Ebola–The WHO is late with updates.  From what I can piece together from very limited news coverage, sounds like we are up to 56 confirmed cases.  Hopefully there is more to report next week.

Bubonic Plague–  Also very little to report on the plague front.  I can’t find any solid updates on cases in China and Mongolia, which strongly suggests there are not more of them (and in fact, the ones being treated are either out of the hospital by now or should be soon).  There were some headlines last weekend about a human case of plague in Colorado.  Remember, yes, there are a few people in the US every year who get plague.  This person apparently caught it in southwest Colorado earlier this year, was all treated, and has already recovered.  The squirrels of Colorado have not managed to infect anyone since one of them tested positive.

Coronavirus–  Yeah, still quite a lot.

–First, let’s lay down the following facts as they stand:

1)  SARS-CoV-2 is the virus that causes COVID, the spectrum of symptoms that starts flu like with fever, cough and sneezing typically 2-5 days after exposure (but as late as 14 days in some rare patients).  SARS-CoV-2 is a coronavirus, and thus member of a family responsible for causing the common cold.

SARS-CoV-2 is as infectious as the common cold, and spread by both aerosol and droplet routes.

Other symptoms of COVID include loss of taste and smell, and kids seem to get diarrhea a little more frequently.

2)  Many people exposed to SARS-CoV-2 will never develop symptoms from it.  They won’t even know they have it.  This may be 50-65% of people, depending on your source, but it’s a huge number.  This is consistent with laboratory evidence that there are immune cells in many people trained from previous infection with other, similar coronaviruses, that react to SARS-CoV-2 as well.

3)  Some patients, however, will develop a problem.  This appears to be due to a combination of the immune system reaction to the infection, causing sepsis-like complications, or other immune related complications such as Kawasaki (like) syndrome in kids (rare, even with SARS-CoV-2) and “COVID toes” from hypercoagulopathy spurred be either/and SARS-CoV-2 infection of cells lining blood vessels and immune reaction to that.

4)  Patients most likely to develop a problem are older (the risk of mortality goes up over 50) and check one or more of the following boxes of co-morbidities:

o–Obese

o–Diabetes

o–Severe heart or lung disease

o–Hypertension

o–Immunosuppression

o–Cancer

5)  There are patients who do not check those boxes who still wind up in the hospital with SARS-CoV-2.  They are the rare exceptions to the rule.

6)  The risk of mortality is heavily skewed by age.  Most deaths are concentrated in the 80+ category.  Even then, more 80 year olds will catch COVID and survive than will die from it.  Starting around 50/60+ is when you start to see an uptick in mortality over the flu at all.  Indeed, overall CFR appears comparable to a bad flu, when mild cases who are not getting tested for disease confirmation are factored in, and low single digit mortality overall if looking only at confirmed cases.

7)  Unless you are in the high risk categories above, the risk to YOU is very minimal.  For example, 166 kids died of flu last year.  SARS-CoV-2 is not any higher than that.  CFR in the under 50 crowd is comparable to flu or less dangerous than the flu.  In fact, the pediatric age cohort is consistently the least affected by either symptomatic disease or severe disease.  You read about kids sick with COVID only because they are uncommon enough to be newsworthy (and they attract eyeballs and attention, which is the business model for those writing the headlines).

8)  People who do not get symptoms, or mild symptoms, recover completely from SARS-CoV-2.  Those who get a pneumonia from it, especially requiring hospitalization, are more prone to lingering effects.  These lingering effects do not appear to be quantitatively or qualitatively different than recovery from any severe community acquired pneumonia of any cause (as we reviewed last week).

9)  The risk to public health of the virus is its high transmission rate coupled with a chance of hospitalization of infected people, particularly those checking the risk factor boxes above, that can occupy all available hospital beds in a region.  If you are NOT in a high risk group, it is this public health risk from sheer transmission rate that is the direct threat to you.
10)  It is sufficiently infectious that contact tracing is useless.  You cannot isolate the virus via known contacts–the virus is already far too ubiquitous globally for that, and again, spreads like the common cold.

Why a review of those basic facts?  Because a reader question this week is “how ‘back to normal’ are you?  It would be useful to hear.”  So first, we need to be clear about the nature of SARS-CoV-2 and COVID.
Building off of those facts, this my personal situation:

–I have none of the high risk factors to suggest that SARS-CoV-2 is much of a threat to me personally

–Nor does anyone in my immediate family, living here in my house.

–I am not in routine close contact with ANYONE who meets those high risk factors

–Nothing actually changed much for me in the pandemic, quite honestly.  I still go into the office, and in fact, was in the office more frequently and much longer at the height of the March/April wave, where most of the hospitalizations, positivity rate, and mortality occurred.–Perhaps most significant for me, there is a high probability, to the point of near certainty, that I have been exposed to a dose of SARS-CoV-2 sufficient to cause COVID already.  And probably more than once.  I haven’t said anything about this before, because A) I never got symptoms to be certain, and since I had no symptoms, getting tested was mostly pointless from a medical standpoint.  And B) my mother reads these, and didn’t need to worry. 

We had one scientist in the lab who tested positive (with symptoms) within a few days of us starting to bring up testing.  This scientist got it on the outside (we were not handling virus at that point yet).  But I was in the room with a half dozen other scientists for about two and a half hours going over operation of the automated extractors we had gotten to support testing, all of us huddled around one machine while the technical rep walked everyone through its use.  I even remember that it was the scientist who wound up testing positive being the one to hand me lab glasses (I had forgotten to grab mine racing from my office back to the lab). 

I can’t remember if we were wearing masks or not.  I know we were conserving what we had, because that was back when getting them was a little challenging, and we would need as many as we could scrounge for when samples started to roll in.  “Social distancing” was just getting started, and we did what we could, but you had to be closer than 6 feet in the lab space we had when we were getting testing started. 

Now, that scientist is a little older than me (but not enough to be at high risk based on age alone).  They had a distinctly “nasty flu” like experience, but did not require hospitalization.  This scientist is back at work and right as rain–no apparent lingering effects.

Not one of the half dozen with me in the room with that scientist ever developed symptoms.  One or two may have been tested shortly after (it was optional to get tested if you did not have symptoms), and they were all negative.  Even when I go back retrospectively with my Whoop strap, which has been used (based on increased basal respiratory rate, which it can detect) to suggest COVID in golf pros, leading to everyone on the tour getting a Whoop strap, my basal respiratory rate has never been in a range suggesting I had COVID.

The second definite exposure (and the one that got me banished to the guest room for about a week) was another physician I was working with very closely on the project and was around a lot.  This physician had decided that catching the virus was inevitable given the transmission rate and the fact Pandora’s box was open, and decided to science.  The doc snuck into the testing line to get a “baseline” sample, sure it would negative (no noticeable symptoms).  Of course, it was positive.  I was accused of having discovered that they had done this, and playing a practical joke with the test result and had to explain, no, I had no idea they had snuck into the line.  Only in retrospect did this doc conclude that a little bit of chest tightness the few days before (attributed to stress of what we had going on at the time) and maybe a rare cough or two were the only symptoms.  All of which resolved in the following week.  Of the close contacts of this person who elected to get tested (again, I did not–no symptoms, and again, nothing on my Whoop strap retrospectively suggesting I was secretly ill), none turned positive.  A couple negative tests later, and this physician was back to work a week later.

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–Demographically, that would fit.  The highest risk folks worked from home at the height of the March/April crush, supporting the mountain of paperwork our testing was generating.  Everyone else, all volunteer, were in low risk categories.  Even if we “caught” SARS-CoV-2, asymptomatic or distinctly mild (like my fellow physician) symptoms were MOST LIKELY, given what we know about the virus.

–If I have been exposed, there is a high probability that my family here in the house has been as well.  It’s basically unavoidable, even if you quarantine.  Current reports in the literature all strongly suggest that its family you are living with that is most likely to spread the virus to you.  Plus, my wife is a physician and back in office.  Although her office takes precautions, odds are great they have had patients either asymptomatic or immediately presymptomatic into the office already.

–None of us in the fam have had symptoms suggesting COVID.  Given the demographics, even if we did have SARS-CoV-2, asymptomatic “infection” was highly likely.  In families we have tested for COVID, that’s not uncommon.  3 will have PCR evidence the virus is there; only 1 might have symptoms–and is the only reason ANY of them are getting tested at all.  There are likely entire family units out there where the virus was there, but everyone was low risk, and beat the virus with NO ONE developing symptoms.

–So, add all of that up, and what you do you get:1)  The virus is not likely to be an unusual morbidity or mortality threat to me or to people I am routinely in close contact with2)  There is an excellent chance I have been exposed to a dose of SARS-CoV-2 already that could (should?) have caused COVID, if I was ever going to develop COVID.  If I have already been exposed, and am immune, I am at low risk of transmitting the virus to others.

–So to (finally!) answer the question with all of that in mind, here is what we are doing:

I go to work every day, unless our regular babysitter is unavailable on one of my wife’s clinic days, and then I cover as much as possible from home.  At work, I follow the social distancing rules and mask rules as often as I remember to do so.  My kids play with the kids on the street pretty routinely, except for a couple families who have not made that same choice.  Their school is planning to go back physically, following the now statewide mask mandate, with partitioned seats, lunch and afterschool care COVID plans, and a lot of outdoor classes as the summer weather here permits.  I have no problem with any of that.  Kids are the lowest risk demographic (if I were one of the teachers and at high personal risk, I would make arrangements to Zoom into classrooms, maybe distributing kids physically among the less at risk teachers to make that happen, or giving those teachers all the kids planning on e-learning for awhile).  The kids are also back to in person Tae Kwon Do and swimming classes.  My daughter has been to a birthday party.  All of those activities have strict mask and social distance rules that fit the activity to minimize risk of spread.  I am cool with all of that.  I am (finally) back to jiu jitsu in the last couple of weeks.  That’s a close contact sport, and you cannot train alone.  The rust shows, and really, it’s only my atypical work schedule that does not have me back on my exact pre-COVID typical jiu jitsu schedule.  I feel perfectly fine with jiu jitsu too–demographically, everyone at the gym has self-selected as people fit enough to be doing it (most are younger than me), and if it were really that easy to catch respiratory viruses doing jiu jitsu, flu should cut through my gym like a scythe every year.  It hasn’t at any point in the last 2.5 years I’ve been there.  In fact, and I was discussing this with some of the black belts the other day and they have never seen a flu epidemic race through a jiu jitsu gym.

Now, we would usually go out for lunch after church pre-COVID.  I haven’t been inside a restaurant to eat since March, and don’t plan to start again any time soon. Carryout works great.  Also totally using the continuing special dispensation to Livestream church–not that I would be concerned attending church given the spacing precautions and mask requirements they have, but more because online livestream is way more convenient than hounding kids into the car to be on time.  When I go into a store, be it grocery, hardware, whatever, I wear a mask.  Also wear a mask when I go to the barber.  Just a few weeks ago, we let the kids do a week at summer camp we had scheduled pre-COVID, since that camp was still open with COVID restrictions.  Over the fourth, we went to my in laws place in Florida (by car)–we had that largely to ourselves.  That was beach–house–grocery store only, masks at the grocery store and all gas stations on the way down and up.  Meals on the way were McDonalds or what we packed to minimize stops.  We did not quarantine coming back from “hotspot” Florida just because we had been there.

Flying domestically to me is still a little dicey at the moment.  That said, still planning to fly to Arizona for the rescheduled birthday trip in October.  I fully expect to be wearing masks for that though.

And yes, I wear a mask in all of these situations.  No, I don’t consider it an excessive burden.  And yes, I wear it even though I don’t perceive myself to be at especially high personal risk from the virus, or particularly high risk to others by inadvertent transmission.  People I might run into know I am a doctor, and it sets a poor precedent if I am not wearing a mask–I do not want to give license to those whose personal circumstances and risk factors suggest they SHOULD be masking up to not wear one, saying “well, we saw that the doc wasn’t wearing a mask so why should we?”  Wearing a mask socially also makes it easier for those in high risk categories who are out and about because they have to be to wear one, and not feel like lepers.  Not a burden to me, and helps out others.  Imma do it.

–So that’s super long, but that’s where I am at in terms of “normal” and “what are you doing right now.”  I also wanted to shed light on my entire thought process on that too though.  Because if I were in a high risk category, or living with someone in a high risk category, or a frequent care giver for someone in a high risk category for SARS-CoV-2 morbidity and mortality, I might be doing a few things differently–mostly to minimize the chance that I inadvertently catch the virus and pass it along to them.

–My answer to the “Black Death” Choose Your Own Adventure has been, has always been, “go on about your regular life–just don’t put yourself in obvious danger of the disease”.

Your perception of risk versus your activities will vary, and will need to be suited to your circumstances though.

–In other news, activity in Africa especially remains high.  Spain is seeing foci of COVID re-emerge (no surprise there, and I suspect other parts of western Europe will catch the “lockdown interrupted first wave” that the US is seeing too).  Tokyo continues to have new cases.  There are parts of China reporting new cases as well.  In the US, California appears to be finally near its peak.  Same for Florida.  Texas and Arizona cases are starting to fall, as are the Carolinas.  Mississippi is your new hottest state, although Nevada keeps climbing its peak.  In the Midwest, Ohio has hit its peak.  I suspect Indiana will be there either this week or next.  Deaths continue to rise via sheer force of numbers, but the death rate is struggling to meet the CDC definition of epidemic right now.  Same for hospitalization and ICU use.  Some local areas are swamped, sure, but only by sheer force of numbers.  The percent of positive tests remains stubbornly stable.

–Indiana’s numbers are a good example.  Right now, daily new cases are as high or slightly higher than the March/April peak.  Back then, 20% of daily tests being positive was about average.  Despite the rising nominal cases right now, the % positive is only about 8%.  Marion County (Indianapolis) is at 10%–in March/April, easily double that.  Despite the rising number of positive cases, ICU use for COVID patients remains very steady, and nowhere close to threatening to overwhelm the system.  There are plenty of ICUs to go around in Indiana right now.  Hospitalization rate is up slightly from June, but only slightly, and is rock solid steady even as daily new cases have been increasing.  This reflects greater availability of testing, and more of the mild/asymptomatic cases getting detected.  The population testing positive is younger, and the disease is being managed better (now that we have the experience of March/April) and more quickly.  The headline numbers are not telling the entire story. 

–Here’s the other thing.  All these states experiencing this “lockdown interrupted first wave”?  Including CA, FL, TX?  They are all going to look like NY going forward, in that additional outbreaks, if any, will move from state/city level to even smaller levels.  Only pockets where the virus has, somehow, managed to not reach in force yet will be susceptible.  Stories crediting how well NY handled the crisis will age about as well as stories about how CA had kept cases low back in March/April. NY looks great now because it looked terrible in March/April, as the first wave crested there before lockdowns could create any kind of delay.  As a result though, enough areas in NY have sufficient herd immunity that new “delayed first wave” or even “second wave” outbreaks will have difficulty finding a foothold.  So it will be for much of the country by the end of the summer–that is now my base case.

–In fact, there is yet another epidemiology model that I am not going to link because it is pre-peer review (and a model, so wrong, but possibly useful) that was suggesting that if some of the laboratory work on “cross over” immunity from other coronaviruses (or maybe other immunizations) and their prevalence in the community is correct, and based on the experience of some especially hard hit regions, only 20% of the population needs to survive exposure to the virus for herd immunity to be met.  In essence, the authors’ argument is that innate resistance is so high in the population already (the high number of “asymptomatic” cases of SARS-CoV-2), the susceptible population is really far smaller than initial projections assumed.  Now, I doubt 20% is the magic number, if only because we would not be seeing the continued second waves that we are right now.  But, bear in mind that the “magic number” to herd immunity may be lower than 50-70%.

If so, my UFC, back of the envelope projections for how many have already been exposed (and what percent of the population is being exposed every week) that suggested something like 26-53 weeks to 50-70% herd immunity is very conservative.  We could be there much quicker.
Indeed, even the CDC was out there this week (using data collected in Indiana, incidentally enough) reporting that the number of people already exposed to the virus may be at least 10 times greater than the number of confirmed positives.  This is because of factors we have described before–not everyone exposed gets tested, not everyone knows they have been exposed to get tested, not everyone with mild symptoms gets tested.  If the true number is higher than that (and it could be), and innate resistance (or pre-existing cross over resistance from other similar coronaviruses) is higher than initially suspected, herd immunity may be closer than 50-70%.  How much closer, not sure.  And how close are we to whatever that magic number is, not sure either.

–A really interesting study would be incidence and severity of COVID among grade school teachers and pediatricians.  After all, sustained close contact in a confined space with limited air circulation among a population not especially prone to good hygiene and social distancing (grade school) is indeed a good virus incubator.  We talk about “germy elementary school kids” all the time.  But could it be, could it possibly be, that this is why they are actually LESS affected by SARS-CoV-2?  Because they circulate and catch all the other similar coronaviruses already, and have high incidence of crossover immunity, and/or an immune system, despite being young, with good recent practice selecting the “right” form of immunity to avoid Ah-nold situations with coronaviruses?  Is this also why the age demographics most likely to have school age kids also seem to be at less risk from SARS-CoV-2?  Because they got exposed to all those similar coronaviruses their kids were swapping in school?  If so, school teachers and pediatricians should ALSO have relatively high innate resistance to SARS-CoV-2 from cross over immunity.  I wonder if anyone has looked at that yet?  If you find out, let me know!

–Speaking of studies, there is a publication out in the Lancet looking at the top 50 countries in terms of number of cases to see what variables were associated with higher cases and what with lower.  You can find the report here:  https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30208-X/fulltext

The long story short:  rapid border closure, full lockdowns, and wide-spread testing were NOT associated with reduced COVID-19 mortality.  They didn’t make it worse, but they did not improve mortality either. 

Early border closure reduced the total number of cases (so far) though, and full lockdown (versus partial or none) and a better healthcare system increased patient recovery rates–even if increased recovery rates had no influence on mortality rates.

Again, my suspicion is that your ONLY chance to keep a virus with the contagiousness of the common cold contained is at the VERY beginning, when there are only a handful of cases in a very small geographic space where you can adequately find and contain everyone exposed or possibly exposed.  Once something that contagious is out, and leaping borders, your chance has likely passed.  That was the catastrophic failure of China last fall. 

Well, I take that back.  If you are a tiny island, with a small population, and thus only a few places people can really go, plus only a few ways in or out of the island, you can probably pull of a Taiwan or New Zealand.  Basically, trace down the few cases you start with and isolate them.  Then everyone coming to your island by boat or plane gets mandatory 14 day quarantine.  Do that, and you can keep the virus off your island.  There are VERY few places in the world that will work though.

Back to the paper, obesity was the single biggest predictor of mortality in these countries.  Higher median country age and higher prevalence of obesity were also associated with a higher number of COVID cases. 

Interestingly, less income inequality was associated with lower mortality. 

IMPORTANT:  The biggest limitation of this study though is that all of this is correlation.  None of these factors may actually be causative of higher or lower rates–merely associated with them.

–The Oxford COVID vaccine group published their Phase 1/2 study this week, also in the Lancet.  With the Phase 2 component, there are a lot more patients.  You can read for yourself and decide how similar to other vaccine publications we have mentioned so far.  Again, I am going to refrain from too much comment.

But, this is another vaccine that measured T-cell response.  Turns out, their vaccine provoked a T-cell response too!  In fact, it appeared sooner than the antibodies.

Am I mentioning this because it agrees with my pet hypothesis that T-cell response is more important for innate or acquired immunity to SARS-CoV-2?

Absolutely!  I mean, it agrees with my idea, so warm up the Nobel Prize Committee–this is clearly genius!  Best study ever.  Best results ever.  Possibly, possibly, the finest scientific reporting in the entire history of science : )

BUT THAT’S NOT ALL!

Reports in the BBC this week (could not find the source paper though) that injection of interferon beta (IFN beta), an immune system signal, reduce morbidity and mortality from COVID dramatically, especially in early disease. 

If true, well, guess which immune response IFN beta favors–T-cells or antibodies?

YEP!  T-cells!  More anecdotal evidence that agrees with me!  Clearly right. 

Clearly.

Now, slightly more seriously, the way to falsify my hypothesis would be to get a bunch of patients who just got SARS-CoV-2.  Serially test them for the signals that indicate their immune system is favoring T-cells vs antibodies.  If there is no difference in the proportion of them that go on to develop COVID, or if the antibody “choice” has a lower proportion of patients that go on to develop COVID, then my hypothesis is disproven.  Finding those patients, and enough of them, and testing them like that is a logistical nightmare though.  But it would be interesting in terms of the pathology, and better understanding who goes on, and how, to more serious disease with SARS-CoV-2.  It would also be important in understanding whether we need to test for reactive T-cells or antibodies (or both) to know who is truly immune already, and who needs a vaccine (or if the vaccine worked to provoke the correct response).

–Finally, more and more cities and states are adopting mandatory mask policies.  To be clear, when properly worn, a mask WILL reduce your chances of contracting SARS-CoV-2, and thus, COVID.  It will also reduce your chances of spreading SARS-CoV-2, should you contract it.  I wear a mask–often, as detailed above, and for the reasons above.  If you are a high risk individual, or around them a lot, yes, you should absolutely be wearing a mask.  It’s not an onerous burden, and protects both you and high risk individuals you encounter.

For those objecting that mask mandates are an unconscionable infringement of inalienable human rights, I will carefully consider such a principled argument on the proper limit of government in respect to the boundaries of individual liberty…

…after those making it dump all the slushee mix from the nearest 7-11 into the harbor in protest of the business’ tyrannical insistence that shoes and a shirt be worn for service.

And ONLY after.

On the other hand, there is an interesting dichotomy to mandatory mask orders.  While a mask will offer some protection on an individual level, and to those individuals you work with, a mandatory mask order as a public policyand on a population level has worked like this:

Governor Newsome of California instituted a statewide, mandatory mask policy on June 18, 2020 to slow the increase in new cases of SARS-CoV-2 in the state.  Since then, cases in California have ONLY increased, and at a more rapid rate than before mandatory masks became statewide policy.  You could try to argue that the policy slowed the rate of increase, I guess, but that’s a pretty steep increase already.
Nor is this restricted to the state level.  Here’s Marion County (Indianapolis) Indiana:

Marion County instituted a countywide mandatory mask policy on July 9th.  Since that time, cases have only gone up.  In fairness to Marion County, that mandatory mask policy is pretty recent to have shown any effect it might have–but this is the week when things should be leveling off if mandatory mask policy is effective public health policy, at least for the aim of reducing the total number of new cases. 

I have no idea why something that works clearly, and demonstrably, so well on the individual level does not translate up to the aggregate population of said individuals.  Yet, here we are.

But, if you are a politician, dealing with rising SARS-CoV-2 cases in your data, and now you need to do something and lead boldly and make data driven decisions to protect the public interest–a mandatory mask policy is great.  Because it’s easy to do–including for you, letting you show your “get in the trenches too” leadership!  Even better, a mandatory mask policy does NOT require you to do painful things like re-close businesses or try to convince your constituents to lock down again (which might look like maybe you screwed up the first time).  Because a mask is individually effective, a mandatory mask policy looks like a clear and sensible step in response to this troubling increase in SARS-CoV-2.

Is it effective as a public health policy?  Very debatable so far.  But what do you care?  As long as you are perceived by your constituents as being effective, that is just as good as actually being effective.
They should re-elect the hell out of you for your wise and decisive leadership in a time of public health crisis.  They really should. 

Mandatory mask policies–they are what they are.  Look at it as a way to take a step to protect yourself and your close contacts and wear the mask when they ask you to. 

–Your chances of catching bubonic plague remain proportional to your insistence on handling dead rodents.  If that’s your thing, you should probably find a new thing.

–Your chances of catching Ebola are equivalent to “Introducing the First Lady of the United States of America . . . . . Kim Kardashian.”

You’re laughing now.  Just remember, it’s 2020.  Anything is possible.  Anything.

–Your chances of catching coronavirus in most parts of the world remain equivalent to “Shoeless, Shirtless Florida Man Charged With Illegal Dumping And Mandatory Mask Order Violation After Slushee Mix Found In Local Harbor.”

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