Ebola:

–Now up to 75 total confirmed cases.  This is probably an undercount, as “community resistance” to sampling continues and contact tracing is inadequate.  Vaccination is not happening in effective numbers either.   Still no updates on the possible vaccination failure from a few weeks ago, but it’s not the first case like that to disappear down a memory hole.  At least 6 confirmed cases are still out in their communities and two more local Ebola treatment centers are now over capacity.  Geographic spread continues, but still within Equateur Province so far.  The WHO warns that it does not have enough money to improve any of these metrics, and COVID response is diverting resources needed to contain Ebola as well. 

Coronavirus:

–General trends:  Worldwide, quite a few places are still climbing their delayed first wave peak.  Australia, for example, still has portions in a very strict lockdown, although new cases are rising despite of that.  Germany reports more areas with new cases.  New Zealand, fresh off global accolades for halting coronavirus, this week saw a cluster of new cases pop up on the island.  This is particularly illustrative of the limitations of lockdowns and contact tracing–at least at this phase of the pandemic.  New Zealand is an island.  They were successful in delaying their first wave a long time by virtue of being an island.  They could control access and trace easily, and did.  Coupled with a lockdown and other mandatory measures early, and they went over 102 days with -no- coronaviruses cases.
All good things must end though. 

Again, and I cannot stress this enough, you cannot trace the common cold away–not when the virus is as widespread, globally, as it is right now.  SARS-CoV-2 found a way back onto a small, controlled access island with strictly enforced containment measures anyways.

The only way out is through.

–“But wait,” you say.  “Didn’t Russia announce a successful vaccine this week?”  Yes, they did.  They may even have one.  There is no significant efficacy or safety data available on it to know for sure.  So ¯\_(ツ)_/¯ . Following trends in Russia will not be informative, unless they drop like a rock to zero in the next few weeks (assuming Russia can vaccinate everyone by the end of next week, which I doubt).  Russia is already trending down following the first wave.  This will be easy to claim, for the less than scrupulous, as proof of vaccine “success.”  Differentiating that from mere biology will require a study that is probably not going to be run.  So again,  ¯\_(ツ)_/¯

–Will vaccines being developed by the West run into the same “proof of efficacy in the real world” problem if adopted in places that are through the first wave (even delayed) and probably have high herd immunity?  Yes.  Yes they will.  By the time the vaccines are ready, even including conservative UFC estimates from a few weeks ago, there is a good chance herd immunity is either very close or already reached in many places in the world.

—Perception of effectiveness is just as good as actual effectiveness.  At least if you are a politician.

–What about treatments?  Trials are still on going for many.  Check back later.

–In the US, the current situation is still a lot of green on the Johns Hopkins trailing new cases rate map.  That comes with a couple of caveats this week though.  First, I got a reader question last Friday about data integrity given the executive order to route new case numbers to HHS.  No sooner do I reply with “nah–the CDC is still getting data, and if numbers were a huge mismatch between official and what people are seeing on the ground, someone would blow the whistle” than California reports that its data collection system for local health departments up to the state level was a total cluster and they have no certainty on how many cases they have had or currently have, or where they are in the state.  To be clear, California may have fewer, as many, or more cases than reported and a positivity rate that is higher or lower than reported once they clear the logjam.  They have updated as of today for about 7 weeks worth of data.  Not sure I trust it yet.
The chief of the state health department in California fell on her sword and resigned early this week.

Florida is also cleaning up data from their previous overcounting debacle. 

Aside from those two states, there are no significant issues I am aware of.  Regardless, trend is down in most places.

The other caveat is Texas.  New cases are down in Texas overall, but so is their level of testing.  Testing numbers are falling faster than new cases, so Texas’ positivity rate is creeping up.  Texas is currently at a positivity rate we in Indiana were seeing back in March/April.  Florida and Arizona are a bit below that rate, and with falling cases.  In Texas, I think it may be where those cases are and access to testing.  Rates in the Houston area have dropped like a rock.  Most new cases appear to be in the BFE that you usually associate with West Texas.

In fact, feel free to imagine your own rolling tumbleweed in an otherwise empty endless desert here.

That tumbleweed is apparently getting COVID at an elevated clip.
This is pretty similar to the experience in Indiana.  Right now, Indianapolis and its suburbs are at or below the state positivity rate average.  Same for smaller metropolitan regions that were hit hard in March/April.  However, rural counties, particularly in the southwest and southeast of the state have positivity rates like we were seeing here in Indy in March/April. 

Like a dying fire, you are seeing the last warm orange glows chasing what little unburnt wood remains among the black and grey charred logs.
Herd immunity is getting closer.  How close, still not sure.

–Sweden is showing a very New York-like steady low state of cases.  No liftoff yet.

–So the Duke mask study made the news this week.  In short, neck gaiters (balaclavas) may increase the likelihood of spread when droplet size and dispersion was measured by a Duke team.  Regular surgical masks and N95, and even some knitted masks, all seem approximately effective in reducing droplet size and dispersion cloud.  I don’t consider this definitive, if only because I doubt Duke could get examples of all the different fabrics and manufacturers of neck gaiters out there.  I don’t think it should necessarily change behavior quite yet.  But it does create an opportunity for a neck gaiter manufacturer to differentiate from the crowd if they can replicate Duke’s method, but show their particular material and make reduces droplet size and dispersion.  

–The other big news, and perhaps driving decisions to postpone college football in some conferences, is reports of myocarditis following COVID.  Myocarditis is doctor for “inflammation of the heart.”  No, it’s not ideal.  There are reports of this in young, healthy people, including athletes, some of whom were asymptomatic, or mildly symptomatic.  That said, the vast majority of myocarditis and other cardiac complications after COVID is in people who were hospitalized with the virus and had underlying high blood pressure or heart disease already.  As you can imagine, the virus doesn’t tend to make that better.

It’s entirely too early to say how often this happens.  The medical school association for myocarditis and a virus is coxsackievirus B that presents anywhere from asymptomatic to GI disease, and in 3.5-5% of cases will have some inflammation of the heart.  Most of you have probably never heard of it.  Coxsackievirus B is everywhere already too.  By age 30, somewhere between 18-94% of people (depending on where, when and how sampled) have antibodies to at least one variant of coxsackievirus B.  Odds are good that if you caught it, you didn’t notice, and even if you had some myocarditis, you didn’t notice and it got better.  Most cases resolve without any lasting damage.

In fact, most experts believe cases of myocarditis (coxsackievirus B or otherwise) are underestimated.  The gold standard is biopsy of the heart, which is virtually never done unless symptoms are severe enough to warrant it.  Clinical diagnosis is made if there are symptoms like chest pain, heart failure, shortness of breath and elevated “heart attack” enzymes, or EKG findings.  The problem, of course, is most people who get myocarditis DON’T have it bad enough to have serious symptoms, let alone symptoms bad enough to check enzymes or get a biopsy.  Even these young athletes after COVID–my guess is these are being detected because they are getting routine EKGs as part of a sports physical, and have new mild abnormalities.  Even then, they appear to be pretty rare.  Some of them may have even had coxsackievirus B too–remember, it’s everywhere too. 

Again, the majority of patients with myocarditis after COVID appear to be those who were hospitalized and have underlying heart or blood pressure disease.

Exactly the patient you would get a follow up set of enzymes, EKG, echocardiogram etc. on after they got out of the hospital with COVID anyways, just as a precautionary follow up.  So if you were ever going to find a myocarditis you might not otherwise have gone looking for, a pandemic that gets your patient with underlying heart disease might just be the place…

Overall, too early to know for sure one way or the other A) how many are due to SARS-CoV-2 for sure, B) how common that is following SARS-CoV-2 and C) how serious they are, or are we just finding them because of populations already likely to get a few extra heart tests.  We’ll keep an eye on it.

–Following up other items we were keeping eyes on, still no definitive update on blood type and likelihood of symptomatic/severe SARS-CoV-2.

–We did have the Washington Post come out this week with the amazing discovery that prior exposure to other coronaviruses may explain why so many people get mild or asymptomatic disease, and why the magic herd immunity number may be less than 50-70%.

I’m blushing you guys.  Nice to have these updates read by the Washington Post itself.

–Dr. Fauci stated today that there is no medical argument AGAINST voting in person in November, although he caveated with “as long as proper precautions were taken.”  For what that is worth.

–In future Washington Post articles about amazing discoveries in SARS-CoV-2, further research on T-cell responses has been published.  Chen and Wherry aggregated and summarized T-cell response in those few studies that have been able to measure them, typically just a handful of patients at a time.

I have lifted the following figure from their paper in Nature Reviews Immunology:

So when you look the preponderance of available data, mild disease does indeed tend to produce the Th1 heavy response, with high interferon gamma and IL-2 (the two main signals).  That’s a fancy way of saying that the immune system is “choosing” the T-cell path to fight infection AFTER it has made it into a host cell, and emphasizing antibodies less.  Going back to leprosy, this is the path that BEATS leprosy.

That’s mild SARS-CoV-2.

Their immune system choosing poorly, severe COVID patients have less interferon gamma and IL-2 production and more IL-10, which shifts towards plasmablast hyperactivation and hyperactivation of certain classes of helper T-cells.  That’s a fancy way of saying “leads to immunopathology” on the bottom of the graphic and that is the “Ah-nold” like response.  And it leads to “inefficient” antibody response, as the authors put it.

The immunopathology from this poor choice may be so severe that you get the “exhausted like T-cells” mentioned in the top “severe disease” picture panel, as the few CD8 T-cells valiantly trying to fight the virus INSIDE your cells wind up going it alone, as the rest of the immune system is off on the wrong path.

So the authors conclude that severe disease patients have either insufficient T-cell responses (a wrong choice overemphasizing antibodies, even decreasing the total numbers of T-cells) or hyperactive (going “Ah-nold”) responses.  That data is limited, but does seem to be a theme among the studies they were able to string together.

Plus, it agrees with me, and confirmation bias is just a wonderful, wonderful thing.

The next step is identifying whose immune system is apt to choose poorly, or is choosing poorly, and how to get it back on the right track. 

–In social issues, Ben Hunt at Epsilon Theory has posted Part 2 on modern day grifts, this one on N95 mask availability.  You may want to check it out. 

Love in the Time of Coronavirus:

–Your chances of getting Ebola are equivalent to the chances that you saw that update on the Las Vegas mass shooting, as they are closer than ever to figuring out what motivated it, and who, if anyone, else was involved.  Yeah, remember that one?

–Your chances of catching coronavirus remain excellent most places in the world.  In some, they are going up (looking at you Europe).  In others, decreasing some.  But overall, pretty good.  Continue to be prudent.

<Paladin>