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.
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.
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!
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!
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!
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.
I just started working on a COVID testing project full-time. This means I will be less available to blog for the next few weeks or months. I will certainly keep blogging, but won’t be as able to respond to questions, or read submitted articles.
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. A few days later, I gave a talk at my church (posted here on March 18th). 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!