Sunday, September 6, 2020

COVID-19 in Italy: The Good, The Bad, And The Ugly

 

Viewing Raphael at the Scuderie del Quirinale gallery in Rome  

Treatment updates

Remdesivir: The manufacturer’s announcement I described back in June, reporting peculiar results in patients hospitalized with moderate COVID-19, has now been published. Those randomized to get 10 days of therapy (they actually got an average of 6 days) did no better than controls, while those randomized to get 5 days (they actually got a similar average, 5 days) were marginally better off than controls on day 11, the benefit barely reaching statistical significance. These results were so weak that the researchers themselves felt obliged to describe their results as “of uncertain clinical importance.” Does this drug really deserve its lucrative superstar status?

Tocilizumab: This once-promising drug did no better than placebo, in a proper randomized trial, at bettering clinical status or mortality of severely ill COVID-19 patients at 28 days. The authors considered the trial a bust – but their drug cut the time to hospital discharge by a full week, better than what’s been reported for the above-mentioned remdesivir. Hmmm…

Icatibant: A hypothesis around for many months but highlighted lately claims that bradykinin, a molecule involved in inflammation, holds the key to COVID-19’s mysteries. Now a pilot study of the bradykinin blocker icatibant, very small and methodologically weak, has suggested it might conceivably help some severely ill COVID-19 patients.

Convalescent plasma: In my last post I called the Mayo Clinic study very promising. But, good God, it certainly didn’t suggest, much less prove, that convalescent plasma cures 35% of COVID-19 patients! The US Food and Drug Administration chief who made that outrageous claim did walk it back a smidge a couple of days later, but that’s nowhere near enough. We’re used to the FDA being unduly influenced by Big Pharma, but for the physician-scientist at its helm to tout outright lies to the public, presumably following the President’s wishes, is far far beyond the pale. Stephen Hahn should have resigned on the spot. How will we ever be able to trust in an FDA-approved vaccine?

Designer antibodies: Two companies with products in this convalescent plasma-like category, Eli Lilly and Regeneron, are having enormous trouble getting their treatment trials going in the United States because of . . . lags in testing!!! Italy, a country much poorer in cash and medical resources, is managing to test everybody arriving from high-risk countries, fast. I find it impossible to believe American hospitals can’t manage to even for a well-funded Big Pharma clinical trial.

Vaccines: Italy joined the race, in its small way, on August 24th, injecting a first volunteer with the Grad-COV2 candidate vaccine, hailed by the Italian press. To me it seems premature to inject human beings with a vaccine when all we know about it is that it stimulates the immune system in mice. As far as I can tell it has never been tried in monkeys, and even the vaccinated mice haven’t been challenged with coronavirus. Elsewhere, the Oxford/AstraZeneca vaccine, now called Covidshield, has become the first major contender to run a Phase 3 trial in India; the Russians are belately starting such trials of Sputnik V after approving it for clinical use. And now, in perhaps the worst possible COVID-19 news, Trump has joined Putin in the Cart Before Horse department, strong-arming Anthony Fauci into going along with possible pre-election approval of a half-baked vaccine, risking not just Americans’ faith in vaccines but also their lives.

Mouthwash: Put this one in the Department of Dream On.

Testing: The Centers for Disease Control have been bullied by the White House into quietly issuing a shocking guideline saying that people without symptoms don’t need to get swab testing, even if they’ve been exposed to COVID-19. This negates the very concept of contact tracing, the technique at the core of epidemic control, and means that safe reopening of colleges goes from unlikely to impossible. After the FDA, my trust in another agency crucial to our health bites the dust. In the meantime, a rapid antigen swab test suitable for use in doctors’ offices, the BinaxNOW Covid-19 Ag Card, has been given emergency authorization for American use by the FDA; the manufacturer, Abbott, claims it is much more accurate than its previous rapid swab test, which missed as many as half of COVID-19 cases. This cheap new test could be a game-changer.

Anticoagulation: COVID-19 is characterized by widespread blood clotting, so it makes  sense to treat it with anticoagulants. But several small retrospective studies and autopsy series have failed to show much benefit. Now a larger retrospective study from Mt. Sinai in New York, my medical alma mater, compared hospitalized COVID-19 patients who did vs. didn’t  receive heparin-type anticoagulants  and found that the ones who did were less likely to die. The problem, as for the Detroit study of hydroxychloroquine I tore apart a few posts back, is that “standard care” probably improved over the course of the study, and by the end of the New York City epidemic doctors were prescribing anticoagulants across the board. So patients who received them were likelier to have been hospitalized late in the epidemic, when treatment was better all around. It’s impossible to verify, since the article doesn’t report the average dates of enrollment in the two patient groups.

 

Italy and the coronavirus: The Good

I wish that when we went into lockdown, we looked like Italy. When Italy locked down, I mean, people weren't allowed out of their houses. Americans don't react well to that kind of prohibition.

-       Dr. Deborah Birx, Donald Trump’s Coronavirus Response Coordinator, August 17, 2020

Dear Dr. Birx,

You’re spot on about the Italian lockdown. But Italians don’t react well to “that kind of prohibition” either. On the contrary – they’re famous for sneaking past no-entry signs, smoking under no-smoking signs, barreling along at 80 in 35 mph zones, fastening their seat belts under their butts. The difference is that they’re no fools, they can tell what’s important from what isn’t, and once they understood that their lives depended on it they did the right thing.

-       Susan Levenstein, MD, Rome, Italy

Much of Europe is having to fight off a second wave of COVID-19, with Belgium, France, Spain, and Germany all reinstating some restrictions. Eastern Europe is even worse. The notoriously anarchic Italians are amazing both Americans and themselves by remaining among the winners, with a swab positivity rate hovering around 2%; it’s 6% in the USA. As Roger Cohen wrote before coming down with COVID-19 himself, “Italy coheres and America breaks apart.” 

How come Italy, famed for disorganization, disobedience, and discord, is doing so well? I sketched the reasons for France2 TV:

1)    As Dr. Birx points out admiringly, Italy’s Phase 1 was one of the strictest and lengthiest lockdowns in Europe, with a truly astonishing level of compliance from its population, who for 12 weeks had to carry a pass every time they left home to certify they were out shopping for food or medications (masked and distanced), or walking for exercise. All within 200 yards of home; no driving except to the hospital.

Life under lockdown was made bearable by community and family cohesive spirit, the willingness of corner grocery stores to make deliveries, and the constant availability of products such as surgical face masks, disinfectants, and toilet paper – no T. P. Arias here. 

2)   The virtues of the Italian health care system, welfare state, and political system shone. Nobody pays for primary care visits, hospitalizations, or COVID-19 swabs, medications never cost more than a couple of bucks, most workers have 3-6 months paid sick leave, and despite some leeway for individual regions the central government has generally been able to dictate policy countrywide… A Facebook friend commented that one reason Italy has done well is “Because despite political differences Italian leaders actually care about their citizens.” Imagine!!! In short, Italy has revealed itself to be a civilized, unified country in a sense that the United States is not. 

Currently hospitalized COVID-19 cases: Italy



Currently hospitalized COVID-19 cases: USA


3)    Despite some grumbling, Italy has not seen the anti-mask, open-it-up madness that has trickled in the US from the White House on down.

4)    Italy has been smart about reopening, with almost all regions resisting opening the bars, nightclubs, and discotheques that have contributed to the second wave in Spain and the ongoing disaster in the United States. Lombardy did make a stab at allowing discotheques in June – for outdoor dancing only – but when the authorities saw the crowds on night one they closed them back down. 

5)    Italy is long over the worst of its testing shortage. For months it’s had so few new cases and so many trained trackers that they can do real contact tracing, finding all the people who have spent 15 minutes within 6 feet of, or shared a closed space with, every person who’s tested positive, and quarantining them for 2 weeks. 

6)    The authorities are offering voluntary random spotchecks with free swab tests at locations such as Ikea parking lots, which have turned up many thousands of asymptomatic cases.


7)    Traditional health mania may be contributing to Italians’ unexpected acceptance of the new normal: fearing pesticide residues on the peel, many won’t just pick up an apple and eat it, instead deftly wielding knife (and sometimes fork) to transform the flesh into neat naked quarters.

8)    But, mainly, Italians have on the whole been careful. 

Stores have no trouble enforcing the mask ordinance, and many add obligatory hand disinfection. 

During patient visits we’re both masked, the window wide open, and the air con blowing. I wash even better than usual after each patient and disinfect anything they might have touched, from chair to stethoscope. It’s a drag, but it makes sense. The waiting room is well-ventilated and near-empty – no accompanying family or friends – and all items that risk repeated handling (including alas the copy of my own book) have been removed.

       We’ve attended only one concert. It was not only outdoors, with assigned seats yards apart and masks whenever you stood up, but the organizers gathered names and phone numbers in case they needed to trace contacts.


We saw the marvelous Raphael exhibition at the Scuderie del Quirinale, twice. Masked groups of six were ushered between one room and the next every five minutes at the sound of a bell. I’d have appreciated another couple of minutes per room, but it all felt perfectly safe. Again, names and phone numbers all around.

One of the joys of emerging from quarantine was scoring an appointment with my hairdresser (he was strictly walkin in the past). Masks, distancing, judiciously worn gloves...

We haven’t eaten indoors in the presence of other people yet, but we’ve enjoyed several tiny social dinners in courtyards or on terraces. All my patients claim to follow the same strategy, though I admit they’re no random sample.

 

Italy and the coronavirus: The Bad 

Italy may be avoiding a second wave, but it has had a ripple. New cases have crept up from 200 a day during July to 1200-1700 now. Recent cases are evenly divided among three groups: people tested because of symptoms, cases detected by tracing and testing the contacts of COVID-19 patients, and asymptomatic cases detected by random mass screening.

What went wrong?

High jinks 

Italy isn’t immune to the raves where young people have been blowing off steam in Europe. There was a rash of indoor bashes in northern Italy back in June. Now, with Carabinieri finding and fining many of the organizers, the ravers seem to at least be sticking to open fields, which are less coronavirus-friendly even without masks. In Rome some discotheques have tried opening on the sly, and gotten busted. The Rome police have even sealed off some of the most popular hangout piazzas – Bologna, Santa Maria in Trastevere, Trilussa.



Vacationers

Several regions, notably Tuscany and Sardinia where young vacationers are the backbone of the summer economy, defied the national shutdown of dance locales, and irresponsible youth (is there any other kind?) have fueled Italy’s modest second wave. Hundreds returning home from fancy Sardinian vacation spots have carried the virus all across Italy. In one locale, modestly named The Billionaire, half the staff including the jet-set owner have tested positive for COVID-19, and at least one wound up on a ventilator. Their clients all left coordinates for contact tracing, but lots of the names and cell numbers have turned out to be phony, reducing the health authorities to making public appeals for club-hoppers to get tested.


The Billionaire, Flavio Briatore's Sardinian nightclub

I have to say if there’s any circumstance the bug can be caught out of doors it’s the groups of 20-year-olds piled up on Italian beaches, making out en masse. And when is “outdoors” not outdoors? When it’s one of those vast Italian discotheques whose dance floor is only nominally outside.  


A Lumbardy discotheque with “outdoor” dancing, reshuttered after one night

Globe-trotters

The disease is also being imported by Italians returning from foreign vacations, especially young nightclubbers, driving the average age of newly diagnosed cases down to 30. Italy now requires everybody returning from Spain, Greece, Croatia, or Malta to be swabbed for COVID-19 shortly before or after arriving. It’s gone surprisingly smoothly, with rapid testing centers set up in boat ports and airports – results within an hour – and a mushrooming of drive-by locations that email results in 24-48 hours.


A drive-by swab center. The sign says "Don't get out of your car"

Furriners

Many of Italy’s newly diagnosed COVID-19 cases have been among foreigners. Some have Italian residency but slip in from high-risk countries, often aware that they have been exposed to the virus. Huge outbreaks have been documented in the Bangladeshi community, with well-publicized cases of swab-positive immigrants landing in Italy with fake no-COVID certificates or sneaking out of self-isolation to bum around on trains and busses, spreading the virus as they go. Rumanians, too, were sneaking over the border, by the nocturnal busload and in private cars. Italy responded by cancelling flights from Bangladesh, ordering returning Rumanians to quarantine, and performing mass testing in both communities. Other hotspots involved Nigerian farm workers and camps holding illegal migrants – hundreds of African “boat people” have, not unreasonably, fled from crowded detention centers when fellow-inmates started to test positive. 

With the minisurge in cases, the number of COVID-19 patients in Italian ICUs has nearly tripled. The death rate lags, staying mostly in the single digits since the last week of July. And with ICU patients now much younger than in Italy’s dreadful first wave, and younger COVID-19 patients are more likely to survive an ICU stay, perhaps the death rate will stay low…




Degrees of nuts

American colleges opened complete with frat houses, karaoke bars, and bacchanals: 51,000 cases among students as of September 3rd, including 800+ at the University of Iowa and North Carolina State, 1300+ at the University of Alabama. San Quentin imported the disease more or less deliberately from another California prison: 2100 cases and 19 deaths. Over-the-top weddings and undistanced schools have handed Israel a second wave many times worse than the first and still ongoing

Ultra-Orthodox wedding in Israel, August 2020


Israel's first and second waves of COVID-19

The frightening Australian second wave has apparently been fed by hotel staff who were extorting sex from recent arrivals in return for letting them sneak out in defiance of quarantine. Spain, despite having peaked at over 9000 new cases in one day and briefly rivaling the US in daily cases per capita, is still allowing indoor bars and nightclubs to stay open, at only slightly reduced capacity. Trump isn’t the only COVID-19 idiot around.

Italy has dodged those bullets, but people are definitely getting sloppier. Even when they obey the requisite 3 feet of physical distancing it seems paltry. I actually felt a momentary shock when friends sent a photograph of 10 of them sitting, “distanced,” at an indoor restaurant table. 

Around Rome moderate prudence seems the norm. Lots of masks even out on the street, one customer at a time in small shops. Supermarkets aren’t overcrowded, no lines on the sidewalk, but there’s not much distancing once you get inside; people seem to think if you’re wearing a mask you can get as close as you want. Coffee bars vary, with some unfussy about masks or distancing, but the risk is relatively minor given the Italian way of coffee: drop in, knock one back, and head out the wide-open door within five minutes.

Outside the big city I gather things are different. Small-town spies tell me they see folks greeting each other with baci e abbracci – hugs and kisses – and visiting indoors cheek by jowl. 

Official Italy is slipping too. The careful screening of incoming travellers seems to have gone by the boards. My husband and I, arriving on a flight from Paris but on a journey originating in the United States, were interrogated in detail and had to provide an address and telephone number for where we would spend our quarantine – the health authorities phoned to check on us every single day. Lately if you’re not coming from a high-risk location they just wave you through. (They’re doing a good job of ensuring people coming in from Spain etc. get tested, though they really ought to make them have a second swab a few days later.)

Public transport is supposed to run more frequently and to plaster “Do Not Sit Here” signs on half the seats, and private cars are being allowed into the closed center of Rome to ease the burden on busses. But the second time I took a tram I waited nearly 20 minutes, the car was packed, the windows were sealed shut, and all the Do Not Sit Here places were occupied. No more public vehicles for me… At least everyone was masked. 


Busses: the dream

Rome bus: the reality


Polls say that if a vaccine against COVID-19 were available, 41% of Italians would probably not choose to get it. But that percentage is about the same in the United States – where one preacher in Maine has told his flocks that the new vaccines contain “aborted baby tissue” – and in Germany, another safe home for no-vaxxers.

Putting food on the table

The coronavirus pandemic has taken an enormous toll on an already frayed Italian economy, though the Financial Times and the New York Times think they’ve done pretty well at juggling money and lives. The economy had been creeping back after the 2009 crash, with official unemployment (considered an underestimate) finally dipping below 10% last year after a peak of 12.7%. Now it’s back only to 11%, but experts call this relative stability “an optical illusion.” The worst hit have been the young, concentrated in decimated industries such as tourism and hired on temporary contracts. Throughout the pandemic half of Italians fear their jobs are at risk, and half of the newly jobless are under 35. 

Italy’s second quarter GDP is down 18% from last year, and at its lowest level since 1995. Pandemic aid packages have expanded Italy’s budget deficit to 12% of GDP and public debt to 162% of GDP – the EU fortunately responded by temporarily suspending its fiscal rules and providing cash support for the labor market.

Many ordinary folk have had €600 ($710) wired into their bank accounts a couple of times, a pittance, and only if they’ve been paying their taxes properly. The already desperate millions working under the table in the “black” economy are eligible for nothing at all. Government assistance has given some small businesses enough of a windfall to make up most of their lost income, and the strings attached requiring workers be kept on the books have avoided some layoffs. But, again, people working off the books or in the gig economy, and small-time independent contractors, are up shit creek. In June 45% of Italians said their income had dropped due to the pandemic and another 35% expected it would.

I ask every patient who comes into my office, and every friend, how they’ve been bearing up under the strain of the moment. Several have burst into tears. Early in the lockdown Italians kept going on shock and community spirit, but once the adrenalin ran down anxiety and depression took over. I’ve heard of 4 suicides.

I commented to one Italian friend who’s old enough to remember World War II that this was the first time since then that people had to tolerate such disruption of their lives. He agreed but added, wisely, “The pandemic is worse. During the war we still had our dreams.” Now people everywhere have lost all sense of the future, and their dreams along with it. 

 

Italy and the coronavirus: The Ugly 

Build The Wall

The ugliest is the neotrumpian antiimigrant frenzy being whipped up by the country’s right wing in the persons of frankly fascist Giorgia Meloni and merely racist Matteo Salvini. As I’ve said, many of the cases in the recent COVID-19 surgelet have been among foreigners. But by far most are Italian born, bred, and transmitted.

Open it up

Andrea Bocelli singing in Milan’s Cathedral


Marginally less ugly are the varieties of COVID-19 minimizers.

As Italian deaths fell mutterings about herd immunity arrived – is there less disease around because by now everybody’s immune? No! No! A thousand times no! In Milan, an epicenter of the Italian epidemic, mass antibody testing was done recently on bus drivers who had worked at its peak and would have been at extremely high risk. Only 7.7% were positive. A similar rate of coronavirus exposure was found in Milan blood donors in early April. In Rome’s Lazio region, in mid-June, the antibody positivity rate was only 2.4% among people who chose to be tested, the likeliest to be positive. 

With less disease around, the sabotage to mitigation measures is heating up a little. A few professorial types blast the lockdown after the fact. The prominent publicity-hound physician Alberto Zangrillo continues to minimizedenying the threat of a resurgence even as his long-time patient Silvio Berlusconi is hospitalized for COVID-19 double pneumonia. It comes as no surprise that right-wing leaders such as the League’s Matteo Salvini are too macho to wear face masks, but I was saddened to hear Andrea Bocelli, the blind kind-of-sort-of tenor, boast on TV that he used to sneak out of his houseduring the lockdown. Ummm, might that explain why he and his entire family got sick with COVID-19? Says Bocelli: “I know lots of people, and I don’t know anybody who wound up in intensive care. So who says it’s serious?” 

None of this comes anywhere near the levels of protest and resistance seen in the United States, though, or even Germany – there unmasked and crowded tens of thousands turn out for protests waving Imperial cum Nazi flags and hoping that Donald Trump will “Save them all.” A right-wing COVID-denier Rome demo on September 5th drew only 1500 people.

COVID denier demo in Germany


At bottom, Italians may simply have more common sense than Germans. Just take a look at pictures of those right-wing rallies. Even at Salvini’s blame-the-immigrants open-it-up events you can see plenty of masks, though admittedly not all cover the nose.

Matteo Salvini COVID denier demo in Ventimiglia




Sunday, August 23, 2020

It Is What It Is

Party your way around Manhattan, coronavirus invited!
Stethoscope and French TV
Producers at France 2, France’s largest television network, ran into Stethoscope On Rome and decided they wanted my take on why the Italians have done so well in battling COVID-19. I barely made it into their transmission (bumped by the Minister of Health), dubbed into French and if you blink you’ll miss me. But if you feel like watching 5 minutes of my replies, in English, they’re posted on YouTube.

Treatment update
Convalescent serum (= convalescent plasma): The Mayo Clinic’s giant study has prepublished its first results of the impact of convalescent plasma on COVID-19 mortality, and I find them (and the very similar findings of another, smaller study) very promising. It’s one of the only observational studies I have found convincing despite not being randomized and placebo-controlled – and I really can’t understand why Anthony Fauci disagrees. My reason is their two types of analyses. First: patients who received their plasma infusion within 3 days of being diagnosed were 20% more likely to survive than patients who were treated later. Second: patients who received plasma that had a heftier load of anti-coronavirus antibodies were 23% more likely to survive than those whose plasma had fewer antibodies; you may recall that one negative Dutch study of convalescent serum was fatally flawed by its use of serum relatively poor in antibodies. Even though we don’t know how well the Mayo patients would have done with no treatment at all, it seems likely that using only antibody-rich plasma and administering it as early as possible will save lives.
AeroNab: Having shown that a llama antibody or something like (see the May 13th Stethoscopecan inhibit the novel coronavirus in a testtube, some UCSF scientists designed cute little inhalers and invented a cute little brand name and have managed to get them splashed all over the media as the Final Solution to the COVID-19 problem before a single person has inhaled a single puff. Need I remind you that hydroxychloroquine works great in the testtube too? I hope these guys are just dreamers, not con artists.
Favipiravir (FabiFlu, Avigan, Favilavir, Avifavir): A Russian pilot study of 60 patients, randomized but open-label, found that patients hospitalized with mild COVID-19 and given a high dose of this oral antiviral cleared the virus more quickly than controls. This is nice. But patients taking a lower dose did worse than controls. These puzzling results seem awfully preliminary to me, but not to the local authorities, who have already authorized the drug for use in COVID-19. The same authorities, I might point out, who are about to distribute a vaccine with no evidence it works.
Methylprednisolone: A Brazilian placebo-controlled trial of this corticosteroid found no improvement in mortality rates, in confusing contrast to a British trial of dexamethasone, another steroid. Their patients were younger than in the UK, and the drug increased the death rate in younger patients; there are also differences between the drugs, the hospital contexts, and the duration of therapy that could help explain the discrepancy. ICU physicians will probably continue to use dexamethasone as per the UK trial.
Oleandrin: Mr. Trump’s latest and by far worst suggestion to doctors is that they treat COVID-19 with oleandrin, an extract of oleander. Far from  being an “experimental botanical extract,” this shrub has been known since ancient times to be a mortal poison, listed by the Encyclopedia Brittanica under “7 of the world’s deadliest plants.” Why is it his most dangerous advice yet? Because it’s so easy to follow. Hydroxychloroquine is a prescription drug so you need a doctor to obtain it, and not many people are dumb enough to actually take a swig of Clorox. But oleander grows in gardens all over the United States, and eating a single leaf, or drinking an infusion boiled from a half-dozen, can kill an adult.
My car parked under an oleander tree in Rome
Vaccines: A two-dose inactivated whole-virus vaccine that I think we haven’t heard about before, apparently from something called the China National Biotec Group Company Limited, has been shown to produce high levels of neutralizing antibodies in human volunteers with relatively few side effects – that’s Phases 1 and 2 – and has joined 5 other candidate vaccines undergoing Phase 3 trials to see whether they actually prevent disease. In this particular game show, the more contestants the better. 
Challenge trials for vaccines: I’ve gone on and on about the truly dreadful idea of “challenge trials,” testing vaccines by deliberately infecting volunteers with the COVID-19 virus – a potentially fatal, untreatable virus that has already likely killed more than a million people. I’ve also mentioned that a vaccine against Dengue fever was developed through a challenge trial, using a weakened strain of the virus that caused only mild disease. Now the United States and UKgovernments are trying to develop weakened strains of COVID-19 for that purpose. But that will take months at least, so it’s not at all clear that challenge trials would bring a vaccine faster to pharmacies – their only justification. 
HOWEVER. I have now probed more deeply into this “weakened strain” business, and the deeper you get the murkier it looks. I had assumed the famous mild strain of Dengue was somehow developed artificially, but no: it was a natural variant that had caused an innocuous Dengue epidemic in Tonga in 1974. So scientists actually have no precedent whatever for developing a weakened virus on purpose in order to test a new vaccine. How will they go about it? How will they know it causes milder disease than the regular SARS-CoV-2? They can try it first in monkeys, but mild in monkeys doesn’t necessarily mean mild in people, and to be sure they’d have to give it to elderly, unhealthy volunteers… I’ll stick with my firm nix to vaccine challenge trials.

The greatest of ease?
The New York Times called a new aerosol report from the University of Florida “A Smoking Gun.” Is it? Maybe yes, maybe no. Certainly it is the only study to make me consider that aerosols might possibly play a role in transmitting COVID-19 from one person to another. The report – thus far only available as a preprint – says infectious virus was isolated from air samples collected in the hospital room of two COVID-19 patients, with the specific strain carried by Patient 1 detected fully 16 feet from his head. This is the first time virus has been detected in air so far away from patients (a University of Nebraska  group detected viable virus in air at the foot of hospital beds, but that was less than 6 feet from patients’ faces), and is probably therefore important. But I don’t know how to get from that result to an estimate of the role airborne transmission might play in COVID-19, or what if anything we should do about it. Two reasons in particular: 1) The amount of distant virus is very small indeed – fewer than 75 particles per liter of air – and comments on the manuscript from people with technical expertise bring into question both whether those doses can transmit disease and whether the lab machines can reliably measure so few virions. 2) Looking carefully at the Figure, 
you can see that Patient 1 had to walk right by that distant air collector, within a couple of feet of it, every time he went to the bathroom. That might to be a simpler explanation for how the device picked up his virus. I’ve submitted a comment on the manuscript and will be interested to see what the authors respond.

Faking Presidential
Henry Fuseli, The Nightmare (mistakenly posted last time, the originally home of this story)
Donald Trump changed campaign manager in mid-July, replacing Brad Parscale with Bill Stepien, a guy whose main claim to fame had been taking the fall for Chris Christie in the Bridgegate scandal. The new broom swept the President straight into an unaccustomed role: Pseudo-Presidential. Suddenly the pandemic was going to get worse before it got better, face masks were patriotic, and even the “safe environment” of the Republican convention was, between one day and the next, not.
But the man can’t help himself. No sooner had Trump been bludgeoned into giving a public nod to science than he backslid, tweeting out a video about COVID-19 so misleading that even Facebook took it down – though not before it had been viewed 16 million times and retweeted by none less than Madonna (who’s also dabbled in vaccine conspiracy theories). The star of the show? A certain Dr. Stella Immanuel, born in Cameroon trained in Nigeria working in Texas, whose disavowal of face masks is actually one of her more sensible ideas. She also believes that endometriosis is caused by copulation with demons, that some medications are laced with alien DNA, and that government scientists are currently working on a vaccine against religion.
He’s also fleshing out his coronavirus advisory team by adding Dr. Scott Atlas, a radiologist whose chief qualification seems to be appearing on Fox News and whose chief mission is clearly to act as counterbalance to actual experts Drs. Anthony Fauci and Deborah Birx.
If that’s the level of science your Supreme Leader and your favorite pop diva are advocating, it’s no wonder we have a high school senior saying she’s immune to COVID-19 because “Only liberals can get rona and I’m not a liberal.” Guess she never heard about poor Hermann Cain
Madonna and Stella Immanuel
Coliseum Dreaming
Many Americans are clamoring to know when they will be allowed back in Italy (and the European Union in general)? There is actually an answer to that question. The official criteria are:
• the number of new COVID-19 cases over the last 14 days and per 100 000 inhabitants close to or below the EU average (as it stood on 15 June 2020)
• stable or decreasing trend of new cases over this period in comparison to the previous 14 days
• overall response to COVID-19 taking into account available information, including on aspects such as testing, surveillance, contact tracing, containment, treatment and reporting, as well as the reliability of the information and, if needed, the total average score for International Health Regulations (IHR). 
The United States is flunking miserably at the moment – an excellent article in the Atlantic helps understand why. The magic June 15th number in the EU was a total of 15.3 new cases per 100,000 inhabitants over the previous 14 days. I calculate the USA is currently at 197, and several EU countries ain’t doing so great either. As of yesterday, Italy gets the only gold star:
As I see it, the only chance my ravaged country has at getting onto the approved list would be a six-week coordinated strict stay-at-home order. But when the person who’s hired to lead the United States can respond to a 180,000 deaths only with “It is what it is,” a national lockdown seems unlikely to say the least.
Incidentally, if Italy followed the second criterion, stable case numbers, Italy should be quarantining all the vacationers coming back from Spain, Greece, Croatia, and Malta, in addition to requiring them to do COVID-19 swabs, and should add countries including France and Germany to the list. 
The only good news I’ve gotten from the US lately is what I heard on WNYC’s Brian Lehrer show the other day: New York City is not only running a rock-bottom 1% positive rate on COVID-19 swab tests and reporting fewer than 10 deaths a day, but it is managing to set up mass rapid testing sites as soon as a neighborhood surges, carry out contact tracing on the spot with a 75% compliance rate, and provide instant access to free food delivery and other aids for people who test positive – even hotel rooms, if needed for isolation. They can do this, as can Italy, only because there are so few new cases and so many contact tracers.

The cat with 99 lives
Whenever I think hydroxychloroquine has disappeared from the COVID-19 world, there it comes again. Newsweek has shown fit to publish a spirited defense of its use, and a pseudoscientific internet screed is also making the rounds, penned by a certain Meryl Nass, MD. She’s “an internist with special interests in vaccine-induced illnesses, chronic fatigue syndrome, Gulf War illness, fibromyalgia, and toxicology,” who asked regarding Dr. Stella Immanuel – she of demon sex and alien DNA fame, “Why do so few Americans speak their truth like she does?” Sigh. In case anyone needs it, here’s a quick summary of the parabolic rise and fall of hydroxychloroquine: Initial enthusiasm was based on misinterpretation of studies in China (it turned out to have worked no better than a placebo), a totally awful study by a French charlatan where patients on hydroxychloroquine actually did worse than controls, and Trumpian hype. Many properly done studies have been done since then, none of them finding any benefit. Lupus patients who take hydroxychloroquine every day get COVID-19 just as often as those who don’t, and they get just as sick; the drug doesn’t prevent COVID-19 in people with intense exposures; it doesn’t help people with mild disease and/or recent symptom onset; and hospitalized patients who receive hydroxychloroquine are just as likely to die or wind up on respirators as those who don’t. 

The birth of bleach
Did you miss the Guardian article back in April that revealed where Trump got the idea of drinking disinfectants? So did I, but we can all catch up now that the bleach peddlers – a Florida father-and-son team – have been arrested in Colombia and are awaiting extradition. Local authorities say their Miracle Mineral Solution, which “cures” not only COVID-19 but cancer, AIDS, and autism, has killed at least 7 Americans.
Mark Grenon, "Archbishop of the Genesis II Church of Health  and Healing," with his MMS
In related news, several people have died, and others have been blinded, from swallowing hand sanitizing gels made with methanol.

It kills me, it kills me not
The Brits have come up with a brilliant trick for reducing COVID-19 mortality: stop counting as COVID-19 deaths anybody who dies more than 28 days after their first positive test. In one fell swoop they’ve lopped 5000 deaths off their official death toll, from 46,706 down to 41,329. These shenanigans are medically absurd – COVID-19 is infamous for keeping people hanging on life support for weeks and months. And they’re easily proved false: the overall death toll from all causes in the UK between week 12 and week 20 of this year was 56,456 higher than predicted from previous years. By this gold standard, even more people have died from the pandemic than the pre-censorship official total.
In parallel news from the United States, the New York Times now reports on the basis of CDC all-cause mortality figures that 200,000 people died due to the COVID-19 pandemic as of July 25th, 60,000 more than the official figure. I estimated a month ago that that milestone had already been passed – but I may have been right after all, since the Times says “many states are weeks or months behind in reporting.”

No one is useless
Like the saying goes, they can always be used as a bad example. Here’s part of what’s driving the American “second wave,” which is really just the first one expanding its reach.
The directors of a Georgia sleepaway camp have shown us how not to run a camp in the COVID-19 era. Campers slept in cabins containing up to 26 kids, wore no masks, and enjoyed daily group “singing and cheering.” Doors and windows were left shut, and physical distancing was likely not even suggested much less enforced. The result? Out of 344 kids and staff who’ve been tested for COVID-19, 260 were positive, most of whom were sick. 
That same great state, of course, had already showed us how not to open schools. One Georgia school district actually (can you believe this?) sent around emails saying, “Staff who test positive are not to notify any other staff members, parents of their students or any other person/entity that they may have exposed them.”
Then there’s the Liberty Belle, a riverboat that tooled around Manhattan two weeks ago hosting an intimate gathering for 170 jammed-in guests. The owners didn’t even bother to get a liquor license, gratuitously inviting (and receiving) additional criminal charges.
More bad examples feeding the new American Holocaust: filthy rich partiers from New York to Los Angeles to Trumpvillebars, nightclubs and raves that draw youthful revelers; and American specials such as teams of lifeguards who share living quarters, fervid COVID-19 deniers“Greek life," and immigrant detention centers.
Coronavirus Russian roulette at Donald Trump's golf club in New Jersey