Lunchtime pandemic reading.
Standard disclaimer: this is a roundup of informative pieces I've read that interest me on the severity of the crisis and how to manage it. I am not a qualified medical expert in ANY sense; at best I am reasonably well-read laity. ALWAYS prioritize advice from qualified healthcare experts over some person on Facebook.
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Parkinson's disease link to SARS-CoV-2. "Parkinson's disease or parkinsonism have been described after infections by viruses, such as influenza A, Epstein-Barr virus, varicella zoster, hepatitis C virus, HIV, Japanese encephalitis virus, or West Nile virus.1 We report a patient with probable Parkinson's disease, who was diagnosed after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.
A 45 year old Ashkenazi-Jewish man was hospitalised in Samson Assuta Ashdod University Hospital (Ashdod, Israel) on March 17, 2020, because of dry cough and muscle pain. A few days before admission, he had also noticed a loss of smell. His symptoms had started on March 11, 2 days after returning to Israel from a week-long trip to the USA. He might have been exposed to the virus on the flight back to Israel, since he recalled that a passenger sitting behind him was coughing repeatedly. His previous medical history included hypertension, treated daily with 200 mg labetalol, 80 mg valsartan, and 5 mg amlodipine, and asthma, treated with salbutamol sporadically and at admission. He was found positive for SARS-CoV-2 by use of a real-time RT-PCR test after a nasopharyngeal swab was done on the day of admission. His complete blood count and CRP measures were normal (CRP 1·5 mg/L).
A brain CT, diffusion and fluid-attenuated inversion recovery sequences on MRI, and an EEG were all normal. But a 18F-fluorodopa (18F-FDOPA) PET scan showed decreased 18F-FDOPA uptake in both putamens, more apparent on the left side. Additionally, mild decreased uptake in the left caudate was also suspected (figure). Genetic testing for mutations in common hotspots of the LRRK2 gene and full gene sequencing of GBA variants were negative. Next Generation Sequencing was done to screen for other genes related to Parkinson's disease (appendix pp 2–4), but this was also negative. We diagnosed parkinsonism, meeting the Movement Disorders Society Unified Parkinson's Disease Rating Scale criteria for the diagnosis of probable Parkinson's disease.2 We initiated treatment with 0·375 mg extended release pramipexole, once daily, which resulted in a quick improvement according to the patient's subjective impression, as well as in clinical signs.
The mechanism that led to the presumed degeneration of nigrostriatal dopaminergic nerve terminals is unclear. Perhaps a susceptible genetic makeup made our patient vulnerable to immunologically mediated mitochondrial injury and neuronal oxidative stress. Another hypothesis could be that the virus causes inflammation via microglial activation, contributing to protein aggregation and neurodegeneration.3 However, the short time interval between the acute infection and the parkinsonian symptoms makes this hypothesis unlikely. Other researchers have proposed the so-called multiple hit hypothesis, by which the combination of toxic stress and an inhibition of neuroprotective responses can lead to neuronal death.4
Parkinson's disease is often preceded by anosmia, which is a common feature of SARS-CoV-2 infection.5 Immune activation in the olfactory system might eventually lead to the misfolding of α-synuclein and the development of Parkinson's disease.6 This mechanism is supported by post-mortem studies, showing increased levels of TNF,7 IL1, and IL6.8 Moreover, patients with Parkinson's disease had an elevated CSF antibody response to seasonal coronaviruses, compared with age-matched healthy controls.9
In Ashkenazi-Jewish people with Parkinson's disease, about a third are carriers of either a GBA or a LRRK2 mutation.10 A genetic analysis for these mutations and 62 other mutations associated with the disease was negative and our patient had no previous family history of Parkinson's disease. However, we cannot exclude an interaction between other, less frequent mutations and SARS-CoV-2. The temporal association between the episode of SARS-CoV-2 infection and parkinsonian symptoms, which appeared during the acute infection, is intriguing. Before his admission to the Department of Neurology, the patient had tested negative for SARS-CoV-2 on real-time RT-PCR on two occasions; however, he was then found positive for anti-SARS-CoV-2 IgG antibodies in serum, but negative for these antibodies in CSF. Nonetheless, we cannot exclude the possibility that SARS-CoV-2 entered the CNS, particularly in view of the olfactory involvement and borderline pleocytosis."
Source: https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(20)30305-7/fulltext
Commentary: This is concerning. Note that this is a single case study; it is not a clinical study and it's important to take away that there is no PROOF of causation here. However, the association means it's POSSIBLE that SARS-CoV-2 triggered parkinsonism. Whether the patient had a predisposition to it that was triggered by COVID-19 or whether COVID-19 caused it is also not clear and wouldn't be made clear without a much larger clinical study, but this case example opens the door to the possibility.
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Another vote for face shields in addition to masks? "In this issue of JAMA Ophthalmology, Zeng et al3 describe a study of patients in Hubei Province, China, at the beginning of the pandemic in which they found that, among a group of 276 patients admitted to a hospital with laboratory-confirmed COVID-19, the proportion of the patients who reported routinely wearing eyeglasses more than 8 hours per day was lower than in the general population. From these data, the authors conclude that wearing eyeglasses more than 8 hours per day may be protective against SARS-CoV-2 infection, and they hypothesize that this may be due to eyeglasses acting as a barrier that reduces the frequency with which people touch their eyes.
Although it is tempting to conclude from this study that everyone should wear eyeglasses, goggles, or a face shield in public to protect their eyes and themselves from COVID-19, from an epidemiological perspective, we must be careful to avoid inferring a causal relationship from a single observational study. The study demonstrates an apparent inverse association between routinely wearing eyeglasses and the risk of subsequent COVID-19. Observational studies such as this one, however, have inherent limitations due to the possibility of various forms of bias in the study data and possible confounding variables.4 Of note, the authors acknowledge several limitations to the study design, including the fact that the data for the general population comparison group were gleaned from a study that took place decades earlier in a different region of China.3 The study results may be misleading owing to confounding variables, and there may be an alternative explanation for the findings if, for instance, wearing eyeglasses is associated with another unknown and unmeasured factor associated with the risk of COVID-19. If this is the case, we would be incorrect to conclude that wearing eyeglasses reduces a person’s susceptibility to COVID-19 or to recommend that people should begin wearing eye protection in public to prevent COVID-19 acquisition. Another limitation of the study is that the investigation took place very early in the pandemic, and the descriptive statistics do not include data on hand washing or physical distancing, 2 main interventions to mitigate the risk of COVID-19. This makes it difficult to assess any incremental benefit of eye protection in public settings over and above these basic interventions that are now the mainstay of COVID-19 prevention.
In 1965, Austin Bradford Hill5 published a framework for interpretation of observational epidemiologic studies that offers guidelines to interpret whether a demonstrated epidemiologic association is likely to represent causation. Several of the factors require examination of multiple studies over time, rather than relying on a single study, so that the strength, consistency, specificity, and coherence of the findings can be compared across the various reports. When presented with a single study such as the one by Zeng and colleagues,3 the data suggest that the observed difference in wearing eyeglasses between the group of patients with COVID-19 vs the general population is unlikely to have occurred by chance alone, but it does not indicate a causal relationship between wearing eyeglasses and preventing the disease. What we can say from this single study is that it appears to satisfy the considerations by Hill5 of both temporality, because the eyeglasses were worn before the patients did or did not develop COVID-19, and biological plausibility, because we know that the virus can be transmitted via viral particles introduced into the eyes or mucous membranes, and it is plausible that eyeglasses might serve as a barrier against such transmission from droplets or contaminated hands.
Although eyeglasses do not provide the same extent of eye protection as goggles or a face shield, they may serve as a partial barrier that reduces the inoculum of virus in a manner similar to what has been observed for cloth masks.6 This is one potential explanation for why the authors saw fewer wearers of eyeglasses among the hospitalized patients with COVID-19. A recent study of cloth masks in an experimental hamster model6 found that, in addition to protecting others from the mask wearer’s respiratory droplets, cloth masks may also reduce the viral inoculum that the mask wearer inhales and thereby contribute to lessening the severity of the disease that subsequently develops. If it is true that eyeglasses provide some degree of protection, then we would expect to see an even stronger protective effect from more complete types of eye protection, such as goggles or a face shield. If future studies show this type of effect, it would satisfy another of the interpretive guidelines of Hill5 by demonstrating a biological gradient effect."
Source: https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2770873
Commentary: The analysis points out that the study does not conclusively prove that protective eyewear materially reduces COVID-19 infection, but leaves open the possibility that it does. Thus, if you are going into enclosed spaces where you know risk is elevateed - grocery stores, restaurants, etc. - there is no harm and little cost to donning protective eyewear as long as you continue to observe all other precautions - washing your hands, watching your distance, wearing a mask, and withdrawing from those spaces as quickly as possible.
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Habits need help. "JAMA:Your report recommends 5 habit-promoting strategies: make the behavior easy to start and repeat; make the behavior rewarding to repeat; tie the behavior to an existing habit; alert people to behaviors that conflict with existing habits and provide alternative behaviors; and provide specific descriptions of desired behaviors. How can these strategies be applied today?
Dr Brossard:People are more likely to act in healthy ways when it’s easy for them to perform that behavior. So let’s think in terms of hand washing, for example. It will be very important to have hand washing stations and hand sanitizer easily accessible to people. Making the behavior very easy to start and to repeat is very important. If you put a mask next to your front door, and it’s easy to grab when you go out the door, that’s going to be easy to implement and you may be more likely to actually do it again. If you want to encourage people to physically distance from other people around them, having signs on the floor is actually something that works. They don’t have to calculate in their mind: what does it mean to be physically distanced? How far am I from other people? They simply stand where the mark tells them. It makes the behavior easy to repeat and easy to perform.
JAMA:So you’re trying to take away any barriers to the behaviors?
Dr Brossard:Exactly. The idea is if you take away as many barriers as possible, you encourage people to repeat the behavior. And then you end up creating a habit.
JAMA:In your report you mentioned that having many hand sanitizer stations sets the norm—that it’s normal to hand sanitize.
Dr Brossard:Mask wearing and physically distancing are new habits we’re creating from scratch. As social animals, that’s not something we do, in general. However, hand washing is a habit that we would have hoped the population already had. The problem is it hasn’t been really implemented. People do it very inconsistently. If you have hand sanitizers everywhere, it’s very easy. As a matter of fact, in supermarkets, when you have the hand sanitizer at the door, people line up and do it. So it’s that idea of the social norm and making it sound like, this is something you do, it’s widely available, other people do it as well, and therefore, this is socially acceptable and highly encouraged, and we should just all do it."
Source: https://jamanetwork.com/journals/jama/fullarticle/2770888
Commentary: If you operate any place that serves others in the physical world, make it as easy as possible to adopt and repeat good habits. At home, make those habits just as easy for yourself and people who live under your roof.
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Voter registration is down. "If this were like any other election year, volunteers for MOVE Texas, which works to engage young voters, would’ve been at Mooov-In Day at the University of Texas at Austin, equipped with sign-up sheets, clipboards and fold-out tables, looking to register thousands of young people moving away from home for the first time.
But 2020 is not a normal year.
“All the traditional places are off limits,” said Charlie Bonner, the communications director for the organization. “We’re not deploying any of our organizers to campuses because it’s not responsible.”
The coronavirus has brought widespread concern about how people can vote safely in Texas this November, especially as the state’s elected leaders have resisted the idea of broadening who is eligible to vote by mail. But the state is already seeing one major effect of the pandemic on voting: It’s much harder to register voters.
Forty-one states have passed legislation to allow residents to register to vote online. Texas is not one of them, and the state’s Republican leadership has long fought efforts to allow for an online voter registration process. Voting advocates and local election officials have made do with mail initiatives, avoiding what were once standard in-person initiatives at community events, high school graduations and public squares.
In the first seven months of 2020, new registrations in Texas were down nearly 24% compared with that same time frame in 2016, according to numbers from the nonprofit Center for Election Innovation and Research. In April alone, registrations dropped 70%. Numbers have climbed back up over the summer, but that rebound might not be enough to get the state back to where it could have been, said David Becker, the center’s director."
Source: https://www.texastribune.org/2020/09/17/texas-voter-registration/
Commentary: In America, every eligible citizen should vote, regardless of party or point of view. It's a right and a civic duty. Encourage anyone you know to register or VERIFY their vote at Vote.org, a non-partisan resource to help people find out how to vote. The site is well-designed and has lots of special resources for COVID-19.
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A reminder of the simple daily habits we should all be taking.
1. Wash/sanitize your hands every time you are in or out of your home for any reason. Consider also spraying the bottoms of your shoes with a general disinfectant (alcohol/bleach/peroxide) when you return home. Remember that cleaners are never to be ingested or injected.
2. Always wear a mask when out of your home and if going to a high risk area, wear goggles. Respirators are back in stock at online retailers, too.
3. Stay home as much as possible. Minimize your contact with others and maintain physical distance of at LEAST 6 feet / 2 meters, preferably more. Avoid indoor places as much as you can; indoor spaces spread the disease through aerosols and distance is less effective at mitigating your risks.
4. Get your personal finances in order now. Cut all unnecessary costs.
5. Replenish your supplies as you use them. Avoid reducing your stores to pre-pandemic levels in case an outbreak causes unexpected supply chain disruptions.
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Common misinformation debunked!
There is no genomic evidence at all that COVID-19 arrived before 2020 in the United States and therefore no hidden herd immunity:
Source:
There is no evidence SARS-CoV-2 was engineered, nor that it escaped a lab somewhere.
Source: https://www.washingtonpost.com/world/2020/01/29/experts-debunk-fringe-theory-linking-chinas-coronavirus-weapons-research/
Source: https://www.nature.com/articles/s41591-020-0820-9
Source: https://www.nationalgeographic.com/science/2020/05/anthony-fauci-no-scientific-evidence-the-coronavirus-was-made-in-a-chinese-lab-cvd/
There is no evidence a flu shot increases your COVID-19 risk.
Source: https://www.factcheck.org/2020/04/no-evidence-that-flu-shot-increases-risk-of-covid-19/
Source: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa626/5842161
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A common request I'm asked is who I follow. Here's a public Twitter list of many of the sources I read.
https://twitter.com/i/lists/1260956929205112834
This list is biased by design. It is limited to authors who predominantly post in the English language. It is heavily biased towards individual researchers and away from institutions. It is biased towards those who publish or share research, data, papers, etc. I have made an attempt to follow researchers from different countries, and also to make the list reasonably gender-balanced, because multiple, diverse perspectives on research data are essential.