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[This article deals with a constantly evolving situation. It was written by Norbert Gleicher, MD, on July 5, 2020 and published on July 6, 2020. For a list of all COVID-19 Bulletins, scroll to the bottom.]
Over the long July 4th weekend, The New York Times (July 5, 2020, pages 15-18) published a revealing lead article, documenting the stealthy nature of the COVID-19 epidemic in the U.S. According to a case report published in the New England Journal of Medicine, a first case of the so-called Novel Coronavirus was diagnosed in the U.S. in Snohomish County, Washington, on January 19, 2020 (Holshue et al., N Engl J Med 2020;382:929-036) in a 35 year-old male who presented in an urgent care clinic with a 4-day history of cough and fever. Shortly thereafter a second case was reported in Chicago per The Times article, and by mid-February, there were only 15 known cases in all the U.S.
Those cases were appropriately isolated and, to much criticism from media and opposition, the federal government, already at that early stage, closed off air traffic from China (though, unfortunately not from Europe because, as we will demonstrate below, that’s where the real problem came from). The virus, nevertheless, “exploded unseen” over ensuing weeks and months to, by now known epidemic proportions. At end of February the virus had, mostly in the east of the country, invisibly spread into local communities far beyond the small numbers of affected patients in isolation and was, basically no longer controllable by standard public health measures, like isolation of infected patients and contact tracing.
As now has become apparent, the country was at the time, however, dealing with two different variants of the virus (a point of considerable importance for the current flair in case numbers, as we will discuss below in more detail). Earliest cases were mostly caused by the Seattle or Westcoast variant, while on the East coast a different variant, the so-called New York City variant, became predominant. While by March 1, among all nationally diagnosed cases the Westcoast variant was domineering, by May 1, the New York City variant had mostly taken over and this variant had reached New York arriving through air travel from Europe that, as of that point, still was ongoing unrestricted.
Interpreting these by The Times well documented facts, a number of so-far poorly understood features of the U.S. COVID-19 pandemic come into better focus: For example, even though first cases in the U.S. were reported on the Westcoast, it was the East coast that bore most of the brunt of the first wave of infections. Nobody, indeed, understood the amazingly large differences in infected, hospitalized and dying patients between East and West coasts. Superficially this made absolutely no sense, but now it does because these observations clearly suggest that the New York City variant, evolutionarily, must have been more successful than the Westcoast variant and that, in turn, meant that the New York City variant must have been significantly more infectious. This conclusion is also supported by how severe European infection rates were in, for example, Italy and Spain in comparison to Asian outbreaks. In other words, it appears reasonable to conclude that the COVID-19 virus, circulating in China at least since November 2019 (and possibly even earlier), reached the U.S. on two different routes: Coming from the West in a less-infectious form and from the East, via Europe, in a more infectious mutation.
But there is also good new in interpreting these findings in this way because this would suggest that we, here in the north-east of the country, where the first wave was so devastating, likely, have significant better herd immunity than states mostly speared between March and May. This, therefore, would also explain why we are now witnessing a so-called second wave in south-western states, while here in NYC, despite having likely experienced the largest mass gatherings during demonstration of any large city in the world since the end of May, we have been witnessing no increases in infection rates.
Why is all of this of importance? Because, if our interpretation of the data published by The New York Times is correct, then what we are reading in newspapers, watching on television news and are being told by politicians and so-called “experts,” is again “fake news.” If our interpretation of these national data is correct, then south-western states are currently just experiencing the natural spread one would expect the dominant virus strain to take. At the same time, it, however, would also mean that NYC and most of the north-eastern states have little to worry from the current wave of COVID-19 infections. For so-called “experts” and politicians, therefore, to conclude that New York state’s reopening should be delayed because of what is happening in Florida, Arizona and California would make little sense.
This, of course, does not mean that distancing and wearing masks when in pubic should be discontinued. Both should be continued for the foreseeable future because they just make common sense and have been practiced in Asian nations for decades to minimize respiratory tract infections of much smaller significance. A recent study from China [Zhang et al., Science 2020;368(6498):1481-1486] quite convincingly confirmed the positive effects of social distancing alone on COVD-19. Real men (and women) practice social distancing and do wear masks!
An interesting, though somewhat controversial, article published in the June 29, 2010 issue of JAMA by Halpern et al. (2020. Doi:10.1001/jama.2020.11623) addressed the cognitive bias and public health policy during the COVID-19 pandemic. In this article the authors asked the following question:
“Why are so many people distressed at the possibility that as patient in plain view-such as as person presenting to an emergency department with severe respiratory distress-would be denied an attempt at rescue because of ventilator shortfall, but do not mount similarly impassioned concerns regarding failures to implement earlier, more aggressive physical distancing, testing, and contact tracing policies that would have saved more lives.”
They concluded that the likely explanation were errors in human cognition that prioritize what can be readily understood over more abstract conclusions based on statistics, prioritizes presence over future and direct over indirect conclusions. They further concluded that these cognitive errors distracted leaders from optimal policy making, even at major teaching hospitals led to pursuit of illogical policies and medical practices and prevented citizens from taking steps in their own best interests. Most interestingly, they concluded that these illogical activities did not represent a repudiation of science but may have been evolutionary selected.
This article appears timely in view of our, here repeatedly noted, criticism of “expert” opinions that have formed government policies in conjunction with the COVID-19 pandemic not only in the U.S. The authors conclude in pointing out the obvious need of behaviorally informed policy making and communications with the public.
The British medical journal, The Lancet, just published a study assessing estimated indirect effects (also called “unintended consequences”) of the COVID-19 virus on maternal and child health mortality in low- and middle-income countries. The study suggested that, should as expected access to health care be disrupted and access to food be decreased, increases in maternal and child death would be “devastating.” This study is a modelling study and, therefore, as on several occasions here discussed in detail in the past, dependent on assumptions. We, therefore, are always cautious in accepting conclusions from such studies (see also the next article). Considering how devastating the virus has been in some economically highly developed countries, one, however, does have to worry about the spread of the virus into poorer countries that we have been witnessing in recent weeks and months, especially in South America and Central America.
Relevant to modelling, the June 25, 2020 issue of Nature _contains an article by Saltelli et al (2020;582:482-484) which argues that medical research requires better models. They point out in this manuscript that, “_pandemic politics highlight how predictions need to be transparent and humble to invite insight, not blame.”
We are featuring this article here not only because we have been making this point at CHR for quite some time, both here in the COVID-19 Bulletins and in our newsletter, the VOICE. This article is featured here because the authors in five distinct obversions also offer very clear recommendations. Those are:
We strongly recommend this article to everybody who, like we, was as shocked about how off-mark most COVID-19 models have been.
In a recent issue of the British Medical Journal (BMJ), the freelance medical journalist, Heba Habib, addressed another subject, repeatedly addressed in these pages and in the CHR VOICE, the Swedish model of addressing the COVID-19 pandemic, which has made Sweden a pariah state among her European neighbors. As we have previously noted, in contrast to the rest of Europe, Sweden built its strategy on the hypothesis that the country could achieve heard immunity with enough speed to prevent the need for a complete shutdown of the economy and without overwhelming its health system with COVID-19 infections. In practical terms this meant that gatherings of more than 50 people were discouraged but bars (in Sweden socially very important), restaurants and other public spaces remained open, though distancing was encouraged.
Sweden was successful in achieving the second goal. Habib now, however, declares the Swedish model to have failed. He bases this conclusion on Sweden having higher infection rates than all other Scandinavian countries, the highest mortality (5.2/1M inhabitants) in Europe but mostly because Sweden appears to have been unsuccessful in building up the necessary herd immunity: Only 7.3% of Stockholm residents (the highest rate in the country) were reported to have anti-viral antibodies. Herd immunity is usually reached at ca. 60% (or more) levels and, in consideration of innate cellular immunity, as a recently here discussed study suggested, maybe, with COVD-19 already in the 40s. Based on low antibody detection rates in other countries (Italy and France), the by now rather infamous World Health Organization (WHO), indeed, has recently warned against the strategy of pursuing herd immunity.
The numbers, of course, speak for themselves and Sweden has, indeed, to be viewed as at least a partial policy failure (even acknowledged by the architect of this policy). Where we, however, cannot agree with the conclusion is, that the Sweden experience negates the concept of herd immunity. There are two principal reasons why we view the Swedish experience a little differently from Habib. The first reason is that nobody ever promoted a concept of only relying on herd immunity. Working with the concept of herd immunity always meant to try to maximize development of herd immunity in a population, while vigorously protecting vulnerable subpopulations, like the elderly.
And this is where Sweden mostly failed. It, simply, ignored its high-risk populations and especially the elderly. Over 48% of Sweden’s COVID-19 mortality happened in old-age homes, an even higher rate than in the U.S. This represents a principal error in how Sweden executed the country’s COVID policy. That the peak antibody-positivity in Sweden was only at 7.3% is, indeed, somewhat surprising, considering the rate was in Manhattan, already weeks ago during peak COVID-19 infection rates, in the mid-20s and by now probably is even higher. In addition, as Habib also notes in his article, testing in Sweden is pretty poor. One, therefore, has really to wonder about these reported rates.
Two additional point are important to make, both previously discussed here in Bulletins: (i) It is now well established that immunity from antibodies (so-called humeral immunity) is only part of total anti-viral immunity. As we recently reported here, it is now also confirmed that anti-viral immunity often is so-called innate or cellular immunity, transmitted not through antibodies but through specialized white blood cells (see also the next section). This form of immunity has not been tested in Swedish populations but would unquestionably significantly raise the percentage of individuals immune to the virus. (ii) We in an earlier section above also noted the likelihood that COVID-19 exists in multiple mutations with, likely, different infectivity. As NYC well demonstrated, here pervasive virus was highly contagious and also highly antigenic (i.e. effective in eliciting an immune response). Whether the virus in Sweden has the same characteristics is not known.
Because the concept of herd immunity applies to almost every other virus, including earlier COVID viruses, it is extremely likely that it also applies to COVID-19. To give up on the concept of herd immunity, therefore, in our opinion would be a mistake. As we noted in the earlier section, the observation that NYC did not experience a spike in cases following weeks of large demonstrations which completely ignored distancing and face masks, may be strongly suggestive of NYC already having achieved a certain level of herd immunity.
In the July 2, 2020 issue of the New England Journal of Medicine (2020;383:4-6) an article by the geriatrician and writer, Louise Aronson, MD, MFA, from the Division of Geriatrics, Department of Medicine, at the University of California, San Francisco, caught our attention. Based on a patient she encountered, she penned the following remarkable paragraph:
“During a pandemic in which 80% of U.S. deaths are in people over 65, especially affecting those who are around 80, with underlying conditions, health leaders and clinicians might reasonably conclude that the’re too busy saving lives to also consider preventing the hazards of hospitalization for elders or their post discharge lives. In a crisis, they might argue, different rules apply.”
She then, however, using that patient’s story, wonderfully debunks this argument, reminding us of the value every patient’s life has. We strongly recommend not only this article from this physician and author, which was obviously written for the medical profession. She, however, has also penned two wonderful books for the public we recommend (“Elderhood” and “A History of the Present Illness”) and is definitely worth a visit to her website (https://louisearonson.com/articles/).
Two prominent individuals published on July 1, 2020 in The Wall Street Journal on the opinion page a brief opinion piece, titled, “An old vaccine may help against Covid.” One among them is the well-known AIDS investigator Robert C. Gallo, MD, currently director of the Institute of Human Virology at the Maryland School of Medicine and a co-founder of the Global Virus Network. The other is Daniel J. Arbes, CEO of Xerion Investments who is also a member of the Global Virus Network board.
What both authors point out in their piece is that there is now considerable evidence that the old-fashioned oral Salk vaccine against polio for at least 3-4 months boosts innate immunity against viruses in general, including COVID viruses and, likely including COVID-19. Similar effects have also been reported for TB-vaccines. Their proposition is that this oral polio vaccine, which has been demonstrated to be extremely safe, be used as a “bridge-immunization” for at least high-risk patients, - if not for everybody, until a _specific_anti-COVID-19 vaccine becomes available.
Overall, we are sensing that things are looking up, despite the recent increase in case numbers we have been witnessing is some states. We just wish the media would do their homework before publishing inflammatory reports that do not inform, but unnecessarily frighten the public.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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