Sunday, July 12, 2020

Just Desserts, Aerosols, and Stampeding Herds

Researchers Warn Coronavirus May Use Propellor Hat To Stay Airborne

Treatment update
Convalescent plasma: Bad news. Contrary to expectations, hospitalized COVID-19 patients in a Dutch trial did not benefit from convalescent plasma in terms of hospital stay, clinical improvement, or mortality. Probably because by the time the patients received their dose of plasma, an average of 10 days after getting sick, most of them had already produced neutralizing antibodies of their own. But this study was flawed – patients received their infusion an average of two days after entering the hospital instead of on admission, and – probably even more important – the plasma donors had mostly had mild disease and had consequently produced only low levels of antibodies. With earlier dosing, and a better choice of donors, plasma might work after all. Or it might turn out to be useful for preventing disease in health care workers or other high-risk groups – a shame, when so much hope has been placed on it.
Hydroxychloroquine: Here we go again. This time it’s researchers from Detroit who looked back at COVID-19 patients they had hospitalized between March 10th and May 2nd, and saw that those who had received hydroxychloroquine, especially combined with azithromycin, were less likely to die. This is undoubtedly true. But hold your horses, read this: “Based on these early reports, hydroxychloroquine alone and in combination with azithromycin was incorporated into our institutional clinical guidelines for the treatment of hospitalized patients with COVID-19.” In other words patients enrolled early in the study did not receive hydroxychloroquine, and patients enrolled late in the study did. But during March and April physicians learned a huge amount about how to treat patients with COVID-19, including proninganticoagulationcorticosteroidsanti-cytokine antibody therapyconvalescent serumCPAPremdesivir, and how best to adjust their respirator settings. So the patients who received hydroxychloroquine, having been enrolled later in time, received much better treatment all around, making it impossible to tell what role, if any, hydroxychloroquine had in their improved prognosis. This study is useless. (Needless to say it’s already been picked up by the hydroxychloroquine czar in the White House.)
Sarilumab (Kevzara): This anti-interleukin 6 antibody, successfully used against rheumatoid arthritis, already had been shown to do badly in COVID-19 patients who were serious enough to be hospitalized but not enough to be on ventilators. The researchers went forward anyway with a trial in even sicker patients, those on ventilators, and failed so completely that they have now thrown in the sponge. Another once-promising drug bites the dust.
Vaccines: The CanSino vaccine has been approved by the Chinese army for administration to soldiers – whether obligatory or voluntary isn’t clear. This is on the basis of old data, from six weeks ago, that it induced an immune response both antibody and T-cell (at the cost of heavy side effects), in volunteers. Seems to me like a premature move.

Italians do it better
1)    COVID-19-related: Italy has fought the coronavirus to a standstill. There have been only 91 deaths in the past week. That’s fewer than in Alabama, fewer than in Pennsylvania – fewer even than Arizona reported on the single day of July 7th. The total number of COVID-19 patients in Italian ICUs is running about 70, down from a peak of 4,000-plus at the beginning of April.
2)    Not COVID-19-related: My musician husband Alvin Curran came back Monday morning after a cappuccino at our crummy corner coffee bar asking, “You know why Italy is great?” In the bar he had noticed there was unusually symphonic music playing in the background instead of the usual pop. He concentrated a few minutes, then guessed “Morricone?” The barman simply said, “Un grande, one of the greats.” Ennio Morricone, the Academy Award winning composer of soundtracks for The Battle of Algiers, spaghetti westerns, and everything in between, had died the night before. The improvised memorial moved Alvin nearly to tears. 

Mask madness
The anti-mask brigade in the United States has now gone beyond impugning the macho of the covered to claiming the things are the work of the devil. As long as the Current Occupant keeps saying people wear masks only in order to spite him, the 40% of the American population who would be fine with him shooting someone on Fifth Avenue will remain blissly barefaced.
Remember the Lady from Jacksonville parody? Real life is now outdoing satire: (a friend tracked down the video link - watch it!)

Citizens speaking out at a Palm Beach County Commission meeting about a mask ordinance

I'm sure you don’t need me to tell you that the American epidemic is exploding. When Anthony Fauci warnedthe number of new cases could go up from 45,000 to 100,000 a day I frankly thought he was hyperbolating, but here we are just 10 days later and we’re over 70,000.
I mentioned in my last post that Arizona, one of the worst-hit states at present, was drawing up theoretical guidelines for who would have first dibs on lifesaving treatments, hoping those guidelines would never be needed. The very thought of that kind of rationing had shocked some Americans, at the height of Italy’s epidemic.
Just a few days later, Texas hospital doctors were already having to use, or improvise, similar guidelines in earnest. One physician from San Antonio Methodist Hospital said sorrowfully that he had found himself with 3 ECMO machines (Extracorporeal Membrane Oxygenation, a kind of external artificial lung) and 10 young people who needed one. Having to choose 3 who would get a halfway decent shot at survival and condemn the other 7 to near-certain death without even having any over-80’s to exclude a priori was, as he put it, “A level of decision-making that I don`t think a lot of us are prepared for.”

Department of Schadenfreude
Remember I said a couple of weeks ago that the UK – which locked down even later than the United States – would soon beat out Spain as having the most COVID-19 deaths per million of the world’s large countries? Well now it’s UK 654, Spain 607. The English went ahead and reopened their pubs anyway. The next worst are Italy, Sweden, and France, with the USA only lately coming within striking distance of its European competition: 405 to France’s 459. Give us another month or so…
Another Great COVID Denier, Brazil’s President Jair Bolsonaro, bites the dust – while presiding over an epidemic that has likely already claimed 100,000 lives, he’s caught a case himself, with fever, cough, body pain, and malaise that can’t be shrugged off as merely “tested positive.” 

Bolsonaro on July 4th with the American ambassador. Physical distancing? Masks?
Sweden: it’s becoming clear that their ill-advised anti-lockdown strategy not only cost thousands of lives, but it didn’t even manage to preserve the economy. Lose-lose.
Trump’s ill-fated Tulsa rally has now landed “dozens” of Secret Service agents in quarantine. The city's health officials now admit if you “connect the dots” it’s clear that the Trump rally is what led to their current spike in COVID-19 cases.
Pence’s trip to Phoenix gave COVID-19 to at least 8 Secret Service agents. What is it about the Secret Service?
Kimberly Guilfoyle, otherwise known as Donald Trump, Jr.’s girlfriend, seems to have exposed half the politicians in Montana (including the Governor and disgraced former Interior Secretary Ryan Zinke) to COVID-19 when she was there last week.
In Florida, one of the states that made a mad dash back to business as usual, more than 50 intensive care units are currently filled to capacity with COVID-19 patients, and many nurses are working 18-hour shifts.
Mississippi state lawmakers convened on June 28th – in person, indoors, packed, and mostly unmasked – to debate whether to drop the Confederate battle emblem from the state flag. By July 9th26 of them had tested positive for COVID-19.
Mississippi state senators on day of flag vote. Physical distancing? Masks?

Schlemiels or schlimazels?

People sometimes say that we Jews are smart. Here’s proof they’re wrong: in May, when Israelis were congratulating themselves on having beaten the coronavirus at the cost of fewer than 300 lives, Netanyahu’s government opened the floodgates – bringing the economy practically back to normal by the end of the month. New COVID-19 cases started surging almost immediately, among a rejoicing population that – among other things – held 2,092 weddings between June 15 and June 25. The big kind, with singing, dancing, and hugging. Now there are so many new cases that the authorities admit contact tracing is overwhelmed, and the number of seriously ill patients is threatening to do the same to hospitals.

What a second wave looks like

“Airborne transmission”
Every day this week I’ve gotten at least one email asking something like “Why has the WHO not acknowledged that the coronavirus could be transmitted via the air?”
The question gets it wrong, but the questioners can totally be forgiven – people assume airborne means what it sounds like. It doesn’t. Everybody, including of course the WHO, agree that the virus is mainly transmitted via the air, in the form of small droplets that are spewed out by infected inviduals when they cough, sing, talk, or breathe, can travel a few feet through the air, then fall quickly to the floor. The issue is whether or how often it is spread by much smaller, microscopic droplets in the form of a cloud called an aerosol that could potentially hang around in the air for several hours, and float away from the contagious person for 10 or even 20 feet, before drifting down out of range of nearby noses and mouths. 
Those kind of microdroplets are known to be produced in certain medical settings where health workers are in intimate contact with COVID-19 patients, but it’s not clear whether they are also created in other settings, and if so how important they are in spreading disease. It’s not even clear whether they can transmit COVID-19 at all – researchers haven’t succeeded in growing viable virus from those aerosols, suggesting they are made up of viral fragments, not infectious organisms. 
The issue went, so to speak, viral last week when 239 scientists wrote a letter more or less petitioning the World Health Organization to change their line on COVID-19 transmission and include aerosols as major culprits in addition to droplets and fomites. (Note: fomites have been demoted: it’s possible to get the virus into your body by touching a contaminated surface and then touching your face, but experts have decided it doesn’t happen very often.)
The WHO responded promptly to the 239 scientists with an updated report. But contrary to how it was billed in the New York Times, it did not conclude “that the virus is airborne” but that aerosols may possibly account for a small percentage of contagions, solely indoors (outdoor air carries away aerosols even faster than it does larger droplets), and probably only when distancing is ignored and ventilation is poor. I strongly advise reading the WHO document itself. Here’s a key excerpt, referring to the few COVID-19 clusters often attributed to aerosol transmission, notably one infamous episode in a Chinese restaurant: “The detailed investigations of these clusters suggest that droplet and fomite transmission could also explain human-to-human transmission within these clusters. Further, the close contact environments of these clusters may have facilitated transmission from a small number of cases to many other people.”
I’m a practical girl, and for me the aerosol story just reinforces what we already know we should be doing when we have to be indoors in the presence of other people: stay 1 or if possible 2 meters away from them, keep those doors and windows open, and wear a mask without deluding yourself it’s a substitute for physical distancing. I tend to dismiss other proposed measures except for exceptional circumstances. High efficiency air filters? According to the people who manufacture them, “in most buildings and in most situations, filters may be considerably less effective than other infection control measures including social distancing, isolation of known cases, and hand-washing.” Germicidal ultraviolet lights? Nobody’s shown they work against the novel coronavirus, and they can only be used in empty rooms. Since even the strongest aerosol advocates admit aersols only hang around in the air for a few hours, it should be just as effective to merely leave a room empty overnight. 

The virologist vanishes?
Anthony Fauci’s disappearing act can be seen as having either ended or moved into a new phase a few days ago when he published podcasts in the Wall Street Journal and Five Thirty-Eight suggesting among other things that, “Any state that is having a serious problem, that state should seriously look at shutting down.” Texas? Arizona? Florida? We’re looking at you. If Tony’s going to contradict Trump that blatantly, we have to wonder whether he may be about to disappear for real, not from the media but from his job. Already he hasn’t spoken to the President for more than a month and hasn’t briefed him for more than two.

Stampeding herds
Three days ago an article in the New York Times shot around the world: 68% of people tested in a Queens neighborhood were positive for COVID-19 antibodies. In an affluent neighborhood elsewhere in New York, only 11%. This report has been interpreted everywhere  from England to India to Israel to Nigeria to Brazil as proving that at least one little corner of the world is hitting herd immunity. Exciting, right?
But wait a sec, 68% of whom? Here’s who is eligible for testing according to the website of the outfit that offered the testing, CityMD. You can have a blood test:
- If you previously had COVID-19 symptoms (Fever, persistent cough, shortness of breath, body aches) and have recovered after 14 days. 
- If you received a positive test result for COVID-19 and have recovered after 14 days.
 - If you believe you have come in contact with someone who had the COVID-19 virus.  
Good god! Is that really what all that fuss is about? That people who live in a high-COVID-19 community and who have either been already diagnosed with the disease themselves or had typical symptoms will probably have antibodies? And those who live in a low-risk community won’t? This is news??? The 68% is real, the interpretation is crap. Is it possible that not one of those journalists took the trouble to check out who was actually tested?


  1. "Having to choose 3 who would get a halfway decent shot at survival and condemn the other 7 to near-certain death....". Near-certain death?

    1. ECMO is only tried on people who have been getting worse despite being hooked up to ventilators. It's a real last resort. The way the doc being interviewed put it (I just now clicked through to the interview) was a bit gentler: "They`re so sick that if they don`t get put on, they don`t get that support, they`re probably going to die."

  2. Vaccine news:

    1. Thank you, yes, the Oxford vaccine has shown some efficacy in monkeys and is beginning phase 3 trials in humans. My fingers are crossed. And wouldn't it be nice if the winning vaccine (or one of several) came from public sector!

  3. Italy doing a much better job than the USA:

    1. You can say that again! (I had known about random antibody screening but not about random swabs for active disease. Will look into it with the author of that article.)