Dear Friends, This is a case update. I’ll also have an important message about antibody dependent enhancement.
Cases continued to rise unchecked in the US, California and San Diego County in the last week, although the long holiday weekend did have impacts on reporting. Some good news is that the number of deaths reported in the US has been slowly declining despite the case increase. Keep in mind however, that deaths will lag behind cases by as much as 2 weeks, so we may yet see an impact from the higher caseload. The number of deaths have been trending flat in California.
Rt Live is reporting that all but 8 US states or territories have Rt values above 1.0, meaning that the virus is expanding in those states.
I’m going to bring up an issue that I’ve been avoiding talking about for some time. I’ve been avoiding talking about it because it’s not a certainty, and also because the possibility will be scary for some. The reason I feel compelled to talk about it now is that many are having a hard time understanding why I am still so concerned about the virus when the fatality rate is low and dropping, and folks want to get back to normal life. I’m even hearing about young people having COVID parties in which people gather with a sick individual so they can all get infected and be immune from the virus thereafter.
Before I share this, I’ll also say that the medical community is doing a better job treating patients with COVID, and the disease is becoming more survivable. In addition, we now know a lot about how the virus is spread, and if a person wants to remain uninfected, they can do that, while still getting together with friends and family, and still working and getting on with life. You can be reasonably certain you will not get infected if you do the following:
1) Wear a mask or face covering in public. Avoid places with unmasked people. 2) Keep 6 ft away from others. 3) Avoid indoor gatherings, especially ones in which singing or shouting is likely. 4) Small outdoor gatherings are fine, even without masks, if everyone maintains a distance. Have guests bring their own food. 5) While many restaurants are open for limited indoor seating, I personally am still not comfortable eating indoors at a restaurant. I enjoy eating outdoors at restaurants, however.
Antibody Dependent Enhancement: Several years ago, scientists were developing a vaccine against Dengue Fever, a mosquito borne disease which causes debilitating joint pain in patients. Some time after trial vaccination, several vaccinated patients died suddenly of Dengue Fever. This became the most studied example of Antibody Dependent Enhancement (ADE). Normally, for the annual flu let’s say, a person gets infected by the flu, is sick for a few days, and the immune system develops a response by creating antibodies against that specific strain of the flu. If they are exposed again in a month, nothing will happen. If the patient is exposed to a different strain the following year, they may still get sick, but the antibodies they developed the year before may help them have less severe disease and recover more quickly. Part of the immune response is that some immune cells display antibodies on their surface to capture new invaders.
With Dengue and some other viruses, the first stages are normal. A person gets infected and develops a response. If they get re-infected a month later, nothing happens. But if they get infected with a slightly different strain months or years later, instead of being protected, the virus attaches to antibodies displayed on immune cells and uses the antibodies as a site of entry into the immune system. The immune system is quickly infected, and the patient has a more severe disease with the second infection. Some estimates are that disease may be 3-4 x more severe in these patients.
As it turns out, SARS-1, which arose in 2002, and MERS, which has small outbreaks every year, are both Coronaviruses and both appear to be able to use the ADE pathway. This raises the possibility that SARS-2, the current virus, can also use the ADE pathway. This means that a person infected for a second time with a different strain of SARS-2, or any other Coronavirus for that matter, may be at much higher risk for severe disease.
This is why I’m not in favor of pursuing herd immunity as a pathway out of this crisis, because it will prime people for ADE related problems if a similar strain should strike next year.
This is not a new idea. If you search for “ADE” or “Antibody Dependent Enhancement”, you will see many articles, some peer reviewed from respected journals, on the phenomena. Dr. Fauci has even referenced it using the term “enhancement” when talking about vaccine development.
Why haven’t the government public health departments been more open about this? They tend to make statements only based on what they can be reasonably certain of, which is why they have been so slow to react to many aspects of the current crisis.
Again, it’s not certain that ADE will play a role next year. It’s too early to know. I’m informing you of the possibility so you can make wise decisions for you and your family.
This long post will be a summary of what we have learned so far about the Coronavirus, and I’ll make some predictions about what to expect next. Since I’ll be sharing so much information, I won’t give references for everything here. I also have to make the disclaimer that new studies are constantly being done, and some of the below information may need to be revised later. To make my standard disclaimer, I am not an epidemiologist or a physician. I have a Ph.D. in molecular biology, and my specialty is infectious disease testing. On much of the below, I have an informed but not expert opinion.
Coronaviruses: Coronaviruses are a large group of viruses unrelated to the flu. What we think of as the common cold, are actually member of several classes of viruses like Adenovirus, RSV viruses, Rhinovirus, and several Coronaviruses. Many Coronaviruses cause diseases no more virulent than the common cold. However, just like novel flus can cause extra trouble, so can novel Coronaviruses. The first SARS virus was much more lethal that the SARS-2 virus, but because SARS had a short incubation period and made almost every infected person sick, it was much easier to contain. The Middle East Respiratory Syndrome (MERS) Coronavirus infects a few people every year, and is very lethal, with a fatality rate of 34%, but it also has not made a global impact. The reason SARS-2 is so dangerous is that it’s VERY infectious (Ro of between 2.5 and 5.7) and has a VERY long incubation time (2-14 days), making it very hard to track. Plus, it’s at least 2x as deadly at the annual flu.
Name: The official name of the virus is SARS-2-CoV (for Severe Acute Respiratory Syndrome-2 CoronaVirus). The official name for the disease it causes is COVID-19 (for COronaVIrus Disease-2019). You may notice that the term SARS actually sounds a lot like a disease. You would be right. So why did they need a different disease name than SARS-2, or SARS-19? I don’t know.
Spread: Early reports were that SARS-2 mostly spread like a flu, with droplets spreading from coughing or sneezing. It became apparent later that the virus was also spread through aerosols by laughing, singing, shouting, or even just talking in close proximity for long periods. As further study was done, it appears that most infected people don’t infect anyone else. Rather, most infections come from “super-spreader” events, in which a single person infects a large group of people. This usually happens indoors (at least 19 times more likely) during activities like fitness classes, funerals, concerts, and choir practices. While outdoor activities aren’t completely immune to these events, they are much more rare.
Viral load upon exposure appears to be an important determinant of how severe a case will be. Basically, this means that if you’re infected by a “low dose” of virus, your disease is likely to be less severe. I have several physician friends who have stated that it seems to them that cases in the hospital are less severe than they used to be. One likely reason for this is that since more people are wearing masks in public than early on, those who are infected are being infected by a lower viral load.
Early studies demonstrated that viable virus can exist on objects for hours or days. However, it does not appear that a substantial number of people are being infected because they have touched a contaminated object.
The WHO made a confusing claim recently that asymptomatic people cannot spread the virus. While this is technically correct, they were not clear that “asymptomatic” is a technical medical term meaning someone who does not have, and will never have, symptoms. Another group is “pre-symptomatic”. These are people who currently don’t have symptoms, but will develop symptoms in a few days. As it turns out, pre-symptomatic people do spread virus, and are likely responsible for up to 80% of new cases. So yes, people without symptoms can and do pass the virus to others.
Risk Factors: Many believe that only old people are at risk. While it’s true that age is a dominant factor, other risk factors are important, and younger people have also experienced severe symptoms. Other risk factors include respiratory conditions like asthma or COPD, heart conditions, kidney conditions, liver disease, diabetes, obesity, auto-immune disease, use of NSAID anti-inflammatory medications, being immunocompromised (HIV infected, undergoing cancer treatment, under medication for a transplant), vitamin-D deficiency, type A blood (Type O appears to be protective), inadequate sleep.
Always check with your doctor before changing your medications. I have an auto-immune disease and take daily anti-inflammatories, but my doctor has advised me to continue taking these unless I experience COVID symptoms.
Make sure your doctor is aware if you have any of the above conditions.
Symptoms: Many people who have SARS-2 experience no symptoms, or experience mild flu symptoms. If you have ANY cold or flu symptoms, contact your doctor and see if you can be tested. If you live in San Diego County, and your doctor cannot offer you a test, call 2-1-1 to get a free test from SD County Public Health. If you have additional symptoms like shortness of breath (you just can’t seem to get enough air), loss of smell or taste, nausea or diarrhea, contact your health care provider or an urgent care immediately.
In severe cases, the virus can do wide spread and permanent damage to multiple organ systems. Early treatment is necessary to prevent the most severe symptoms.
Precautions: While lockdowns may have been effective in the US during the early stages of the pandemic, especially at a time when masks were hard to come by, recent evidence suggests that lockdowns provide only a moderate benefit over other means of control. Here’s what appears to be beneficial:
Masks: Masks are not all the same and some are better than others. Their main benefit is that they stop, reduce, or slow the travel of virus from infected people. This prevents surrounding people from infection, or lowers the viral load of exposure. Some, but not all, also prevent the wearer from inhaling airborne virus. N95 style masks without a valve are best if you can obtain one.
Social Distancing: Aerosolized virus can travel through the air. Staying 6 ft away from others helps prevent infection.
Adequate sleep: Sleep is very important for a wide variety of body functions, including the immune system. Get 7 – 8 hours of sleep per night. A 26 minute power nap during the day is also beneficial if needed.
Vitamin D: Several studies have suggested that patients with the most severe cases of COVID also have the lowest levels of Vitamin D. Because of our often indoor lifestyle, most Americans are Vitamin D deficient to some degree. The best way of getting some Vitamin D is to make it yourself by going outside in shorts and a T-shirt for 30 minutes a day. This is because Vitamin D is manufactured in our skin in response to sunlight. If it’s not practical for you to do this, consider a Vitamin D supplement. Darker skinned people are more likely to be Vitamin D deficient in the US.
Home isolation: If you have cold or flu symptoms, contact your doctor immediately and see if you can get a test. Tests are much more available that early in the pandemic, and you should be able to get a test by request. Also, if at all possible, isolate yourself from the rest of your family until you can be tested as negative. Many new infections are taking place among family members.
Testing: There are several kinds of tests, and they tell you different things.
PCR: These tests use material collected from the nose and need to go to a specialized laboratory for processing. They are very sensitive and specific, and indicate whether the patient is currently infected. This is the most common kind of test.
Antibody: These tests detected antibody from a patient’s blood to see if the patient has been infected for at least a few days. IgG tests may also tell if a patient was infected weeks or months previous, but are no longer infected. Some patients do not mount an immune response that will provide long term antibody.
Isothermal amplification: The Abbott ID Now COVID tests uses this relatively new technology. These tests are similar to PCR and are both sensitive and very fast.
If you have cold or flu symptoms, contact your doctor immediately and see if you can get a test. Testing is much more available than it was early in the pandemic. San Diego County is encouraging anyone who wants a test to be tested.
Treatments: Treatment for COVID is complicated and not all patients can be treated in the same way. Additionally, treatments are evolving rapidly, and your doctor many not treat you in the ways listed below.
Ventilators: Some doctors now state that ventilators carry risks that may be unacceptable for COVID patients. Many doctors now favor a nasal cannula, using ventilators only as a last resort if breathing is labored.
Hydroxychloroquine, Azithromycin, Zinc: Several doctors from several countries have reported success with this combination. Studies on the effects of these drugs have as yet still been non-conclusive. Some positive studies suggest that Zinc is the main virus fighter of the treatment, with Hydroxychloroquine allowing better penetration of Zinc into cells. Unfortunately, the debate on the efficacy of this regimen has taken on a strongly political tone, which almost always interferes with the scientific process. Now pundits, as well as scientists, weigh in on this regimen. I’m still holding a “wait and see” posture with this treatment.
MATH+: This regimen uses Methylprednisolone (an anti-inflammatory), Vitamin C, Thymine, and Heparin, as well as optional other treatments including Vitamin D and Zinc. Early reports suggest success with this treatment.
Vaccines: Each spring, scientists learn which flu is likely to be prominent by the following Fall. They make some guesses and create a vaccine for the flu season. The manufacture process takes a few months. But it’s only this short because they already know how to make a flu vaccine. Development of a brand new type of vaccine takes between 4 and 30 years! There are many methods to make a vaccine, and scientists must try many of them before finding one that works. Then they must try the vaccine on patients and make sure they are relatively safe. Every vaccine carries some risk of side effects.
Early estimates for a Coronavirus vaccine were around 18 months. My guess is that this is too optimistic. Personally, I wouldn’t count on a vaccine for at least a few years. In addition, some studies have suggested that Coronavirus vaccines in particular may cause side effects that may make vaccine development challenging. My standard practice for my family is to wait on new drugs for a few years before using them myself. While I pro-vaccine in general, I would personally recommend waiting for a few years before getting a Coronavirus vaccine.
Herd Immunity: Some are promoting herd immunity as a way to move through the crisis faster. The idea of herd immunity was popularized in pre-pandemic discussions on vaccines, promoting the idea that the more people are vaccinated, the more protection for those who can’t be. This is a good idea when a vaccine is available, but not when there is no vaccine. Putting many people in harm’s way to protect fewer others is not wise and is not standard medical practice.
The Future: Of course, it’s impossible to know what will happen next. My initial prediction was that the first wave would be over by July, and at this point, this doesn’t look likely. New confirmed cases have started to rise or rise faster in the 3 areas I monitor most closely, the US, California, and San Diego County, and cases are rising fast in some countries previously unaffected, especially Brazil, Russia, and India. So I’m starting to think we may not be out of the first wave before the Fall season.
In addition, RNA viruses, such as Coronavirus, can mutate very quickly because the proteins used to copy their genomes are very error prone. This means that a virus may change to a new form that can re-infect a person who has already had a previous version. Some reports suggest that this may already be happening with SARS-2. Some good news is that on the very long term (years), novel viruses tend to evolve to be less virulent, because it’s not in the “interest” of the virus to make the host very sick. The message is, we may need to adapt to a new reality for the next few months or years. We can’t really afford to be “locked down” anymore, but mask wearing and elbow bumps may be a part of the landscape for some time.
This is a case update. New confirmed cases are starting to trend upward for the US again for the first time since about April 9. In 19 US states, the Rt number is higher than 1.0, suggesting that the virus is spreading in these states. On endcoronavirus.org, you can clearly see recent spikes of new cases in some states, and in many countries.
In California, the number daily new cases continues to accelerate. San Diego has started to go up too. San Diego County has started to publish the number of recovered patients. My graph of cases in SD County now includes active cases, taking recovered people into account. Some of these points of data on my graph are given by SD County, the others are calculated by me based on the data points. Looking carefully at the SD County data, the number of recovered people is approximately the number of total cases from 17 days previous. The suggestion is that it takes approximately 17 days to recover after being confirmed as a COVID case, so I’ve made a similar calculation for California. Just to be clear, in my graph of active cases in California, the data points are based on assumptions about recovery time, not actual data.
For San Diego, active cases have been hovering around 2,000 for several weeks, without much change, but for an increase in the last few days. For California, we’ve seen a steady trend upward in active cases from 20,000 in early April, to 40,000 cases today. There are of course lots of potential reasons for these increases, from gradual re-opening to the protests and riots stemming from the George Floyd incident. I was once optimistic that the first wave of cases would be over this Summer, but new trends have called this into question. I’m now feeling totally unable to predict how things will go.
I heard a radio commentator talking about a recent study that I haven’t been able to find. The study said that while Social Distancing account for maybe a 50% drop in new cases, the lockdown accounted for only a 5% additional drop. Given the economic and social cost of the lockdown, the study suggested they were not on the whole worth the cost. If you’ve seen the actual study, please post it in the comments!
So please continue to social distance and wear your masks in public! But it’s time to figure out how we can get the economy running again! We have big problems to solve, time to get to work!
Yesterday right after I posted, Mark Rasmussen sent me an article that ran in Science Magazine, one of the 2 most highly regarded science journals in the world. It’s a news article, not a peer-reviewed journal article, but it attempts to pull together information from different sources, and I think clarifies the picture regarding SARS-2 viral spread. The take-away message of the article is that while the R0 appears to be between 2.5 and 3 (more on that later), it’s not true that the average individual will pass the virus on to 2 or 3 others. Rather, most infected people don’t pass the virus on to anyone at all, rather a few infected people are “super-spreaders”, infecting a large number of people at once. There are many documented cases of super-spreading, from choir practices, funerals, concerts, fitness classes, and meat packing plants. The commonality appears to be indoor locations with lots of people in a small space, with some of them shouting or singing. While the risk in outdoor venues isn’t zero, indoor venues account for 19 times the number of super-spreading events, according to a Japanese study.
According to the article, SARS-2 has a tendency to cluster in this way more than other respiratory diseases such as the flu or colds. This may be partially because of the “viral load” effect mentioned in the Erin Bromage article I posted on May 12th. In that article, it appears that the initial number of viruses an individual is exposed to partially determined if they will be infected, and how sick they will get. This also explains why so many medical workers in Italy got very sick or died in the early stages of the pandemic. Many medical procedures such as intubation create a bloom of floating virus from a sick patient, exposing unprotected workers to high viral loads.
The science article suggests that while the virus is still dangerous and outdoor venues are not completely without risk, it may be appropriate to relax restrictions on some outdoor activities. So here’s my informed but not expert advice on how to adapt to life with COVID:
Staying at home all the time may no longer be the best approach, although it was probably very helpful in the early stages of the pandemic. Going outside to get some fresh air and exercise is probably a good thing, although still not without risk.
When doing outdoor activities, it’s probably OK to not wear a mask, but maintain at least 6-10 ft from others you don’t live with. Locations with a gentle breeze will help move virus away from you!
At work or shopping, wear a mask when around others to reduce the viral load that you are wafting into air should you be infected without your knowledge. Any reduction in viral load will help.
If you suspect you may have been exposed, contact your physician and see if you can get a test.
If you have a yard, invite a few friends over for lunch or dinner at a safe distance. Since Summer is starting, an evening outdoor dinner will be a welcome break from the isolation. You may want to have your guests bring their own food and utensils. Don’t invite a large number of friends, and sorry to say, don’t invite those friends who can’t resist hugging everyone! Young children may require supervision to be safe.
Now that restaurants are open in California, I would personally only be comfortable with outdoor seating at the moment. If you’re comfortable, visit your favorite local restaurants to give them some business, sit outside, and leave your server a big tip if you’re able!
I am a church goer, and I want to see my peeps again, but singing in a congregation is still a high-risk activity. Churches will need to be creative to open up again safely. Consider lower density services without singing, and/or hold services outdoors.
Regarding the R0 value for SARS-2. I saw a CDC website last week that gave the R0 value as 2.5. After 10 minutes of looking, I couldn’t find this site again. The Sanche paper I’ve referenced before (High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2, EID, July 2020), published in the official CDC journal, Emerging Infectious Disease, gave the R0 as 5.7. So the CDC itself seems confused about what the R0 number is. My guess is, it’s somewhere between 2.5 and 5.7. That was a joke. Obviously, this range is far too large to be useful, and 2.5 and 5.7 are very different as applied to an R0 number. 2.5 is a very infectious disease, 5.7 is a super-infectious disease.
I’ve mentioned this before, but I want to remind everyone. Herd immunity is only a goal when a vaccine is available. Seeking herd immunity when there is no vaccine is not a good idea, because it will put large numbers of people at risk. Additionally, I am generally very pro-vaccine, but because of the risks of side-effects with this particular virus, a vaccine may not be available for several years. We will need to adapt to this reality. My hope is that we will start seeing daily cases come down this Summer.
Today I’m going to discuss the JP Morgan study on transmission (among other things), how the Moral Matrix effects how people see the fight against the virus, and the boom stage in many Southern Hemisphere countries.
Frankly, when I think about anti-coronavirus efforts, I have tended to lump lockdowns and social distancing together, especially since many use these terms interchangeably. Notably, the study separates these 2 concepts and suggests that will social distancing (staying a distance away from people in public) may be valuable, lockdowns (staying in your home) is not.
You might say there have been 2 primary models for dealing with the pandemic in the last month after we’ve flattened the curve, but have not brought the numbers down, at least not in the US. I’ll call those models the Lockdown and the Re-opening models. Some want to continue the lockdowns to keep everyone safe from the virus, others want to re-open right away without restrictions. For several weeks, I have been gravitating toward a third Adaptive model. Of course, there can be many flavors of this model. Personally, I think masks, even bad ones, are far better than nothing, especially when worn by everyone, and can help us get back out of our houses and help us re-start the economy with reasonable safety. So I’m very open to the idea that the lockdowns have not been beneficial. Some of you will disagree.
The JP Morgan study is at odds with the endcoronavirus.org study, which recommends brief, very strict lockdowns. It could actually be that these 2 studies actually agree, depending on the time frame you’re talking about. I do think the lockdown was very helpful in the initial “boom” stage of the epidemic here in the US, but may have lost its usefulness later.
The Moral Matrix: ZDoggMD is a physician and medical YouTuber with a very silly screen name, but who posted VERY interesting video on how different people see the pandemic we are all facing. Using Jonathan Haidt’s work on the Moral Matrix, he talks about how different people’s moral framework shapes how we are viewing different efforts to address the issue. I was aware of Haidt’s work, but not had yet applied it to the pandemic in my mind. As someone who is sometimes exasperated with people who disagree with me (as they are with me I’m sure), this video is helping me remember to see their point of view. If you’re exasperated with your friends or family, I HIGHLY recommend you watch this video.
Upsurge in the Southern Hemisphere: Lastly, I just want to mention that many countries which have been relatively little effected until now, are now experiencing a big upsurge in cases. These countries include Russia, Brazil, and Mexico, and many are in the Southern Hemisphere, which is in the late Autumn months right now. Let’s hope they are able to get things under control quickly.
Don’t fear, but be smart!
PS. We went hiking in nearby Calaveras Park today for the first time in months, without our masks. There were a lot of people on the trail, and most were well behaved. When I can’t avoid someone on a narrow trail, I use an old SCUBA diving trick for ascending without getting the bends. Just close your mouth and blow slowly out of your nose as you pass someone. You’ll gently move any virus away from your nose! To maintain my friendliness, I greet people early, with plenty of time to start this little maneuver!
On Wednesday, San Diego County announced that the county will be moving further into California’s Step 2 re-opening plan. This means restaurants will be opening for modified seating with some other restrictions, and many more businesses will able to open as well. To sum, customers will still need to maintain 6 ft separation, and everyone will need to wears masks while shopping. Restaurant guests will need to wear masks while not at their table. Tables in restaurants will need to be moved so that seated customers are at least 6 ft apart. Tables that cannot be moved will need to have barriers between them. Restaurants can also expand outdoor seating!
I’m excited for this change, but it will be important for the public to follow these new guidelines. We want to keep making forward progress!
Today I’m going to wade into the piranha filled waters of the vaccine discussion. I’m also going to talk about the issue of herd immunity, and my advice for re-opening. I’m not prepared for a discussion of the MRM vaccine that has been raging for the last several years, I’m going to discuss vaccines in general, and the hopes for a COVID vaccine in particular. I will say to start out, that I’m a big fan of vaccination in general, but each vaccine is different, and I may not be in favor of a particular vaccine.
Vaccines: I’m not an immunologist and I haven’t made vaccines myself, I’m just sharing with you what I’ve learned from an informed perspective over the last few months. When I first started sharing about COVID, I said something wrong, that it would take at least a few months to create a vaccine against COVID, which seemed like a long time to many. This was based on the time it takes to develop a flu vaccine every year. In the Spring and Summer, scientists find out that strains are likely to cause flu later that year, and they begin making a vaccine. This process takes several months. As it turns out, it’s only this fast for flu because there is a standard way to make a flu vaccine, they just need to know what strains will be likely to arise in the Winter. And sometimes they are wrong.
Unfortunately, however, there isn’t just one way to make a vaccine. There are many different ways, and it can be different for every virus or bacteria. So for every new infectious disease, a vaccine must be developed from scratch, testing all these different methods. The process can take from 2 to sometimes as long as 30 years! Some scientists have said that Dr. Fauci’s prediction of a vaccine by next Summer is actually very optimistic! In my informed, but not expert opinion, we should not count on a vaccine for this current COVID-19 crisis. However, the vaccine work being done will likely help with future outbreaks. At least part of Dr. Fauci’s optimism is that a lot of red tape is being cut to speed the process, and that’s good, but less development time will also mean more risk for the final product.
Herd immunity: I have heard many people promoting the idea that herd immunity will help us get out of the crisis. Even some governments have been promoting this idea. Herd immunity is a useful discussion for diseases for which there is a vaccine, but in my opinion, it is not something we should be striving for now with COVID. We shouldn’t put a bunch of people in danger to keep fewer different people out of danger. Herd immunity requires a lot of people to be immune, and that number is different for every virus. I’ve heard the numbers 50 – 70% for COVID thrown around. That’s a majority of the population! Why would we risk exposing the majority to the virus to save the minority? To be crass, it’s kind of like saying that once the pool is full of bodies, no one else will drown.
Reopening: More states continue to begin the reopening process. I actually strongly support this, as long as people continue to take care as they interact in public! Even California has entered Phase 1 (CA calls it Stage 2) today, Friday May 8. The stages CA will use, as well, as the announcement for the May 8th reopening were announced by Twitter by the Governor. Not my favorite method of making an official announcement, but there it is. Re-openings have a much higher chance of being successful if we continue to take care! Continue to wear masks in public, and continue to distance when appropriate (see my May 5th post). I’m hopeful that we can advance quickly through the stages if people continue to take precautions. Also, it will be important for us to continue to expand testing, and for businesses to take advantage of expanded testing by screening employees as appropriate. Some municipalities are starting to have drive through testing, including parts of San Diego (you must still have an appointment to be tested). Check with your health care provider or public health department to see if and how you can be tested. Keep watching how other states are doing! We can learn a lot by observing what methods are working, and what methods are not! I predict that outbreaks will occur in places that become relaxed too soon.
2nd Wave: Again, I’m not an epidemiologist, and the following is an informed guess, not an expert assessment. In my informed opinion, we will have second wave in the Fall or Winter, and history suggests it may be more severe than the first wave. But I’m still optimistic. Why? Because I think that with expanded testing, we will be able to test far more broadly this Fall than we could in March and April. This will help us identify and quarantine infected people rapidly, and will help us control the spread much better than in the first wave. For the 2nd wave to go well, we will need to stay diligent!
The messaging on masks has been very confusing. For several weeks, the CDC said the public doesn’t need masks, then finally, the surgeon general was demonstrating how to make a mask out of a T-shirt. I’m convinced that the CDC was so slow to recommend masks simply because they have been so hard to come by. But the delay in recommending masks has caused a lot of confusion.
______________________________________ Section added 2/22/21: Masks have produced a lot of controversy, but I am a big fan of mask wearing indoors. This does several things, it usually prevents infection if you’re wearing an N95 or KN95. However, studies suggest that even if you get infected, a masks will help you have a lower initial viral load on exposure, greatly reducing your symptoms! I personally always wear a mask indoors, and I rarely eat indoors right now.
Outdoors are a different story. Unless you are in a tightly clustered large group of people, you probably do not need to wear a mask outdoors! Some municipalities encourage or require mask wearing outside, but this is usually unnecessary. I am not saying you should ignore local requirements! I’m just saying that when you are going for a walk, a hike or a bike ride, a mask is not necessary. _______________________________________
First, let’s talk about the words you’re hearing now!
Cloth Face Covering: A “cloth face covering” (I’ll say CFC for short here) is not technically a mask as the CDC defines it, and is not considering Personal Protective Equipment (PPE) from a medical perspective. This a t-shirt, bandana, buff, or anything else that can be used to cover your nose and mouth. The virus can still get both into your nose or mouth, or leave your body through these coverings, but it’s much better than nothing. A lot of people who are trying to be responsible, but can’t find a mask to buy, are using these coverings. If you hear someone saying they don’t work, they mean that they aren’t completely effective, but they are much better than nothing! Even if you sneeze, a face covering will capture larger droplets, slow the velocity of the sneeze, and help protect those around you. If all you have is a CFC, you should still wear it when you go out!
According to Fischer et al, gator style masks may be even worse than wearing nothing at all, since they may break up droplets into a smaller size that stays in the atmosphere longer! So avoid a neck-gator style mask!
Face mask: A “face mask” is a filtering mask that covers the nose and mouth, but does not seal around the nose and mouth. This includes the blue surgical mask that you see a lot of today. These masks are designed to prevent material from medical worker’s face and nose from getting to a patient during a procedure, while still allowing somewhat normal breathing. They filter incoming air to some degree, but there are large gaps at the sides of the mask, so there are not very effective at preventing infection by SARS-2. Coughing, sneezing and singing will still expel air from the sides while wearing these masks! They aren’t completely effective, but they are certainly better than nothing, and will prevent transmission through simple talking. If you have one, please wear it!
UPDATE: Now that KN95 masks and some N95s are available (see below), I can no longer recommend wearing these masks.
Respirator: These masks seal against the sides of the face cover at least the nose and mouth. They are designed to filter the air and prevent particles from entering the nose and mouth. N95s prevent 95% of viruses from getting through and are the preferred mask for medical workers in most situations right now. Unfortunately, they have been in very short supply since the beginning of the pandemic, so the public is being asked not to purchase these for now. Doctors tells me that N95s are not adequate protection while performing certain procedures on COVID patients! One told me a story about 14 medical workers being infected by a single patient during a procedure! This work requires a Powered Air-Purifying Respirator (PAPR). These masks cover the entire face and also blow air into the mask, pushing virus out.
If you have an N95 with a valve in the front, these masks will still vent air when you cough or sneeze, so be aware that it will not protect others from virus coming from you! N95s with no valve are the best choice for protecting both you and those around you. Again, hold off on purchasing these until there are in greater abundance.
I see a lot of very nice looking fitted masks with a little round filter in the front. These filter out large particles like dust or large droplets, but not necessarily small virus particles. While much better than nothing, these are not necessarily N95 masks! Read the product information carefully when buying these masks.
KN95 Masks: A new style of mask is being sold in the US now, labeled KN95. These masks are made in China and designed to filter out 95% of viral particles, like N95s. However, they are certified by a Chinese agency, and not by the FDA or CDC. They have been allowed to be sold in the US on an emergency basis. Users say they fit more loosely than N95 masks.
There are lots of studies showing the effectiveness of these masks, and unfortunately I don’t have one ultimate study to share with you. Suay, a clothing company in LA, did a study suggesting that normal blue shop towels (like Tool Box Shop Towels or Zep Industrial Towels) do a much better job at filtering than cotton, and are a cheap and available alternative to an N95 when sewn into a mask. My sister-in-law Penny is part of a team that makes masks for the local hospitals in Bozeman. These are homemade masks with a pocket for a HEPA filter. She’s sending me some, and I’m going to add a Shop Towel to mine! Both designs are posted below.
Here’s a few tips for wearing your mask:
Your CFC or mask must cover your mouth and nose. Leaving your nose hanging out, or simply wearing it as a chin mask is not adequate!
When adjusting your mask assume both your hands and the mask are contaminated. Wash your hands before AND after adjusting.
30 min of UV light effectively kills SARS-2 virus. In the bright sunlight, it may only take a few minutes. I sterilize my mask by leaving it in the sun for a half hour after a shopping trip. If you have a cloth face covering or mask, machine washing is a better choice.
In addition to preventing infection, masks appear to reduce the viral load in newly infected patients, leading to less severe symptoms! So even if you get infected while wearing a mask, your symptoms are likely to be less severe!
As we think about re-opening the economy, face coverings, even the bandana type, will really help keep new infections low. So wear a mask when you go out in public! Any improvements will hasten the day when businesses can re-open. I am awaiting data to see what the infection rate is at businesses in which employees wear masks. Hopefully, this data will come out soon.