Friends, For those of you living in San Diego County, there is a lot of news on the evolving situation in San Diego and California.
First, San Diego County reports that the county has met 4 of the 5 criteria for entering Phase 1 of re-opening. We have had down-trending new symptoms and cases for the last 14 days. However, to meet the last criterion, the County needs to have more testing, PPE, and hospital capacity available in the county. Let’s hope this happens soon!
Also, after a brief beach opening for walking, swimming, and surfing, Gavin Newsome has closed all beaches and state parks effective today, May 1st.
Friends, This post doesn’t have much science in it, it’s about why I started posting about the virus, and something about my philosophy on communication. If you’re not interested in that, feel free to skip it.
Much of the reason stems from how scientific information is often communicated to the public. So often a scientist or public official shows up on a news show, and basically gives a conclusion, but no real data. Instead of giving a persuasive case, they just make a claim without much support. Because of this, many in the public have been confused or lost trust in what they learn from the media.
On March 9th, I started posting to Facebook, since I don’t yet have a blog. If you’ve been one of my Facebook friends for a long time, you know that I rarely post, really only to change my profile picture for Talk Like a Pirate Day! I felt it was important to give some data in a digestible way, so people would have some understanding of what was going on. I just wanted to show some data so people could understand why SARS-2 was not like the typical flu.
I started out by giving my credentials, since many of you, especially my high school friends, may not have even known I was a scientist. And yes, it might have helped me get my foot in the door with some of you. However, one of the things I don’t like about our public discourse, is how many scientists expect that their credentials means that they must be believed by the public. Being an expert isn’t enough to automatically be believed. You still have to show your data and show why it supports your conclusion. Anyone who has been to a scientific conference or even a journal club knows that experts often disagree. You can’t just say “I have a PhD” to a room full of PhDs. So when experts try to make a case to the public, they still need to show data, and how they came to their conclusion. Unfortunately, because they often just have 60 seconds on a news show, they don’t have time for that. What too often happens, is that they just make a claim without support, and say that if you don’t believe them, you’re just a <news anchor, YouTuber, insurance salesman> or you’re just anti-science or racist or whatever. This is just lazy, and ironically, is anti-science. Scientists must make observations, show data, and be persuasive. Taking short cuts like name-calling isn’t persuasive, and it just makes your opponent irritated and unwilling to listen. In fact, if your opponent knows how to argue, you’ve just clearly told them that you can’t make your case. You lose.
Here’s what I do: I show a piece of data, then say what it means. I’m prepared to tell you where the data come from, and how I manipulated it if I did. If I quote a source, I give a reference. This shows I have reliable information, and also relieves me of some of the burden, since I’m just reporting what someone else said. I also think graphs are much easier to digest than tables, and tables are much easier than numbers in a paragraph, so I make content visual when I can.
If a news story makes a scientific claim, I try to find the original source, since journalists often oversimplify, misunderstand, or misrepresent scientific information. Politics and science make a terrible combination. As soon as a scientific issue gets politicized, it becomes difficult for scientists to figure out the truth, and nearly impossible for the public to. If you want to understand a scientific issue that has become political, you’ll have to read widely on all sides of the argument. Most people just don’t have time for that.
Here are a few of my rules for being persuasive. If you’re one of my lunch buddies from Quest, you know I did this well sometimes, and also failed sometimes!
If you can’t support a claim, don’t talk until you can. Go study and come back.
If you do speak, don’t just lean on your credentials or criticize someone else for not having any. You both need to be persuasive. And if you have data and can support your claim, you don’t need a degree, although training certainly helps to develop these skills. I am a molecular biologist, specializing in medical testing. I am not an epidemiologist or a physician*.
If someone asks you to support your claim, and you find that you can’t, you may need to change your position!
Ask clarifying questions. This may give you time to think, and also helps you learn their position. It’s OK to have an entire discussion in which you only learn their position.
Don’t accept the burden of proof. When someone makes a claim, many will just offer an opposing claim. When you do that, you’re accepting the burden of proof! Don’t do that! Just ask them where they heard it, or why they believe it. A lot of people can’t tell you either of these things.
If you don’t know something, say you don’t know. Making something up undermines your credibility! You may lose a discussion in the short term, but you’ll build trust.
Don’t hide important information. This of course is a favorite trick of media and politicians. It’s a handy way to deceive your audience without technically lying. However, if you’re caught doing this, you completely undermine your credibility. Plus, you can’t really hide the opposing facts, you just bury them alive. They’ll eventually come out like a zombie and eat your brain.
Your job is not to “win”, it’s to be persuasive. Jerks aren’t persuasive. Play the long game! It’s OK to lose a discussion if you can earn another discussion by being respectful.
Find common ground and build from there. If you can show your opponent that you’re on the same team, you have a head start.
If you find that someone is more interested in being insulting than seeking truth, it’s OK to disengage. Some also give you a burden of proof so great, it’s impossible to meet it. They may not be seeking the truth, and there are some people that you will never convince. Relax! It’s not your job to convince everyone!
Don’t post angry! Take a walk, have lunch, maybe even sleep on it, and think before you respond to something obnoxious. You will lose credibility if you say something destructive. While live conversations are always better, social media allows you to think before you post!
Don’t fear, but be smart! Erik
*A medical license grants the legal right to order tests, interpret results, prescribe medication, and give medical advice. Also, your doctor knows your medical history, and the particular tests and medication you’ve taken. So always consult with your doctor when making medical decisions!
____________________________________ Update: October 26th, 2021 This past few years have become incredibly contentious and polarized in the US on many important topics of public life. So many times, the default response to disagreement has become to break off discussion and even relationships. This is a tragedy. In addition to above points, I’m adding a new one:
12. When discussing a controversial topic with someone with whom you disagree, do your best to at least understand why your opponent would hold the opinion they do, rather than just assuming they are crazy or evil. This has 2 functions, it allows you to consider points that you may have not considered before, and it also allows you to better understand their view so you can know how to address it. You may still disagree, but you’ll be better equipped to address their view, and may also be able to preserve the relationship.
Friends, This is a little longer post, this time with lots of science. I’ll talk about new measures of the fatality rate, some of the new Antibody testing, and also about the new re-opening guidelines. As always, consult with your doctor when making health care decisions!
First, very briefly, I’ll just say that we have seen a big up-tick of cases in the last few days. I’m trying to be optimistic about this and assume for now that this is because of increased testing. The large labs have been purchasing new instruments of different types to broaden their offerings.
There have been a handful of studies trying to discern the number of asymptomatic cases. One recent study in New York tested all pregnant women coming in to deliver. It showed that at least in this sampling, there we about 7x more asymptomatic women testing positive for COVID than symptomatic women (Sutton et al, Universal Screening for SARS-CoV-2 in Women Admitted for Delivery. April 13, 2020. NEJM, nejm.org). If this is roughly correct, then most confirmed cases numbers you see can be multiplied by 8 to get the real number of cases, as least until testing becomes more comprehensive. This also means the real fatality rate may be approximately 0.7%, about 5x higher than the typical flu.
Some have suggested that the fatality rate for COVID is the same as the flu, but this is the low end of new estimates, and for now, my guess is that it is higher. I think 0.7% is a good estimate for now. The rate for the typical flu 0.14%. Keep in mind that the Ro value for SARS-2 is about 5.7, much higher than the flu at 1.28.
On to Antibody tests! There has been a lot of excitement recently about antibody tests, and I have promoted them in my posts as well. As many of you know, the PCR based tests look for viral RNA in nasal swabs and detect an active infection. They are very sensitive, but they are more expensive, and need to be performed at specialized sites. Because the virus mostly lives in the lungs, nasal swabs don’t always collect virus from an infected person, and the false negativity rate has been estimated to be around 29%, at least initially. This is very high.
Antibody (Ab) tests detect an immune response by the patient by isolating antibody from the blood. Most detect 2 kinds of antibodies. IgM antibodies are produced during infection, and start appearing after about 3 days. IgG antibodies are produced later, at about 7 days, but continue to be produced for weeks to months after infection. The antibody tests are often less sensitive than the PCR tests, and they do not work during the first few days, since antibodies are not produced that early.
As you might guess, combining PCR and Antibody tests may give a good indicator if and even when an asymptomatic person was infected. Below is a table of possible interpretations of test results, assuming testing is accurate. Always confirm results and discuss with your doctor when making health care decisions! The FDA regulates testing in the US, and several tests have received Emergency Use Authorization (EUA) status. This is not FDA approval, but allows tests to be performed under emergency conditions. Several labs have started to perform antibody testing along with PCR. At first, Ab tests will be given in combination with PCR tests to see if health care workers have already been infected. If you want an antibody test, you’ll need to check with your doctor to see if you meet availability criteria. Many other companies have tried to offer tests without EUA status, including at home tests. Many of these tests have very high false negativity rates, and are basically no good! As of this writing, I would not use any at home test kit. Before taking any test, check with your doctor, or confirm with the FDA or CDC websites to see if a test has EUA status.
Re-opening: The federal government has released guidelines on the re-opening process. These are recommended guidelines, and most states are likely to adopt them, but the final decision will be up to the Governor of each state. I’ll provide the link below. In short, to enter the first phase of re-opening, states or counties must show a downward trajectory of cases and symptoms for 14 days, and must have certain hospital capacities and infectious disease surveillance procedures in place. Each additional phase can be entered if these conditions continue to be met for an additional 14 days. Some states or counties may already meet the criteria for phase 1, and some states plan to enter phase 1 on May 1st. Looking at the criteria, the guidelines seem reasonable to me, and I hope Governors will learn from the experiences of other countries and states while making these decisions.
Friends, Mark Rasmussen sent me a link today that you’ll be interest in. It’s a new site that tracks the Effective Reproduction Number, Rt.
Ro, which we’ve talked about before, is a measure of infectiousness, and is the average number of people that a person would pass a virus to in it’s natural state, in a completely naïve population, and with no counter measures. For SARS-2, this number is 5.7. Rt is similar, but takes into account the measures we have taken to counter it. The Ro doesn’t change, but Rt does. The site shows the current Rt for every US state, and also shows a graph of Rt over time. Above 1.0 is bad, because that means each person is spreading the virus to at least 1 other person. Below 1.0 is good, and means the number of infected people is beginning to go down in that state. And yes, this is for confirmed cases only. There are more. We can only graph what we have information on.
The results are very interesting. For California, the state was below 1.0 for a few days, but as of April 20th, has climbed back up. This pattern is true of several states on the site, It appears many states started to climb as good news was coming out last weekend! Apparently people started feeling confident, and were less careful. An alternate explanation is that as testing is done on broader range of people, more cases are found.
As we discussed before, New York state has had a very rough start, with more confirmed cases than any other state, and indeed more than any other country, except perhaps China. Recently, however, they’ve done much better, and have had an Ro below 1.0 since April 10th or so.
Using this site, you can see how your state is doing, and we can watch almost in real time, how the reopening process is affecting each state. This will really help us find the right approach.
Friends, This will be a longer post, so buckle up!
While I certainly have political opinions, I’ve been trying to minimize them for the purposes of these posts, in order that more of you will be willing to read! Today, some of you may be able to figure out where I stand on some things, although I’ll still try to keep the controversy to a minimum. This last weekend, there were protests in many cities of the US asking for the economy to be opened up. Of course, most of these requests took the form of slogans shouted or written on signs, rather than specific policy proposals. I’m very sympathetic to the need of many to get back to work so they can provide for their families, pay the rent, etc. I also share the frustration that much of the information provided by the media and government agencies is untrustworthy or incomplete. This is why I write these posts!
I want to reiterate the differences between the typical flu and the SARS-2 virus:
The R0 value (a measure of infectiousness, see my April 13th post) for the flu is 1.28. For SARS-2, it’s 5.7, 4.5 times higher!
The incubation time for the flu is 2-4 days, for SARS-2, it’s 2-14 days, and asymptomatic people are often contagious!
Yes, the fatality rate for both is impossible to know. And it’s probably over-estimated for both, since we don’t know the number of infected people with mild to moderate symptoms for either disease. But estimates are that the fatality rate for the typical flu is 0.14%. The current rate for COVID-19 in the US is 5.36% (deaths/confirmed cases), 38 times higher.
In short, SARS-2 is not the typical flu.
We have to concede that in an event like this one, there are many valid interests that are in some ways are opposed to each other. People at risk want to stay safe. Doctors and nurses want to treat their patients, but also face constant exposure of themselves and their families to the virus. Those in government do not want to expose their constituents to unnecessary risk. On the other hand, many have lost their jobs and need to get back to work. Mental health workers worry that their patients cannot withstand prolonged isolation and stress. Employers wonder if they have to lay off more people or close their businesses. All of these are real concerns, and they can’t be dismissed.
It will be difficult moving forward to strike a balance between these competing interests, and no solution will be perfect. We need to understand that most are doing their very best to manage a very difficult situation. There is lots of blame to go around, but remember that the nature of the virus has never been completely clear. For myself, I gave a talk at my church on March 13th (Posted here on March 18th). During the previous week, I was trying to determine if the virus was spread by droplet transmission (coughing and sneezing), or by aerosol transmission (shouting, laughing, singing, even talking). At the time, most outlets including the CDC said it was only spread by droplet transmission, but a few scientists were warning that it may be aerosol. Should I really be giving a talk on virus safety to room full of people? It appeared at the time that it would be OK, so I moved forward. Luckily for me, the decision was made to cancel gatherings, and my talk was recorded for the web. As it turned out, the SARS-2 virus is much more infectious that originally thought (see my post from April 13th), so add me to the list of people who were wrong! Thank God I didn’t have a crowd in the room during my talk!
Again, I am not an epidemiologist, I am a molecular biologist specializing in infectious disease. But in my informed opinion, reopening the economy without great care is a mistake. A similar experiment has already been done. On March 11th, California Governor Gavin Newsom banned large gatherings including sporting events, church services, and university classes. On the same day, New York Mayor Bill De Blasio was encouraging people to eat out and enjoy themselves. As of this writing (April 19th), California has 31,000 confirmed cases, and New York City alone has 138,000, more than all but 6 countries (yes, I’m including China, the Chinese Communist Party is almost certainly heavily under-reporting their case load)1. For a time, New York hospitals were overwhelmed, and bodies were being temporarily buried on Hart Island. This is the possible consequence of going back to normal too quickly! If you choose to gather in large groups during this time (for example at protests in downtown San Diego), I would strongly encourage you to take extra care to isolate yourself from those at risk or those who may come in contact with them.
I am less sympathetic to those who want to get back to normal just so they can go to Disneyland or to their favorite restaurant. As we reopen the economy, we have to do so carefully. Theaters, restaurants, and amusement parks are among the last things that should be reopened.
We will need have adequate testing and hospital capacity to handle the additional case load. Each area will be different in this regard, and New York City should not be treated the same as Ennis, Montana. We will also need to have grace for one another, as well-intentioned mistakes will be made along the way. Ideally, we should also have contact tracing, contacting those potentially exposed to an infected person. This practice, along with aggressive testing, was used very effectively in Taiwan, So. Korea, and Singapore, to minimize caseload. Unfortunately, we are not yet able to do contact tracing in the US.
While I am very sympathetic to individual rights, and am in general for small government, we may need to voluntarily lay down certain rights for a time in order to protect each other. Pray for our leaders, regardless of party, and take care of each other!
I’ll have another post soon on the topic of antibody testing.
Don’t fear, but be smart! Erik
1 Editor’s note: As of the date of posting, the statistics here were correct. As of July 7, 2020, however, the situation has reversed. New York State as 398k confirmed cases, California has 284k confirmed cases. New York state daily cases are trending downward, while California daily cases have been trending upward.
I know I’m not exactly Mr. Fun these days, but I have another little update. According to March 16th paper in Science, one of the worlds 2 leading scientific journals, asymptomatic people who are infected with the SARS-2 virus are about half as contagious as sick people. However, because there are so many of them, asymptomatic people account for 80% of new infections! (Li et al, Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2), March 16, 2020, Science Magazine).
The take away is, yes, even if you are not sick, you can spread the virus! So please stay home, and protect your neighbors!
Just a little up date from last week’s talk. I mentioned in the talk that I saw a 10 fold increase in cases since I gave my first talk to a small audience on March 3rd. The US had 125 cases on the 3rd, and 1762 cases on the evening of March 12th. This morning, March 21st, the US has 19,931 cases, another 10 fold increase since my talk last week! Some of this is because of increased testing, but there are certainly many, many cases we don’t know about yet.
The caseload has been going up consistently by about 34% more each DAY in the US, 6000 new cases just yesterday March 20th. We NEED to get the rate of new increases to come down. Increased social distancing measures will help, but because of the long incubation time, it may take a few days or weeks to see a benefit.
Autoimmune disease: There have been recent reports, that those with autoimmune diseases (like me) are at special risk because our immune systems are already overactive, and will do extra damage to our bodies while trying to combat the SARS-2 virus. In a brief search online, I have not been able to find confirmation of this report. If you have Celiac Disease, MS, some kinds of Diabetes, or other autoimmune disease, take special care.
My state, California, has instituted a voluntary ban on non-essential outing from your house, except for:
Getting food Care for a relative or friend Get necessary health care Go to an essential job
If your job is essential, you know it by now!
Going for a walk is still a good idea if you keep a safe distance (at least 6 feet) from neighbors.
Also, consider texting neighbors, or using Nextdoor or a similar site to try to find people in your area who maybe do not have social connections and may need extra assistance, like food and supply delivery. Ding dong ditch!
I also heard a good idea about buying gift cards from your favorite stores in town to support them until things get back to normal.