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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A letter signed by 239 scientists on COVID-19 and SARS-CoV-2 and its airborne nature.
"We appeal to the medical community and to the relevant national and international bodies to recognize the potential for airborne spread of COVID-19. There is significant potential for inhalation exposure to viruses in microscopic respiratory droplets (microdroplets) at short to medium distances (up to several meters, or room scale), and we are advocating for the use of preventive measures to mitigate this route of airborne transmission.
Studies by the signatories and other scientists have demonstrated beyond any reasonable doubt that viruses are released during exhalation, talking, and coughing in microdroplets small enough to remain aloft in air and pose a risk of exposure at distances beyond 1 to 2 m from an infected individual (see e.g. [1-4]). For example, at typical indoor air velocities [5], a 5 μm droplet will travel tens of meters, much greater than the scale of a typical room, while settling from a height of 1.5 m to the floor. Several retrospective studies conducted after the SARS-CoV-1 epidemic demonstrated that airborne transmission was the most likely mechanism explaining the spatial pattern of infections e.g. [6]. Retrospective analysis has shown the same for SARS-CoV-2 [7-10]. In particular, a study in their review of records from a Chinese restaurant, observed no evidence of direct or indirect contact between the three parties [10]. In their review of video records from the restaurant, they observed no evidence of direct or indirect contact between the three parties. Many studies conducted on the spread of other viruses, including respiratory syncytial virus (RSV) [11], Middle East Respiratory Syndrome coronavirus (MERS-CoV) [8], and influenza [2,4], show that viable airborne viruses can be exhaled [2] and/or detected in the indoor environment of infected patients [11-12]. This poses the risk that people sharing such environments can potentially inhale these viruses, resulting in infection and disease. There is every reason to expect that SARS-CoV-2 behaves similarly, and that transmission via airborne microdroplets [10,13] is an important pathway. Viral RNA associated with droplets smaller than 5 μm has been detected in air [14], and the virus has been shown to maintain infectivity in droplets of this size [9]. Other viruses have been shown to survive equally well, if not better, in aerosols compared to droplets on a surface [15].
The current guidance from numerous international and national bodies focuses on hand washing, maintaining social distancing, and droplet precautions. Most public health organizations, including the World Health Organization (WHO) [16], do not recognize airborne transmission except for aerosol-generating procedures performed in healthcare settings. Hand washing and social distancing are appropriate, but in our view, insufficient to provide protection from virus-carrying respiratory microdroplets released into the air by infected people. This problem is especially acute in indoor or enclosed environments, particularly those that are crowded and have inadequate ventilation [17] relative to the number of occupants and extended exposure periods (as graphically depicted in Figure 1). For example, airborne transmission appears to be the only plausible explanation for several superspreading events investigated which occurred under such conditions e.g. [10], and others where recommended precautions related to direct droplet transmissions were followed.
The evidence is admittedly incomplete for all the steps in COVID-19 microdroplet transmission, but it is similarly incomplete for the large droplet and fomite modes of transmission. The airborne transmission mechanism operates in parallel with the large droplet and fomite routes, e.g. [16] that are now the basis of guidance. Following the precautionary principle, we must address every potentially important pathway to slow the spread of COVID-19. The measures that should be taken to mitigate airborne transmission risk include:
- Provide sufficient and effective ventilation (supply clean outdoor air, minimize recirculating air) particularly in public buildings, workplace environments, schools, hospitals, and aged care homes.
- Supplement general ventilation with airborne infection controls such as local exhaust, high efficiency air filtration, and germicidal ultraviolet lights.
- Avoid overcrowding, particularly in public transport and public buildings.
Such measures are practical and often can be easily implemented; many are not costly. For example, simple steps such as opening both doors and windows can dramatically increase air flow rates in many buildings. For mechanical systems, organizations such as ASHRAE (the American Society of Heating, Ventilating, and Air-Conditioning Engineers) and REHVA (the Federation of European Heating, Ventilation and Air Conditioning Associations) have already provided guidelines based on the existing evidence of airborne transmission. The measures we propose offer more benefits than potential downsides, even if they can only be partially implemented.
It is understood that there is not as yet universal acceptance of airborne transmission of SARS-CoV2; but in our collective assessment there is more than enough supporting evidence so that the precautionary principle should apply. In order to control the pandemic, pending the availability of a vaccine, all routes of transmission must be interrupted. We are concerned that the lack of recognition of the risk of airborne transmission of COVID-19 and the lack of clear recommendations on the control measures against the airborne virus will have significant consequences: people may think that they are fully protected by adhering to the current recommendations, but in fact, additional airborne interventions are needed for further reduction of infection risk. This matter is of heightened significance now, when countries are re-opening following lockdowns - bringing people back to workplaces and students back to schools, colleges, and universities. We hope that our statement will raise awareness that airborne transmission of COVID-19 is a real risk and that control measures, as outlined above, must be added to the other precautions taken, to reduce the severity of the pandemic and save lives."
Source: https://academic.oup.com/cid/article/doi/10.1093/cid/ciaa939/5867798?searchresult=1
Commentary: If you read and take away nothing else from this newsletter today, this is the article to contemplate. These health professionals are refuting the guidance from WHO that SARS-CoV-2 is primarily droplet-spread and not airborne.
The implications of an airborne disease are straightforward: any space with other people in it should be treated as contaminated airspace, which means you must use protective equipment in that space, no matter how close you are to someone else. This is critical: 6 feet of distance is irrelevant in an airborne disease within an enclosed airspace - i.e. indoors. Someone on the other side of the restaurant can infect you.
If you have the means to do so, you should be wearing N95 or better masks/respirators in any environment where you are likely to breath concentrated doses of other people's air. That means anywhere indoors, period. This also changes guidance for how you should travel. A cloth mask is better than nothing on an airplane, but I would suggest you wear nothing less than an N95 mask/respirator if you have to get on any form of mass transit, period. I would suggest the same for grocery stores, malls, etc., and I would avoid spending time indoors or around other people as much as possible.
Indoor dining? No thanks.
This disease is highly contagious and airborne. Protect yourself accordingly.
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Let's hit the talk show circuit. First up, Mayor Sylvester Turner of Houston.
"The President said 99% of COVID-19 cases are totally harmless. Is that the case in Houston?"
"No, that's not the case. I would tell you a month ago, one in 10 people were testing positive today. It's one in four. The number of people who are getting sick and going to the hospitals has exponentially increased. The number of people in ICU beds has exponentially increased. In fact, if we don't get our hands around this virus quickly, in about two weeks, our hospital system could be in serious, serious trouble. That's what I mean overwhelmed right now we have we have bed capacity. But let me just tell you, I want to highlight the major problem is staffing, we can always provide additional beds, but we need the People, the nurses and everybody else, the medical professionals, to staff those best. That's the critical point right now. At the end of April, the beginning of May, our numbers were relatively low, in terms of people getting infected and people dying. We were, our numbers were quite good. What we did see as we started to reopen, and I said then we were opening too quickly, too fast in the month of May, if you look at the second week in May, going forward, the numbers started to increase. I was never reporting more than let's say 200 250 cases a day, in terms of people testing positive, and then towards the end of May into June, those numbers started increasing exponentially, around mid Jim, I started reporting 678 900 a day. And so from the beginning when we started opening too quickly, and when you layer that on top of everything else, all the other activities that were taking place, and people starting to resocialize, then you started to refuel the virus. And that's when the numbers started to increase."
Source:
Commentary: Testing positivity rates tell us a great deal about the epidemic. In areas where testing increases and the positivity rate goes down, we know we're getting a good handle on how bad the epidemic is. 5% or less is the target - meaning 95% of the people tested won't have the disease. When you're testing and showing 10%, 25%, or higher, it means you have a serious problem if testing is also increasing, because you're not finding the edges of the infection. Large portions of the United States are in serious trouble.
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Next, former FDA Commissioner Dr. Scott Gottlieb. "Well, I think right now, we're where we were New York City was having its peak epidemic. If you look back, when New York City peak, we had about 34,000 cases a day at the time, we were probably diagnosing one in 20 infections. So that meant we were having 700,000 new infections a day. Right now we're gonna have about 60,000 infections a day this week, maybe we'll reach 75,000 or get close to it. We're probably diagnosing one in 12 infections, CDC said one in 10 a few weeks ago, it's probably one in 12. Now, because we're falling behind, that means we have about 700,000 infections in a day nationally. So we're right back where we were at the peak of the epidemic during the New York outbreak. The difference now is that we really have one epicenter of spread when you York was going through its hardship. Now we really have four major epicenters of spread Los Angeles cities in Texas cities in Florida, in Arizona and Florida looks to be in the worst shape, and Georgia is heating up as well. And that's concerning.
We need to separate the number of deaths going down from the actual case fatality rate. How lethal is this, the case fatality rate is going down, although we're not able to measure it right now, because we're able to save more people who are hospitalized and get critically ill because of advances in care. The number of deaths has gone down because the number of infections went down for a period of time and more of the new infections right now are in younger people, and we're protecting more vulnerable populations like people nursing homes, but the total number of deaths is going to start going up again, as the number of hospitalizations starts to spike again, so we're going to see deaths creep up. And I wouldn't be surprised in the next two weeks to see deaths go over 1000. That doesn't mean the case fatality rate, the actual death rate isn't declining. But when you have more infections, even if the death rates declining, you're going to get more deaths tragically, so if we cut the death rate in half, if we make this half less lethal than it was, but we double the number of infections, we're going to get more deaths. And I think we're going to start to see that so we shouldn't just focus on the crude mortality rate, the number of deaths to tell the story of what's happening medically, we are improving, but we just have so much infection around this country. We're going to see unfortunately, a lot of lethality.
We missed the window to do it (surge production) on remdesivir because that drug has a long manufacturing cycle, we're unlikely to be able to ramp up supply between now and the end of the year. And that's when we would have needed it because we face a hard fall. We're going to take all this infection into the fall and winter. It's Not clear that it's going to get better. We're going to have epidemics that that come and go across the nation in different cities that light up at different times. But we're not going to really be able to crush this virus at this point, because there's just so much infection around. We really don't seem to have the political will to do it."
Source:
Commentary: In short, death rates will be going up, and we're not going to do much about it.
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Miami-Dade County Mayor Carlos Jiminez. "Well, there's a difference between what is the real what's the official number and what's the real number. We ran a, a study down here in Miami Dade a couple months ago that said over 200,000 people had already had the virus or had the virus at the time. So our official numbers maybe 40,000 have officially had what concerns me is the positivity rate. We had it down to about 8% of the people getting tested. were showing up positive now they're over 20 percent are showing up positive. That's the problem for us.
We just have more people that are being positive. And so the more you have, at the end, you're going to have more people, you know, pass away, unfortunately, because it's just a question of, of numbers. And so we do have a lot of young people that have gotten that have gotten positive results. We have seen an increase in the number of hospitalizations, we have seen an increase in the number of ICU and also an increase in the number of ventilations, simply because we have a more of our people are actually testing positive which indicates more the people of Miami Dade County are coming up with COVID-19. And so when you have more You obviously will have more hospitalizations, more ice use more more respirator, and unfortunately, you'll have more fatalities."
Source:
Commentary: ICUs are running out of space in Houston and Miami. What's critical from the commentary from Mayor Turner previously is that beds are not the only issue, staffing is.
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1 in 20 COVID-19 patients experiences the long-tail version of the disease that lasts for months. "According to the latest research, about one in 20 Covid patients experience long-term on-off symptoms. It’s unclear whether long-term means two months, or three or longer. The best parallel is dengue fever, Garner suggests – a “ghastly” viral infection of the lymph nodes which he also contracted. “Dengue comes and goes. It’s like driving around with a handbrake on for six to nine months.”
Prof Tim Spector, of King’s College London, estimates that a small but significant number of people are suffering from the “long tail” form of the virus. Spector is head of the research group at King’s College London which has developed the Covid-19 tracker app. This allows anyone who suspects they have the disease to input their symptoms daily; some 3 to 4 million people are currently using it, mostly Britons and Americans.
Spector estimates that about 200,000 of them are reporting symptoms which have lasted for the duration of the study, which is six weeks. There is good clinical data available for patients who end up in hospital. Thus far the government is not collecting information on those in the community with ostensibly “mild” but often debilitating symptoms – a larger group than those in critical care.
“These people may be going back to work and not performing at the top of their game,” Spector says. “There is a whole other side to the virus which has not had attention because of the idea that ‘if you are not dead you are fine.’”
As more information becomes available, the government’s Covid model seems increasingly out of date. Many Covid patients do not develop a fever and cough. Instead they get muscle ache, a sore throat and headache. The app has tracked 15 different types of symptoms, together with a distinct pattern of “waxing and waning”. “I’ve studied 100 diseases. Covid is the strangest one I have seen in my medical career,” Spector says."
Source: https://www.theguardian.com/world/2020/may/15/weird-hell-professor-advent-calendar-covid-19-symptoms-paul-garner
Commentary: There is no binary outcome to COVID-19; there appears to instead be a spectrum of illness. For a majority of people, there may not be lasting damage, but a substantial minority may have long, if not lifelong, damage from it.
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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. Wear gloves and a mask when out of your home. Consider wearing a face shield if you can't breathe at all through a mask. 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. Avoid indoor places as much as you can.
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.