two weeks there have been about 1,000 cases according to the Massachusetts department of health. https://www.mass.gov/info-details/covid-19-response-reporting#covid-19-interactive-data-dashboard-

So the hospitals must be packed and deaths must be soaring.  Right?

Wrong — the same article tells us that there are currently 100 people in Massachusetts hospitals with COVID-19 and that there was one death today

This means that what they are calling a case of COVID-19 is not enough to put 90% of people with it in the hospital.  Most of the ‘cases’ of COVID-19 in Massachusetts are either asymptomatic or mild.

It’s hard to find comparable statistics from states with lower vaccination rates (e.g. the south) but deaths are also lower there.

Well what about the Delta variant?  It is definitely more infectious, and the disease it causes is more severe.  We should be in big trouble if Delta takes over in the USA.  Right?

Wrong.  Delta has taken over.  According to the CDC, Delta accounts for 58% of all new cases of COVID-19 in the USA — https://abcnews.go.com/Health/delta-variant-now-accounts-58-covid-19-cases/story?id=78834579.   Deaths have not spiked.  The vaccines are working.

Presently nearly all the deaths from COVID-19 are in people who were not vaccinated, so to lower your odds further please get vaccinated.

My friends and I did — https://luysii.wordpress.com/2021/05/19/anti-vaxers-what-is-it-that-you-know-that-we-dont/

Welcome to the world of the physician


In a sense, the uncertainty about hematologic complications of the pandemic vaccines is good in that it is a real teaching moment for the public about what docs confront every day — balancing risk vs. reward. 

No drug is without side effects.  No surgery is without complications.  It is good to see the public  wrestle with these things.  

For a very good explanation of what those complications are and the risks and rewards of taking the vaccines please see — 

https://blogs.sciencemag.org/pipeline/archives/2021/04/14/vaccine-side-effects-q-and-a

Even more interesting are the 139 comments found at the end of  the article.  Some are from experts, some are from frightened lay people; as always there are people with an ax to grind.  As is usually the case in medicine, the data are not clear cut and sometimes contradictory.  As is always the case more data would be helpful, is desired and rarely available.  What is particularly interesting to me is the way some very knowledgable people wrestle with the data, interpreting the same data differently.  Welcome to the real world. 

On a more positive note, a friend who teaches at Hopkins sent me the a copy of the eMail below, with permission to share it.  This provides lots of excellent data on the protective effects of vaccination in a  group of people with a fairly high risk of exposure to the virus,  working at a major medical center where lots of very sick COVID-19 patients are being treated. 

35,000 were vaccinated.  Nonetheless 51 became infected at a time of maximum protection (5 weeks or more after the first shot), demonstrating that the vaccine isn’t 100% protective.  But no one ever claimed that it was.

 But only 2 of the 51 required hospitalization.  So the vaccine is effective in preventing serious illness from the virus (2/35,000).  So who cares if the other 49 had the symptoms of the flu.  They don’t and you shouldn’t.  The number of hematologic complications wasn’t stated. There were two at most, as they always result in hospitalization.  

To the Johns Hopkins Medicine community

 

Dear Colleagues,

 

As we continue to monitor COVID-19 infection and vaccination trends at Johns Hopkins Medicine (JHM), we want to share some data about the incidence of infection among JHM personnel following partial and full vaccination.

 

You are considered fully vaccinated, per the Centers for Disease Control and Prevention, two weeks or more after receiving the second dose of a two-dose COVID-19 vaccine regimen and two weeks or more after receiving a one-dose COVID-19 vaccine regimen. This is when the body has had a chance to produce the antibodies and immune response that protect against infection. Before this time, if you have started the vaccination series, you are considered partially vaccinated and you do not yet have the full amount of protection the vaccination provides against infection. While full vaccination has been found to be highly effective at preventing COVID-19, infection (the incidence is very low) is still possible even after being fully vaccinated.

 

We are monitoring the situation to determine how often infection seems to occur after partial or full vaccination, and the severity of those infections.

 

As of April 12, 2021, of the nearly 35,000 employees who were fully vaccinated (14 days or more after a second dose), 51 employees (0.14% of those who have been fully vaccinated) had tested positive for COVID-19. This demonstrates that SARS-CoV-2 infection is possible even after full vaccination, and it highlights the importance of continuing to practice basic infection prevention precautions after full vaccination. The good news is that acquiring COVID-19 after full vaccination appears to be relatively rare and, among these 51 cases, only two were severe enough to require hospitalization. This shows that the COVID-19 vaccine is highly protective against severe disease, hospitalization and death. If you have not yet been vaccinated, please schedule your appointment as soon as you can to protect yourself and others.

 

 

Is the virus still within you? Will it cause trouble?

Let’s say you’ve recovered from a bout with COVID-19. Is the virus still with you? Could it come back and cause trouble? Given the data in a recent paper [ Nature vol. 591 pp. 639 – 644 ’21 ] — https://www.nature.com/articles/s41586-021-03207-w.pdf, it’s quite possible.

But first a story about my grandmother.  She was born somewhere around the Baltic Sea in 1880 and came to America in 1893.  She died of undiagnosed (hence untreated) miliary Tuberculosis in a University Hospital in 1967.  Just about everyone in Europe in the 1880s was exposed to TB and just like SARS-CoV-2 many if not most were asymptomatic.  Their lungs walled off the organism in something called a Gohn complex — https://en.wikipedia.org/wiki/Ghon%27s_complex.  The organism didn’t die — and probably broke out of the complex as my grandmother aged and her immune system got weaker and weaker.  It is very unlikely that she picked it up by exposure in the 1960’s.  As they say TB is forgotten but not gone.  

Which brings me to the Nature paper.  At first I thought it was great and very optimistic.  Some 87 people from New York City who had symptomatic SARS-CoV-2 infection (proven by finding the viral genome using RT-PCR technique).  The authors studied the antibody responses at an average of 1.3 and 6.2 months after infection.  Although the antibody levels dropped (which always happens) they changed so they bound the virus more tightly.  This is called affinity maturation — https://en.wikipedia.org/wiki/Affinity_maturation.  

So that’s good? 

No that’s bad because it implies that the protein stimulating affinity maturation is still around. The authors note the persistent antigenic stimulation of the immune system is possible because an “antigen trapped in the form of immune complexes on follicular dendritic cells .. . . . can be long-lived, because follicular dendritic cells do not internalize immune complexes”.  

Well maybe, but the paper gives evidence for another mechanism of antigen persistence (which I find more persuasive). 14 of the people had intestinal biopsies for appropriate clinical indications (see Table 7 in the supplementary information of the article). In some of the biopsies they detect viral antigen in some of the enterocytes (cells which line the inside of the gut) — I’m assuming the antigen is the viral spike protein, but it’s hard to find exactly what it is. 

This is quite bad, as the lifetime of the enterocyte is 5 days.  This means that the antigen is being continually produced, which means that the mRNA for the antigen is being continually produced, which in turn means that the viral genome is still around.  The mean lifetime of cellular mRNAs is 10 hours although some hang around for days, however I doubt that the mRNA responsible for the viral antigen had lasted for 2.8 to 5.7 months which is the time after clinical infection when the biopsies were done. 

So it is possible, that like TB in the Gohn complex, the immune system has fought the virus to a draw, but that the intact organism could be still present.  As in my grandmother, it is possible that the virus will reappear as the immune system weakens with age (something that happens in all of us). 

In that case we wouldl have recrudescence not reinfection. 

PS:  My grandmother came to this country at age 13 alone and speaking no English.  Every time I feel sad at what the pandemic has put us all through, I think of that generation.  

PPS: When she got sick, I wanted to put her in the hospital where I was an intern, but our family GP (Dr. Richard A. Gove) told me taking care of my own family was a very bad idea and put her elsewhere.  I doubt that I’d have made the diagnosis, or that anyone at our hospital would have. 

PPPS:  I don’t know if they still do autopsies, but I was always able to get one after I’d tell families of the deceased about my grandmother.  It meant that my wife and I and our two little kids were all screened for TB. 

PPPPS — a friend brought up the following — Eleanor Roosevelt, who was thought to have aplastic anemia, was treated with prednisone and later found to have died of military tuberculous, probably the recurrence of tb acquired some 4 decades earlier.

 

 

 

A non-coercive way to get people to accept vaccination for the pandemic virus

Many people are afraid of being vaccinated (for anything, not just the pandemic flu). Yelling at them won’t help. Calling them stupid won’t help. You can’t pass a law to coerce them, but here’s a law that would likely convince them that it is a good idea.

Can you think of it?

I’m not sure if congress could do it, or whether it would have to be done state by state.

Just require all death certificates for people dying with COVID-19 to state whether they’d been vaccinated or not. Certainly now all of the deaths will be in unvaccinated people, but as time passes (say 3 – 6 months) and 95% of them remain in the unvaccinated (as studies of the vaccine have shown) and 1/3 to half of the population is vaccinated, people will take notice.

I don’t know any legislators, but maybe you do, and you should suggest it to them.

DON’T TOUCH YOUR MASK !!!

I am fortunate enough to have a beautiful reservoir within a half mile of my house. Over the years in the 3.5 mile circumferential stroll it requires I’ve seen 3 black bears, 20 or so American Eagles, Swans, Mergansers, deer, chipmunks and 20 billion Canada geese.

I don’t wear a mask when I’m out there, because at most I’ll see 100 or so people during the walk. Everyone is very good about social distancing and actual propinquity lasts a few seconds at most when we’re walking in opposite directions. About 80% are wearing masks, or at least have them around their neck. Those wearing them around their neck grab them and cover their mouth and (sometimes) their noses.

This is a terrible mistake. The only way the pandemic virus can cause you serious trouble is if it gets to your mouth, nose or eyes. It will never get through your skin. Unless you carefully washed your hands before leaving for the reservoir, you might have it on the skin of your hands. Do not give it a free ride to your mask where it will happily reside getting a shot at entry every time you inhale.

Amazingly, this is not generally known, and people seem genuinely surprised when I tell them this. Most of them thank me.

Places like the reservoir are among the few where you don’t need to wear a mask. So protect yourself if you wear one, and don’t touch it.

Lots of people seem to be using cell phones on the walk, which is even worse, should they contain the virus, as contact is much more prolonged than a simple mask adjustment. How many people clean their cellphones?

One happy point now that winter is almost on us in these parts. The crucial spike protein of the virus (which is how it gets into your cells) deteriorates and becomes nonInfectious after storage for a week at 4 centigrade (about 40 F). What an overnight chill does for it is anyone’s guess. This is from a non-peer reviewed preprint — https://www.biorxiv.org/content/10.1101/2020.07.12.199588v1

The Public Service of President Trump

The number of new cases of COVID-19 is likely to significantly drop in the the coming months and we have President Trump to thank for that

Why? Because people don’t respond to abstract facts and exhortations given by people they don’t know. They do respond to particular examples.

The fact that Trump and Co. disparaged masks, and then came down with the virus will be far more convincing, than any pronouncements from Dr. Fauci or various mayors, governors, congressmen or senators.

I saw this many times in practice.

An example.

Neurologists treat migraine headaches. It is well known that migraines are triggered by stress. When someone was having a bout of several migraines under the stress of divorce, illness, finances you name it, I’d tell them this, but I could see they didn’t believe me.

So I’d say let me tell you about my wife’s migraines. She’s had them even before I met her when she was 19. And as is typical of migraine, they became less frequent and less severe as she got older.

So she had gone 18 months without one, until the afternoon that she found out that our 12 year old son, had a bone tumor in his ankle which would need surgery. Immediately, I could see the patient had bought in the particular what I’d just told them in the abstract.

I think the populace is presently saying to themselves. Maybe we ought to wear masks and only be around people wearing them. Look what happened to Trump and the Senators.

Addendum 5 October:

A sardonic friend (and retired ambassador) responded as follows

“Thanks for helping me appreciate President Trump’s public service.

The potential benefits of this style of leadership seem almost without limit.

Think, for example, of how the President could affect automotive safety if he were to demonstrate the perils of driving a car over a cliff.

Regards”

XXXX

If I were a billionaire

If I were a billionaire I’d fund the following research study immediately.  Where ?  Not Research Triangle Park, the Acela corridor or the Bay Area but Sturgis South Dakota.  Why?

Spend 11 minutes of your time looking at the following video — https://www.youtube.com/watch?v=aNIEOCFGr3s&feature=emb_rel_end%3Chttps://nam02.safelinks.protection.outlook.com/?

The 80th Annual Sturgis Motorcycle Rally began there 9 August. It is expected to attract between 250,000 and 500,000 people and last 10 days.  Masks are not required and the video shows that very few are wearing them.  Note the rather close seating for eating and drinking, the stores and restaurants with low ceilings and long horizontal extent (and rather poor ventilation)  I’m sure the actual event will have far closer human contact than shown as the video was shot when the festival was about to begin.

You’d never get an experiment like this to pass an institutional review board, but there it is for the taking  Mr. Billionaire.

Spend some of that cash getting vans to Sturgis and offer free COVID-19 testing (both antibody testing and genome testing) to any one wanting it.  This is an independent bunch, so all you ask is that they stay in touch and let you know how they’re doing in the weeks and months ahead.   Tell them, they’ll hear the results after the 19th when the festival ends if they want, so they’ll need a way for you to contact them.

Probably most will not divulge information about themselves, but you will  surely find some cooperative people.  So ask them to tell you about age, sex, medical conditions.  Offer to do a BMI for them.  Have your staff eyeball their ethnicity, rather than ask.  Since you are funding the study, you’l be able to keep the information completely private.

The study will tell us a huge amount about transmission, susceptibility, clinical course etc. etc.  You don’t need another house or mistress.  Take that cash and do something for humanity.

Of course, the population isn’t representative.  Almost entirely white, very few people over 70 or under 15 (please spend 11 minutes of your time looking at the video.  The level of obesity and smoking  is impressive).

Of course there will be ethical concerns.  Suppose you find someone shedding the virus — do you contact them?  Probably best to wait a few a weeks before testing.   This is a naturalistic study after all and you’re a billionaire not a doc.

Hurry there are just 7 more days to go.