The virus is not going away anytime soon so we have to adjust how we live in order to cope.
By Allan Maynard – June 12, 2020
We have been living with the CoVid-19 virus for over 6 months now and it is still a mystery in many ways. While governments around the world are looking at ways to open up their economies, the scientific community is urging caution and trying its best to keep current with developments. New information is published almost daily – in what many are calling ‘fast science’. Unfortunately, scientists are also having to battle misinformation and wishful thinking coming from some political leaders along with wacky conspiracy theories that are multiplied through social medial platforms – (see previous article on this web site).
The CoVid-19 pandemic presents one of the clearest examples in modern history regarding the critical need for evidence-based decision-making. In terms of leadership around the response to this pandemic, we are witnessing first-hand – the good, the bad and the ugly. And leadership is critical. Some areas are now benefitting from flattened coronavirus curves. Meanwhile, parts of the US, India, Russia and Latin America are still recording thousands of new cases every day. The first wave of the coronavirus is not over. If anything close to this trend continues, we have to wonder what the threshold will be for many areas to reinstate stay-at-home orders and close businesses again, just as they are starting to reopen.
The future shape of the pandemic will be decided by informed leadership, human action in the form of social distancing and hygiene, testing and other traditional methods of disease control, but also gaining more knowledge around several unanswered questions about the nature of the virus itself.
WE KNOW WHAT WORKS TO LIMIT INFECTION RATES — For countries that implemented highly effective interventions such as testing and contact tracing, this first wave of coronavirus cases may be the last they experience, at least for some time. For one example, New Zealand, has managed to virtually eradicate the virus, acting early to implement a lock down and installing robust systems to monitor outbreaks. The country will likely be able to avoid future waves until a vaccine arrives.
Countries with small populations and isolated geography such as New Zealand and Australia may be able to pull this off. South Korea and Taiwan also provide examples whereby virus detection and suppression systems may be advanced enough to smother any future outbreaks. But this will be extremely difficult for most countries, especially those with large populations and porous borders.
We have been fortunate to have such good leadership in BC. We are successfully entering the first phase of re-opening and the numbers of new cases are falling significantly. Moreover we were able to avoid overwhelming our medical facilities. So again – early intervention, science based leadership, adequate testing and contact tracing proved successful. It is worth looking at some numbers (from June 11, 2020) for BC, Canada, USA, Washington State (as this is closest to BC) and New Zealand as mentioned above.
Cases /M population
M – million
We can see how successful New Zealand has been even though it is an isolated country and had some advance warning. However it is clear that strong and effective leadership, made the difference. That applies to BC as well. The messaging has been factually constant, consistent, and considerate of people’s concerns. In the messaging, kindness to one another was constantly emphasized and most BC residents have cooperated without reservation.
To further re-enforce this message of what works is a large study recently published in “Nature” concerning 11 European countries. The authors state the following: “We estimate that, across all 11 countries, between 12 and 15 million individuals have been infected with SARS-CoV-2 up to 4th May, representing between 3.2% and 4.0% of the population. Our results show that major non-pharmaceutical interventions and lockdown in particular have had a large effect on reducing transmission. Continued intervention should be considered to keep transmission of SARS-CoV-2 under control.”
UNDERSTANDING TRANSMISSION – From the early days of this pandemic, the experts have recommended wearing masks, staying at least six feet away from others, washing hands frequently and avoiding crowded spaces. What they’re really saying is: Try to minimize the amount of virus we encounter. It’s likely that a small amount of virus particles will not make us sick as our immune system would react and vanquish the invaders.
But how much virus is needed for an infection to take root? What is the minimum effective dose? A precise answer is impossible, because it’s difficult to capture the moment of infection.
Not surprisingly, the current body of knowledge is clear that the worst-case scenario for outbreaks have occurred in care homes, cruise ships, prisons, factories, places of worships, large office settings and more – all as a result of people indoors and in close quarters, for a period of time. One oft-quoted case was a choir practice in Washington State wherein one infected person spread the virus to 87 percent of the choir members – with 2 members dying. Recently, in BC Provincial health officer Dr. Bonnie Henry revealed the isolation of an outbreak that erupted as a result of a family dinner inside (and outside) a residence. Of the 30 people at the gathering, 15 have become infected.
There is now a growing concern that the recent protests in cities around the world will also cause spikes in infection rates. Especially worrying is the use of tear gas, which makes people cough whilst in close proximity to one another. There are also major concerns about the prospect of political rallies related to the upcoming election in the US. The first one – an indoor event, is planned for June 19th in Tulsa, Oklahoma. This plan goes against all scientific advice, as it’s likely to produce a virus fog within the facility. The organizers know this and in fact those planning to attend the rally will be required to indemnify the Trump campaign and others involved in the event so they will not be able to sue if they contract coronavirus.
The Achilles Heal – in understanding transmission is the fact that people who are asymptomatic or pre-symptomatic are nonetheless spreaders of the virus. For example, one study published (early June) in the Annals of Internal Medicine suggested asymptomatic people seem to account for 40 to 45 percent of CoVid 19 infections and they can transmit the virus to others for an extended period of time. Another study found 23 percent of transmissions in Shenzhen, China were from asymptomatic people. Also, a study published in Nature found people shed the virus most when their symptoms are mild (likely pre-symptomatic).
Apart from avoiding crowded indoor spaces, most experts are now claiming the most effective protocols are to practise good hygiene and to wear masks. Even if masks don’t fully shield us from droplets loaded with virus, they can cut down the amount we receive, and perhaps bring it below the infectious dose.
SO MUCH MORE TO LEARN – There is so much more to learn about the CoVid 19. It is reassuring to know that there are significant research undertakings on many fronts and in many countries that should provide better tests, drug therapies, a clear understanding of immunity and hopefully an eventual vaccine. All this will take time. Some points:
Immunity — Recent data shows that fewer than 10% of populations in countries studied have developed the antibodies that would be evidence of having caught the virus and, in theory, becoming immune for at least a short time. That also means the vast majority of populations remain susceptible.
Immunity – There is not yet a clear understanding of immunity to the CoVid 19. Resistance to some earlier discovered coronaviruses has been thought to fade within a year. This could be a concern with respect to a vaccine if the resulting immunity is short-lived.
By age – CoVid-19 is definitely a disease of the elderly. Recent analysis is showing that the chance of a person over 75 dying from this disease is 10,000 times likely than it is for a 15 year old.
Children – Emerging evidence suggests children are not significant transmitters of Covid-19. These data, coupled with the enormous adverse impacts of continuing closures, argue for reopening schools by fall of 2020. Of about 400,000 Covid-19 deaths worldwide, only about two-dozen children are known to have died. Moreover reports of serious complications among young people are statistically rare and, if detected early, most afflicted youths recover within weeks. It is hoped that more will be learned from the recent partial reopening of schools in many locations that can thereby help to aid in decisions for a more widespread opening.
Drug Therapies – Trials are now under way for a number of antiviral drugs that were developed to deal with other diseases but are now being repurposed in the hope that they can be used to tackle Covid-19. Results are expected in a few months. If successful, some of these could help cut death rates. It should also be noted that hydroxyl-cholorquine, despite the very strangely hyped promotion by President Trump appears to be an unlikely therapy and may even cause heart issues when used.
Vaccines – the holy-grail – At last count there are over 100 initiatives around the world to develop a successful and effective vaccine. With testing underway on five short-listed experimental vaccines in China and four in the United States, the race to produce a vaccine for Covid-19 has taken on political dimensions that echo jockeying for technological dominance during the Cold War. Moreover – both countries are also taking huge financial risks to scale up production of possible vaccines even before they know any are safe and effective — a gambit to ensure their citizens won’t have to wait. “We’re going to start manufacturing doses of the vaccines way before we even know that the vaccine works,” Anthony S. Fauci said in an interview with the Journal of the American Medical Association. Most experts agree though – the prospect of a vaccine is IF – not WHEN. They also predict that it will be at least another year away. But who knows, perhaps with so much effort worldwide, it could come sooner. We can only hope.
Seasonality – Most influenzas spread more easily in the winter because the virus is thought to prefer dry air over humidity, and because people in cold environments spend more time indoors and close to each other. Existing coronaviruses (common cold) also follow seasonal patterns. If this coronavirus behaves in the same way – and there is not yet strong evidence that it does – we could see some improvements at least in the Northern Hemisphere. However these is significant information to contradict this hypothesis. CoVid 19 infections are increasing in many warm climates – such as Brazil, Texas and Arizona. The point is, the vast majority of people around the world are still susceptible.
It can seem very discouraging indeed to face the prospect of having to deal with this pandemic for an undetermined period of time. However there’s a degree of hope with respect to drug therapies and vaccines. Moreover we know what we must do to control and even contain this virus. We are learning to take the needed intervention measures and yet still return to some semblance of normality. We should in time be able to safely open schools, do some limited local travel, have small groups visitors in our homes and most importantly see loved ones that we have been separated from. However, we must be prudent to note that most of society is still susceptible. Thus – a return to political rallies, major sporting events, concerts, extensive air travel, cruising, and hosting large gatherings, will (or should) not be considered for some time. Our elected leaders must recognize this reality and adhere to the advice coming from the medical experts. As we can see from the numbers presented in the table above – leadership and societal cooperation make the difference.
The CoVid 19 pandemic presents one of the clearest examples in modern history regarding the critical need for evidence based decision-making. Unfortunately, the presentation of scientific evidence has often been undermined by deadly denial (see paper – on this web site – Deny Delay Deadly), misinformation about the consequences of such denial and even outright wacky conspiracy theories. As citizens and voters, we need to be vigilant in seeking out the truth by using trusted sources.
A documentary-style video called ‘Plandemic: The Hidden Agenda Behind COVID-19′ has been removed by social media platforms after peddling potentially dangerous conspiracy theories about the coronavirus pandemic. The documentary features a Dr. Mikovits’, a discredited scientist who states that the coronavirus pandemic was planned. In the video, she claims that the virus was created in a laboratory, that wearing masks actually makes people sick, and that flu vaccines increase people’s odds of contracting COVID-19. No medical or scientific evidence exists to support any of Mikovits’ claims in the video.
An even more whacky conspiracy claims that the pandemic is really caused by the rollout of 5G (high speed -5th Generation Cellular) networks around the world. Despite there being no scientific links, a number of 5G towers have been set on fire. The 5G conspiracies make no sense whatsoever. The virus is spreading in countries without access to 5G – in other words – the correlation falls apart.
It is indeed a head-scratcher to understand the motivations for such nonsense let alone fathom how these wacky theories gain traction – but they do. And with social media, the false information spreads quickly. Our willingness to share content without thinking is exploited to spread various forms of disinformation.
It does not help when we have world leaders also peddling misinformation. When the President of the United States promotes unproven drug therapies and even muses about injecting sanitizing chemicals to kill the virus, the implications are worrying. The scientific community is understandably growing increasingly frustrated. This frustration boiled over when, on May 16, the Lancet, perhaps the preeminent international medical journal, took an unprecedented step and published a front page editorial calling on the US administration to properly recognize science and even concluded by stating “Americans must put a president in the White House come January, 2021, who will understand that public health should not be guided by partisan politics.”
The lack of evidence-based leadership in the USA, the UK, Russia, China, Brazil and others has resulted in enhanced infection rates in these and other countries. For example, Brazil, led by a full-on anti-science president, now has more CoVid cases than China. The United States accounts for about 4.25% of the world’s population, but currently has about 29% of the confirmed deaths from the disease.
What we are dealing with here is a pandemic of information disorder. It has sprouted a whole new area of investigation in how lies originate and spread. Generally, the language commonly used to discuss misinformation problems can be too simplistic. Effective research and interventions require clear definitions, yet many people use the problematic phrase “fake news.” Used by politicians around the world to attack a free press, the term is dangerous. Recent research shows that audiences increasingly connect it with the mainstream media. It is often used as a catchall to describe things that are not the same, including lies, rumours, hoaxes, misinformation, conspiracies and propaganda, but it also papers over nuance and complexity.
The 3 main categories of untruths is well presented in a paper by Clare Wardle in Scientific American entitled “Misinformation Has Created A New World Disorder” The following schematic is from this article.
Most of what we are dealing with in the context of the science associated with CoVid 19 crisis and in the push back against climate change science is mainly that overlapping area in the circles of misinformation and disinformation.
Understanding the motives for the lies
For the most part, the misinformation and disinformation can be understood in terms of the motives of those initiating the falsehoods. Withstanding the wacky conspiracy theories the motivations regarding the falsehoods by politicians are not all that difficult to discern.
Initially – the motivations were all about money. The denial or initial downplaying of the CoVid crisis by a number of leaders (USA, UK, Russia, China, Brazil, Italy and more) is well documented and for certain linked to a determination to protect markets. See paper on this web site – Denial, Delay, Deadly. Of course we all know now that the denial strategy backfired.
Now that the virus has spread around the world, the motivation for the spread of misinformation and disinformation is to distract and even cover-up mistakes that were made and also to offer optimism even though not backed up by science. A few examples:
The world cup of testing – an example of exaggeration. You would think in watching the news that testing rates is now an international competition. Donald Trump has falsely stated a number of times that the US has done more testing than any other country. His latest – more than twice as much testing as all other countries combined. This is not even remotely true. Moreover, it’s irrelevant. The correct metric is tests per capita and the US is improving but still is not doing enough. (Some numbers – US – 36,000 tests per million population, Canada – about the same, Italy 50,000, Denmark – 80,000). Most scientists point to Denmark as the benchmark to attain or even exceed.
Miracle cures – an example of wishful thinking – Despite cautions by medical experts, there has been a dangerous promotion by many in politics citing so called evidence that malaria drugs can treat the CoVid virus. This caused a major run on supplies creating dangerous shortages in some countries. Results from a number of studies, including the first randomized controlled trial, are providing further evidence that the antimalarial drug hydroxychloroquine may not help COVID-19 patients and in fact can cause premature deaths from heart problems.
Origin of CoVid 19 – an example of the blame game. China and Russia initially blamed the USA. The Trump administration has continued to claim the virus came from a lab in Wuhan although it has recently backed off this stance. The evidence strongly suggests the source of the corona virus is bats. A new University of California study finds that bats have a fierce immune response to viral infections, which likely causes the viruses to replicate more rapidly.
These are only 3 examples – there are many more especially in other crises such as climate change. It is disconcerting to see how these lies spread and even more so, how they are blindly believed. But, in many ways it’s not surprising. Social scientists and propagandists have long known that humans are wired to respond to emotional triggers and share misinformation if it reinforces existing beliefs and prejudices. The success of the purveyors of falsehoods also relies on people’s cognitive dissonance – when someone feels genuine mental discomfort when confronted with a view that upends their viewpoint or belief system. So – an alternative story winds up being believed even if lacking in facts.
No government could have been completely ready for the pandemic, but taking the public for fools is destroying trust. The truth is out there if we are willing to dig – using fact-check sites, listening to medical experts and trusting our own instincts not be fooled by bullshit even if it appears profound.
UPDATE ON TESTING FOR COVID-19 Allan Maynard – May 8th, 2020
There is a great deal of new information along with political noise about testing for the CoVid 19. For the past 6 weeks, almost all countries have been in various forms of lock-down; in some cases a complete shut down. Understandably there is desire by most citizens to be able to safely move past this phase and return to some sense of normality, however that may be defined for our post CoVid future. Most medical experts caution though, that the key to slowly re-opening our economies is to significantly ramp up testing, followed by quarantining those who test positive and additionally tracing and testing their contacts.
For most countries, the testing frequency is insufficient despite the statements of some politicians. Some examples – testing totals per 1000 citizens as of May 3rd, 2020 – Italy -34, Germany – 30, USA – 20, Canada – 22, South Korea – 12, France – 11. The South Korea numbers may seem low in comparison but that country was very quick to implement widespread testing, combined with combined with contact tracing and isolation which enabled the country to ‘flatten the curve’ (slow infection rates) much earlier than other countries. The USA had a slow start due to a defective test system but is now catching up. The UK also had a late start. Both countries have unfortunately, been following an infection trajectory comparable to Italy.
According to most medical experts, even though testing numbers increased through April, the numbers are still insufficient to allow a substantial opening of commerce. For instance – the USA has now conducted just over 6 million tests in total but the target should really closer to 1 million per day (about 10 times more than over the past 2.5 months). France is now conducting 700,000 tests per week. In the UK the target is 100,000 tests per day. Canada has set a goal of over 500,000 tests per week. It should be noted however that increased testing will not have the desired outcome unless it is accompanied by contact tracing and isolation. Moreover, herd immunity, an epidemiological concept that describes the state where a population is sufficiently immune, will not be possible until a vaccine is available – likely 1.5 years away at the earliest.
To meet the ever-increasing demand for more testing, research has expanded around the globe to produce more, better and faster tests. The latest count – there are over 60 forms of the viral swab PCR tests and over 130 forms of the antibody tests. Many of these have been introduced without undergoing full approval processes in the various countries. In the USA – the FDA provides an “Emergency Use Application (EMA)” for many of the new tests. This can be sensible in such dire situations as long as the tests’ performance characteristics are very carefully monitored. So – how are the various tests performing?
THE PCR TEST FOR THE COVID 19 VIRUS – MAIN ISSUE – FALSE NEGATIVES. – As described in my earlier blog, the first type of test introduced worldwide, the polymerase chain reaction (PCR) test, diagnoses CoVid infections by analyzing virus material in mucous collected from the nose and/or back of the throat. The test then isolates the genetic components of the virus and converts it into DNA (Deoxyribonucleic acid). Then, using “polymerase enzymes”, the DNA is duplicated again and again so that there’s enough to be detected (if it is present at all). This process is known as “amplification.”
The inherent issue with this test is that the incidence of false negatives can be high. This makes sense. If a patient is tested too early in the disease, there may not be a sufficient viral load to be detectable. If a patient is tested later in the disease, the viral material is likely concentrated more in the lungs and trachea and thus may not be isolated. Furthermore, there are now a number of more rapid PRC tests on the market without the same degree of amplification of the DNA. This may mean there is less genetic material within the test, for detection. There are now a number of studies underway or reported that show the incidence of false positives can be significant. In the early stages of the pandemic, Chinese scientists published a paper that found the false negative rate of some of the tests conducted at the Third People’s Hospital in Shenzhen, southern China, between Jan. 11 and Feb. 3, were as high as 40 percent.
More recent studies (University of Cleveland, Mayo Clinic) calculate a false positive rate of closer to 15% and stress the need for follow-up tests to reduce the health risk created by infected people mistakenly being told they are infection-free. This objective of repeated testing is hampered by the shortage of supplies needed to conduct the PCR tests. Many who should be re-tested or even initially tested, are not able to do so.
These problems may seem untenable but that is not the case. The PCR test is highly complex. The global developments to expand testing and speed up test results are impressive. The main point, the limitations of the test must be well understood and further assessed as we deal with the CoVid health crisis.
ANTIBODY TESTING – MAIN ISSUE IS FALSE POSITIVES – The second kind of test involves testing blood samples for the presence of antibodies to the virus. Antibodies are evidence of the body’s reaction to an infection. The presence of CoVid antibodies might then suggest that the person is now immune to the virus. It should be cautioned however, that the notion of immunity to the CoVid virus being acquired through infection is only, for now, an assumption based on past experience with other viruses. No scientific studies have confirmed this hypothesis yet. Nonetheless – serology testing for antibodies is a critical part of national testing programs.
Antibody testing is generally less complex and certainly more rapid that testing for the virus itself (the PCR test). In fact there are even test kits on the market that are similar to home pregnancy tests. Most kits however, involve the need for a blood sample to be collected with a finger prick, which is then analysed in a lab setting. However, as stated above most of the new tests on the market have bypassed the needed oversight.
The issue is that many of the new tests have a high rate of false positives. This makes sense given the many types of antibodies in our blood stream, with some, such as the common cold corona virus, very similar in structure to the CoVid virus. Of the 12 antibody tests that were studied by the CoVid testing project in the USA, one of the tests gave false positives more than 15% of the time, or in about one out of seven samples. Three other tests gave false positives more than 10% of the time.
It is a work in progress though and some of the larger firms (Roche, Abbot and others) seem to be close to getting full approval by organizations such as WHO, and the FDA. It seems likely that by June 2020, there will be more reliability in antibody testing.
NEW APPROACH – TESTING FOR COVID GENETIC MATERIAL IN BLOOD SAMPLES – In what could be a significant breakthrough is a blood-based test that will be able to detect the virus’s presence as early as 24 hours after infection – before people show symptoms and several days before a carrier is considered capable of spreading it to other people. In other words — around four days before current tests can detect the virus.
The test has emerged from a project set up by the US military’s Defense Advanced Research Projects Agency (Darpa) aimed at rapid diagnosis of germ or chemical warfare poisoning. It was hurriedly repurposed when the pandemic broke out. The new test is expected to be forwarded for emergency use approval (EUA) by the US Food and Drug Administration (FDA) in May 2020.
Like the viral test, the new blood test hunts for the virus’s RNA (Ribonucleic acid) — in this case it is messenger RNA (mRNA). “Target mRNA is part of the immune response to viral infection,” a Darpa representative said. The test needs about 1 ml of blood – thus blood collection would need to be done in a clinical setting. More will be known about this potential test by June 2020.
_______________________________________________________________ In summary – testing for the CoVid virus is expanding in scope and the tests are improving in terms of their reliability. However the limitations of the tests must be fully considered in analysing data concerning infection rates and disease mitigation measures.
It is impossible to escape the daily barrage of news about the CoVid Pandemic unless we were to add an additional dimension to our isolation by turning off all screens and cancelling all publications. In following the news outlets we are seeing examples of informed, decisive leadership. We are also seeing examples of responses riddled with muddled misinformation and untruths. For certain, the muddled responses are providing us with the clearest examples of the dreaded “Ds”: DENIAL (the problem does not exist); DELAY (we don’t know for certain – let’s wait and see and not disturb the economy), DODGE or DEFLECT (the questions that then come) – all leading to DEADLY OUTCOMES. Clearly, the need for evidence-based decision-making is critical with this kind of crisis.
Risk Assessment – it would be expected that progressive governance involves sound policies around societal risk assessment. Broadly speaking, risk assessment is the combined effort of identifying and analyzing potential events that may negatively impact individuals, assets and/or the environment followed by making judgments on the tolerability of such risks. Another way of putting it – prepare for the worst while hoping for the best. It is frustrating indeed to consider how different things might look had these principals been rigorously applied. Of course hindsight is 20/20 and casting back can look like a blame game. However it is a necessary exercise to acknowledge the many failings that have exacerbated this mess. That is the only way to learn for future planning.
There has been extensive research around the world and particularly in China about zoonotic corona viruses – especially the role of bats as primary carriers. The CoVid 19 virus first emerged in the Chinese city of Wuhan in December, and is thought through most investigations (but not all) to have leapt to humans at a seafood and wild-animal market (Huanan Market), where many of the first people to become infected, worked. After the SARS outbreak in 2003, the Chinese government closed wet markets and banned the ‘farming’ of wildlife. But this ban was later reversed. This is a clear failing in terms of risk management. While it is not straightforward to close these markets, the Chinese government had over 17 years to work on solutions to this, but denial and complacency set in.
The first signs of danger associated with this new (novel) corona virus were probably detected in November or early December, 2019. The Chinese government first tried to keep it quiet (and contained?) and even silenced one of the early researchers that made the information public (a Dr. Li Wenliang who later died of the disease). The Chinese first notified the World Health Organization (WHO) on December 31, 2019. This should have been done sooner. Moreover they did not initially reveal that human-to-human transfer was occurring – likely because of lack of evidence of such.
By January 23rd, 2020 Wuhan was in full lock down and the virus had spread to other countries – mostly in Asia. Despite this WHO decided that it was ‘too early’ to declare a global health emergency. This was then declared a week later but without recommending trade and travel restrictions, claiming these would be an unnecessary disruption. As well, from December 31 to January 14th, WHO and China stated that there was no clear evidence of human-human transfer. By January 23rd however, this statement was updated with the warning of clear evidence of human-to-human infection.
By March 11, WHO declared the outbreak to be a Global Pandemic. By then the CoVid virus was found in almost all countries with infections rates often doubling every 2 to 4 days. At least by then, WHO had developed a fairly reliable test, which was rapidly put to use in many afflicted countries. Those (example South Korea and Taiwan) that did extensive testing, followed by quarantine and contact tracing – along with social distancing and lock downs, demonstrated an ability to start reducing infection rates. But many of the European countries were slow to accept the gravity of the CoVid virus and infection rates ramped up drastically and rapidly.
By some measures the responses from early January through February can seem acceptable but not through the lens of rigorous risk management. The most significant failings in retrospect were the warnings about human-to-human transfer. Because of the similarity of the CoVid 19 to SARs, it would have been prudent to assume human-to-human transfer right from the onset. The primary obstacle to taking more drastic action at some of the critical points seemed to be the fear of disrupting the economy. Initial denial and delay were evident from the onset. Of course – the delays made both the health crisis and the economy much worse.
In no country was the denial/delay/dodge strategy more glaring that the USA. That is because President Trump, from mid- January until around March 10th, verbalized the denial almost daily. Six to eight precious weeks were mostly squandered. This was made worse by the unfortunate roll out of a faulty test protocol. Now the USA has the most cases worldwide and one of the highest rates of infection. These failings cannot now be re-written.
Claims by Trump and his administration that they could not possibly have been ready for this pandemic and was then misinformed by WHO, are incorrect. Seven days before Donald Trump took office, his incoming team faced a sober briefing from the outgoing Obama administration about the possibility of a global pandemic and the need to be prepared. The Obama administration had learned from the H1N1 and Ebola outbreaks. As such, the Obama administration had created a pandemic preparedness team within the White House that was then ‘reorganized’ in 2018 with the loss of expertise. Moreover, the US embassy in China initially had a large team of health professionals which was then cut over 60% by the Trump administration thereby removing expertise that would have been ‘on the ground’ at the onset of the outbreak. Furthermore – in 2018/19 a pandemic simulation conducted by the Dept. Of Health and Human Services showed the nation was unprepared for a pandemic, according to a critical draft assessment. The exercise, code named “Crimson Contagion,” had eerie similarities to the current real-life coronavirus pandemic. As well, a program funded by USAID (named PREDICT) that was set up to investigate corona viruses in bats and pangolins, was cancelled in 2019. The failings in response to this pandemic are wide spread and in many locations continuing. In most cases the failings have resulted in denial leading to delay. Delay is not an option in fighting a pandemic. It’s deadly. Time matters. Expertise matters. Evidence based decision-making matters. The countries that were much more successful in dealing with this crisis such as Germany, South Korea, Taiwan and others, prove this.
The corona virus pandemic has brought a definite urgency to the defining political question of our age: how to deal with risk on a global scale. For certain, this question also applies to climate change, which is an even greater crisis in the making. There can be no question about that. The CoVid pandemic is a crisis in fast-forward whereas climate change has been building over 50 years and counting. But the same principles of risk assessment and evidence-based decision-making, apply. Denial followed by delay of both crises is deadly.
This is a topic of great interest to me because my career was in the field of measurement science – in my case measurements for environmental contaminants. Reliable measurements are required for many aspects of our lives from ensuring safety of foods, medicines, infrastructure, water supplies and of course to the monitoring of our health. Now testing is critical for the CoVid 19 pandemic.
It has become increasingly evident that reliable, wide spread testing is one of the key strategies to slow down the rate of infection from the CoVid -19 virus. Germany is one of the best examples of this. Germany’s preparedness was helped in part by an early recognition that coronavirus was likely to become a global problem. Lacking a gene sequence for the new virus, the German team designed their first test kit based on SARS and other known coronaviruses. The protocol was published by WHO (World Health Organization) on January 17, even before the Chinese had a test. By the end of February, the Germans were producing 1.5 million test kits per week. Globally – Germany is among the lowest in infection and mortality rates.
Another of the earliest tests was developed in mainland China by the Chinese Centre for Disease Control, and details of it were posted on the World Health Organization website on January 24, just after the Wuhan lockdown was announced. Fortunately, we are seeing unprecedented speed in CoVid research thanks in large part to early Chinese efforts to sequence the genetic material of the virus that causes Covid-19. China shared that sequence in early January, allowing research groups around the world to grow the live virus. Having this viral material has resulted in research groups around the world to work on developing tests.
HOW DOES THE CURRENT TEST WORK? – A short biochemistry lesson.
The shorts version – a swab is used to collect viral material from the back of the nose, the swab is sent to a lab that isolates the genetic component. The genetic material is rapidly grown (replicated) and then detected by very specific dyes.
A more complete description – For a patient, the process of being tested for the virus is easy and can potentially be done anywhere. It is the same basic protocol used to test for other viral infections. It typically involves taking a swab from deep in a patient’s nasal cavity to collect cells from the back of the nose. The sample is then sent to a lab, where it will be tested to determine if the patient’s cells are infected with the virus.
The swabs are then tested in specialized labs that are able to look for genetic material. The genetic material in the CoVid 19 virus is called RNA – (Ribonucleic Acid). RNA and DNA (Deoxyribonucleic Acid) are nucleic acids and, along with lipids, proteins, and carbohydrates constitute the macromolecules essential for all life.
In the test – the RNA must be converted to DNA. The DNA then replicates itself millions upon millions of times until there is enough genetic material for detection. The method is referred to as “polymerase chain reaction” or PCR. The PCR test was developed by Kary Mullis from California who was awarded the Nobel Prize in 1993 for this important discovery.
The resulting genetic material during the PCR chain reaction binds with a special fluorescent dyes. During the test the fluorescence increases and the genetic material amplifies. There are variations of this test in terms of the way the chain reaction is carried out and in the manner by which the genetic material (DNA – from the RNA) is detected.
The turn around time for this standard test (as is the case for most other viral tests) usually 24 to 72 hours – mainly because of the need to transport the samples to special labs and high volume in these labs. This is clearly has not been adequate and more rapid tests are in development – see below.
WHAT HAPPENED IN THE USA?
As mentioned, China developed its own test. The WHO first adopted a test from German researchers in mid-January. These 2 protocols were basically adopted by other countries in order to produce their own tests. Some countries simply used tests provided by WHO.
The CDC (Center for Disease Control) made the decision to develop its own test towards the end of January with the intention of being the conduit for testing in the US. But there were warnings that the CDC would struggle to keep up with the volume of screening and should focus on working with private industry to develop easy-to-use, rapid diagnostic tests that can be made available to providers. Unfortunately, the CDC did the opposite. When it became clear that testing had to be ramped up, the CDC created tests kits for distribution to state labs. It soon became evident that the test kits sent were not reliable (faulty reagents). This meant that only the CDC could carry out the initial test work. As such the testing had to be restricted to only ‘high-risk patients’ who had recently travelled from China. CDC was ‘back to the drawing board and valuable weeks were lost.
This was a significant set back for the US and is one of the reasons the US has one of the highest rates of infection in the world. Fortunately, this is rapidly changing with more widespread testing now occurring.
TESTING NOW GREATLY ENHANCED AROUND THE WORLD
The short version – due to the urgency of this crisis government incentives were rapidly in place for research organizations and the private sector to develop more rapid and portable test methods. There are a number of these methods now coming on-line. It is encouraging.
A more complete version – Human ingenuity can be amazing when we face a crisis. The research efforts pertaining the CoVid virus around the world has been more than impressive. Now testing protocols have been developed in many countries with 2 main objectives in mind – 1) much more rapid and 2) being portable for use in multi-locations. For the most part – the technology is the same in that the tests focus on identifying viral genetic material. It’s the overall process that has improved in a major way. Here are just 2 examples but needless to say, there are many more.
Abbot Labs – USA – Recently (3 days ago), Abbot Labs announced a new test kit. The “ID NOW” machine as it has been dubbed can test samples one at a time. A health care provider would use a swab to take a sample from a sick patient’s nose or throat and then mix the swab into a chemical solution that breaks open the virus and releases its genetic material. The sample is then placed into the ID NOW instrument, which uses a special “isothermal technology” to replicate and amplify, if present in the sample, the small section of the virus’ genetic sequences in order to quickly detect whether a person is positive or negative for COVID-19. Such a test will allow frontline health care workers to see a patient, quickly diagnose them and make immediate decisions regarding treatment and care, thus helping prevent further transmission of the virus to other people.
Simon Fraser University – Simon Fraser University researchers will use their pioneering imaging technology — called ‘Mango’, for its bright colour — to develop coronavirus testing kits. They’re among a small set of Canadian researchers who responded to the rapid funding opportunity recently announced by the Canadian Institutes of Health Research (CIHR) to help address COVID-19. The latest research, involves using special reagents to detect individual molecules of RNA within a living cell. Dubbed the “Mango system’ it consists of an RNA Mango aptamer. Aptamers are short, single-stranded DNA or RNA molecules that can selectively bind to a specific target — in this case a special dye. The aptamer acts like a magnet – targeting and binding those dye molecules. The dye becomes excitable when bound and glows brightly. RNA molecules modified to contain the aptamer ‘magnet’ now stand out from the other parts of the cell, which makes it much easier for researchers to see and study RNA molecules under a microscope.
WHAT ABOUT A BLOOD TEST?
Short version – blood samples can be collected and tested for antibodies that are formed if a person is infected with the virus. The test mainly determines if a person had the disease rather that for use in early detection.
A more complete version – Blood tests can be very rapid and in some ways easier to get a reliable sample. To do a blood test for the CoVid 19 virus would involve analysing for antibodies to the virus. An antibody, also known as an immunoglobulin, is a large, Y-shaped protein produced mainly by plasma cells and used by the immune system to neutralize pathogens such as pathogenic bacteria and viruses.
Antibody tests are different from the typical diagnostic tests used to determine whether someone has COVID-19. As mentioned above, the latter involves taking samples of mucus and saliva and running a test in a lab to see if those samples contain the coronavirus’ genomic sequence. A serological test, on the other hand, can tell whether a person has coronavirus antibodies in 10 to 15 minutes. In some ways the test can be developed along the lines of a home pregnancy test.
To create the test, the researchers began by designing a slightly altered version of the “spike” protein on the CoVid 19 outer coat. They also isolated the short piece of the spike protein called the receptor-binding domain (RBD), which the virus uses to attach to cells it tries to invade. They then used cell lines to produce large quantities of the altered spike proteins and RBDs. Those lab-made molecules provided the basis for the test, in which antibodies in a sample of blood or plasma trigger a color change when they recognize a target protein.
This test is being used extensively in New York. But it’s main objective will be to determine who has had the disease. It will not provide early detection as it takes time for the antibodies to form in the blood stream of an infected patient.
WHAT ABOUT THE RELIABILITY OF THE TESTS
Tests are generally judged in terms of their sensitivity, accuracy (or in this case specificity) and precision (applies to quantitative tests).
The tests are proven to be “sensitive” in laboratory conditions — in this case, a technical measure of the smallest amount of the target virus they can detect. The tests must also be “specific” — for example, ensuring they do not mistake other pathogens, such as the cold coronaviruses, for the new CoVid 19 virus.
The genetic tests being used are typically very sensitive and specific under lab conditions, but in the real world, how the swab was done and the stage of illness the person was in can make a big difference. To complicate the situation, there isn’t one test. Many different tests are now being used by commercial laboratories, hospital labs and governments around the world. The interpretation of the results will therefore depend on not just the test, but other external factors.
The tests have not been around long enough to know precise information about the sensitivity and selectivity of each one. The rule of thumb that seems to becoming adopted is to assume a 5% chance of false negatives. In essence if a sick patient get’s a negative result, they should be tested again. That is acceptable given the urgency of our situation.
It is encouraging to see how quickly researchers have stepped in to enhance testing around the world. It will make a difference.
I have made some updates to my article that was initially posted on March 14, 2020. The new information is in blue font. So much has changed over the past 2 weeks. It is very difficult to keep up. In many cases – do we really want to focus on such dire news? But we must.
There is a great deal of concern and even hysteria about the spread of the corona virus. I have done a lot of research on the topic and decided to collect the information for those interested. I have a strong personal interest in this topic given that my wife is in a care home and I am currently not allowed to visit. Should we worry? Yes – to the point that we take precautions and listen to the advice coming from medical authorities. Should we panic? No – it will be temporary and the disease does seem to be peaking in China and South Korea. Moreover, the majority of those infected do not need hospitalization.
There’s no doubt though that this outbreak is upending our lives in ways that we could not have guessed even 1 month ago. There has never been a better of example of why we need evidence based decision-making. The following is the evidence taken from reputable sites such as the WHO (World Health Organization) and others.
What is a corona virus?
Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases. The current crisis is due to a new strain that has not been previously identified in humans.
Researchers first isolated human coronaviruses in the 1960s, and for a long time they were considered generally mild. Mostly, it resulted in a cold. But the most famous coronaviruses (SARS, MERS and this one – CoVid19) are the ones that jumped from animals to humans.
NOTE – SARS – Sever Acute Respiratory Syndrome – outbreak in 2003
MERS – Middle East Respiratory Syndrome – outbreak in 2012
The name comes from the ‘studded spikes’ within the virus. It looks like a ring when viewed under an electron microscope – like a crown (corona is Latin for crown). The current corona virus outbreak – the virus was initially called novel corona virus because it is new (novel). It was more recently recently given the name CoVid 19.
Names of outbreaks matter! This is why there has been a significant outcry when a number of politicians and media personalities have been referring to this outbreak as the “Chinese Virus” of the “Wuhan Virus”. In 2015, the World Health Organization issued guidelines on how to name diseases. These guidelines stipulated that the names should NOT single out particular human populations, places, animals or food. Names that commit those sins often wind up being wrong but by then the damage can be done.
Consider for example the so-called “Spanish” Flu. That name came from a major misunderstanding. Spain was one of only a few major European countries to remain neutral during World War I. Unlike in the Allied and Central Powers nations, where wartime censors suppressed news of the flu to avoid affecting morale, the Spanish media was free to report on it in gory detail. Since nations undergoing a media blackout could only read in-depth accounts from Spanish news sources, they naturally assumed that the country was the pandemic’s ground zero. The Spanish, meanwhile, believed the virus had spread to them from France, so they took to calling it the “French Flu.” But there is also evidence that it started in the United States since the first known case was reported on March 11, 1918 – in an army base in Kansas and spread into other army bases before being transported to Europe.
It is vital that science based factors drive discussions on disease outbreaks. Global cooperation is needed as opposed to useless finger pointing. As an example – we are seeing unprecedented speed in CoVid research thanks in large part to early Chinese efforts to sequence the genetic material of the virus that causes Covid-19. China shared that sequence in early January, allowing research groups around the world to grow the live virus and study how it invades human cells and makes people sick.
Origins of COVID 19
Coronaviruses are zoonotic, meaning they are transmitted between animals and people. Detailed investigations found that SARS-CoV was transmitted from civet cats to humans and MERS-CoV from dromedary camels to humans. Several known coronaviruses are circulating in animals that have not yet infected humans.
CoVid 19 is thought to have originated in bats that in turn infected animals held for human consumption. It has also been suggested that pangolins (ant eating mammals) could be carriers.
The virus first emerged in the Chinese city of Wuhan in December, and is thought to have leapt to humans at a seafood and wild-animal market (Huanan Market), where many of the first people to become infected, worked. Pangolins were not listed on an inventory of items sold at the market — although the illegality of trading pangolins could explain this omission. These kinds of markets are referred to as wet markets and there is growing concern that they will continue to be the source of other virus outbreaks. After the SARS outbreak in 2003, the Chinese government closed wet markets and banned the ‘farming’ of wildlife. But this ban was later reversed. After the recent outbreak of the CoVid 19 – a large number of wet markets have again been closed – hopefully for good.
More information has been published of late about the role of bats. A new University of California study finds that bats’ have a fierce immune response to viral infections which likely causes the viruses to replicate more rapidly. The bats carry huge viral loads which can be easily shed and thus transfer to other animals – including humans. A research team in China is headed by a well-known virologist (Dr. Shi Zhengi) who is now known as the ‘bat lady’. Her team has identified hundreds of corona viruses – most harmless but dozens belong to the same group as SARS and CoVid 19.
‘Wet markets’ where wild and domestic animals are kept alive in cages for purchase are prevalent in warmer climates (Africa, China, SE Asia, etc) where refrigeration is scarce. There’s no doubt that wet markets were the source of SARS and CoVid 19. As such there will be an intense pressure to close these markets down. But it will not be easy as millions of poorer people rely on them for food. However, a good start would be to disallow the inclusion of wildlife in these markets. It should also be noted that factory farming of domestic animals (eg. highly crowded chicken farms in North America) could also easily become a source of viral outbreaks.
The pathogen can travel through the air, enveloped in tiny respiratory droplets that are produced when a sick person breathes, talks, coughs or sneezes. These droplets fall to surfaces within a few feet (6 to 10 feet or 2 to 3.5 meters). That makes the virus harder to get than pathogens like measles, chickenpox and tuberculosis, which can travel 100 feet through the air. The droplets land on surfaces where the viruses can remain infections for a number of hours. When people touch these surfaces, the viruses are transferred to hands and then eventually to the face near the mouth, nose and eyes. The virus can also be inhaled from the air if close to a person who sneezes or coughs. In both cases the virus then lodges in the trachea and lungs and the infection takes hold. The incubation period is likely around 5 days. Hand washing and keeping distance from others are two of the most effective ways to prevent this route of infection.
There has been some recent reports concerning how long the virus lasts on certain surfaces. The New England Journal of Medicine just published a study that tested how long the virus can remain stable on different kinds of surfaces within a controlled laboratory setting. They found that it was still detectable on copper for up to four hours, on cardboard for up to 24 hours, and on plastic and steel for up to 72 hours. But it’s important to note that the amount of virus decreased rapidly over time on each of those surfaces and so the risk of infection from touching them would probably decrease over time as well.
Degree of contagion
Research is still in its early stages, but some estimates now suggest that the CoVid virus is 20 times more contagious than the seasonal flu. That is enough to sustain and accelerate an outbreak, if nothing is done to reduce it. Projections as to how widespread this will become vary widely. In some locations the rate of infection is increasing around 30% each day. Italy and Iran provide worst-case examples of a rapid spread. Projections for the United States vary widely with some estimates showing 1/3 to ½ of the population eventually becoming infected.
The ease by which people can become infected is the worrisome piece. In fact – 2 studies have shown that people not displaying symptoms can nonetheless spread the virus. An analysis of infections in Singapore and Tianjin in China revealed that two-thirds and three-quarters of people respectively, appear to have caught it from others who were incubating the virus but still symptom-free. It should be cautioned that these were 2 relatively small studies but it is nonetheless a note of concern.
Despite some of these more dire warnings, it is encouraging to note that when global health authorities methodically tracked and isolated people infected with SARS in 2003, they were able to bring the average number each sick person infected down to 0.4, enough to stop the outbreak. Also note – frequent hand washing can reduce the chances of infection by 50% or more.
The current growth of CoVid 19 infections is in most countries is considered to be exponential. Something is said to increase or decrease exponentially if its rate of change must be expressed using exponents. A graph of such a rate would appear not as a straight line, but as a curve that continually becomes steeper or shallower. Perhaps a better way to consider the growth is the number of days it takes for the infections to double. According to “Our World in Data” – associated with a number of prestigious universities, the rates of infections doubling are: World (number of infections doubled in 6 days), Italy (7 days), Spain (4 days), USA (3 days), Canada (4 days), China (45 days). It is clear that China’s rate of infections are levelling while most other locations are still in the exponential growth phase.
The coronavirus outbreak hit amid flu season in the northern hemisphere and even doctors can struggle to distinguish between the two The overlap in symptoms probably contributed to slow detection of community infections in some countries, including Italy. Typical flu symptoms, which normally come on quickly, include a high fever, sore throat, muscle aches, headaches, shivers, runny or stuffy nose, fatigue and, more occasionally, vomiting and diarrhea.
Doctors are still working to understand the full scope of symptoms and severity for Covid-19, but early studies of patients taken to hospital found nearly all of them developed a fever and dry cough, and many had fatigue and muscle aches. Pneumonia (lung infection) is common in coronavirus patients, even outside the most severe cases, and this can lead to breathing difficulties. A runny nose and sore throat are far less common, reported by just 5% of patients. The only real confirmation of having Covid-19 is taking a test though.
Early research indicates the virus may be significantly more deadly than the seasonal flu, which kills roughly one in 1,000 people. An analysis of outcomes for more than 44,000 confirmed patients in China found that roughly one in 50 died (2% mortality rate). Eighty-one percent of patients infected with the new coronavirus had mild illness, 14 percent had severe illness and 5 percent had critical illness, according to the study.
The current (as of March 12, 2020) number of cases worldwide is about 135,000 resulting in 5000 deaths. That equates to a 3.7% mortality rate. In Italy there are just over 15,000 cases with 1000 deaths (6.6 % mortality rate). In the USA – 1600 cases with 41 deaths (4.1 % fatality rate). Note – the numbers are changing daily. NOTE – see new number below.
It is assumed, however that there are many more mild cases that do not get to hospital and are not being counted, which would bring the mortality rate significantly down. Most researchers feel the true mortality will calculate to about 1 to 2 % making the CoVid 19 ten to 20 times more fatal than the flu. The mortality rate for the H1N1 (swine flu) of 2009 was 0.02%.
Deaths are highest in the elderly, with very low rates among younger people, although medical staff who treat patients and get exposed to a lot of virus are thought to be more at risk. But even among the over-80s, 90% will recover.
Some current numbers as of March 29, 2020 – 17:29 GMT
World 707,738 cases 33,526 deaths (4.74% mortality rate)
Italy 97,689 10,779 (11%)
Germany 60,659 482 (0.79%)
USA 133,146 2363 (1.7%)
Canada 6213 63 (1.0%)
China 81,439 3300 (4.0%)
One of the most notable points is the difference in mortality rate between Italy and Germany but there are considerations as to why. Firstly, Italy has one of the highest ratios of elderly residents. Secondly, it cannot be fully confirmed that each recorded death over the past month or so is directly due to the corona virus. In one study that involved a re-evaluation by the National Institute of Health, demonstrated that only 12 per cent of death certificates showed a direct causality from coronavirus, while 88 per cent of patients who died had other factors that could have contributed. A third factor is a suggested higher rate of lung issues due to air pollution and a high percentage of smoking within the population.
Is it seasonal?
Regular flu outbreaks are generally seasonal in the Northern Hemisphere. People are outside more and a degree of immunity can set in. For the CoVid 19 however, no one can say if this will be the case.
Cures and Vaccines
Efforts to develop an effective vaccine for Covid-19 have been quick compared with historical epidemics, such as Ebola. A number of teams are already testing vaccine candidates in animals and preparing to carry out small trials in people. However, the second and third phases of development will involve thousands of volunteers and will look more closely at efficacy. It is currently felt that a vaccine to protect people from the coronavirus would require a timeframe of a year or 18 months.
There is also work being done on antiviral drugs. The most hopeful at present are Kaletra, which is a combination of two anti-HIV drugs, and remdesivir, which was tried but failed in Ebola patients in west Africa in 2013 and 2016. Some Chinese doctors are also trying chloroquine, an antimalarial drug, which is off patent, therefore cheap and highly available, and would be very useful in low-income countries. The first results are expected in mid-March and should indicate if the drugs will at least help those who are most severely ill. A miracle cure is not expected.
Vaccination development is being undertaken on many fronts as is drug therapies. See upcoming article on my blog.
It is very difficult to predict what will happen over the coming months and year. We need to be concerned but also act in a rational way. The medical community is extremely knowledgeable with monumental efforts underway to decrease the risks we face. Life must to go on. It is crucial though that science based decisions are made.
The 3 largest impact measures will be –
TESTING – South Korea is demonstrating that testing on a massive scale is very effective. That country is testing people at a rate of 10,000 people per day. The USA is very far behind having only tested 11,000 people to date. This is a worry. Fortunately, in Canada – testing is about where it should be. It is becoming more and more clear that testing is absolutely critical in fighting this pandemic. In Canada we have so far carried out 66,000 tests (as of March 20th). This is not enough. The main reason is a shortage of supplies and a back-log in labs. In the US – the situation is more dire as the country lost about 6 weeks due to a deficient test protocol and a slow federal undertaking. As of March 20th – the US had conducted 313 tests per million people as opposed to over 6000 tests per million people in South Korea. This is changing as some new test protocols are being developed. I will write about testing in a new blog.
READYING HOSPITALS – Most hospitals are already at maximum capacity so it is important that emergency measures are considered to expand available beds and ventilators.
FULL SOCIETAL COOPERATION – it is critical that all citizens follow the advice of the medical experts – hand washing, social distancing, staying home if sick, restricting travel, avoiding large groups and getting tested if needed.
I could political here but I might get carried away. In closing – we need to pay attention to health experts — NOT politicians and nonsense flying around on social media.