COVID-19 Update X

General Course of the Pandemic

There has been a sharp spike of cases in the United States. At least half of the new cases are bunched in our most populous states. Texas, California, Florida, and other states have felt obligated to walk back some of the “reopenings” that they had approved. Hospitals in many states are feeling a certain sense of urgency. I have heard a couple of reports that there is concern that we will have still another shortage of PPE to protect all essential workers. Part of the surge in positive tests is due to the increased number of people being tested. By no means does this account for all of the increase. Death rates per 1,000 population and per case have decreased. Experts attribute the decline to several factors: An increased proportion of the positive cases come from younger people, who tend to have milder disease; we have gotten better at treating those people who require hospital stays; there is better follow-up of those who test positive.

The rest of the world remains split. The European Union is successfully reopening. All member countries have had flares of outbreaks here and there. They are being handled forcefully. All of the Americas south of Texas are doing poorly. They will probably get worse. Africa shows signs of worsening. Australia and New Zealand are doing well, and Southeast Asia continues to be a model for all of us.

Most experts believe that the death rate from infection (this counts people who are probably positive but have not been tested) is a bit less than 0.7%.

Although this sounds (and is) encouraging, we have to remember that:

1. This does not mean, like our president says, that 99% of cases are “mild.” The president fails to count those people who were infected, ended up in the hospital, and took weeks to recover. Many of these people, although they are out of mortal danger, still feel like crap and are nowhere near close to functional.
2. We do not have accurate numbers as to what the death rate is for people who have preexisting conditions. It is at least 7%.

There has been a recent report from a scientist that felt that the WHO and CDC were not paying enough attention to transmission of the virus via aerosol droplets. He advocates that buildings should have more efficient filtering systems for recycled air. A brief lesson on droplets: Sneezing; coughing; singing and loud talking; all generate larger size droplets.

Because they weigh more, they fall to the ground or floor faster (please do not remind me of Galileo and his Tower of Pisa experiment; larger particles do fall faster because they do not float as well). Also because of their size, they carry a higher number of virus particles. Aerosols remain suspended for much longer but are only able to carry a few copies of virus per droplet. In theory, it is possible that you could walk into an empty room and still be prone to getting infected if there are a few “infected” droplets hanging around from the last time that the room was used. This reinforces the need to use masks whenever you are indoors. But to be realistic, the chances of any person becoming seriously ill from such an exposure is vanishingly low.

Testing

One report that I read today says that many workplaces have given up on testing employees. At $100 a test, with dwindling supplies, and the need to repeat tests at least once a week, this frustration is understandable. I cannot understand why we have not fully thrown ourselves into testing ten people with one test, or examining sewage, which are much cheaper alternatives. Tracing of contacts of people who have positive tests is in its infancy, and therefore in need of much improvement. One report that I read said that half of contacts did not answer their phone (which is what I do when I get called by a number that I do not recognize). Use of social media looks like a good alternative, but we are so obsessed (I do not use this word in a negative sense) with privacy and individual rights that a Facebook/Instagram solution to the problem, although likely to work, may never be adopted.

Treatment

An article published in Cell, a very respected journal, says that inhibition of a class of enzymes known as kinases inhibited the reproduction of covid-19 viral particles in the lab. This could be a game changer. There are many oral, once a day, kinase-inhibiting medications available. They are mostly used to treat cancers and autoimmune conditions, but what we call their “therapeutic repertoire” is potentially vast. Side effects are minimal. Since there are many kinase enzymes in our bodies, the next step is to figure out which enzymes the virus most depends on, and then to see which of the medicines that we have now best inhibits this particular protein. The most promising part of this scenario is that we already have these pills available, and that safety studies would therefore not be necessary (or would not need to be as exhaustive as what “new” medicines are subjected to).

I listened to a TED talk with Bill Gates; a recent one. Like me, he thinks that monoclonal antibodies are our best hope in the near future. Using these antibodies is like cheating on a test: we figure out what protein our bodies make in response to an infection or a vaccine. Instead of getting injected with a vaccine and hoping that we make enough “good” antibody to protect us from the virus, we make this “good” antibody in the lab and give it to everybody. In this way we do not have to worry if the vaccine will work or not. The problem is that monoclonal antibodies are a lot more expensive than vaccines, so we would have to restrict their use to people who are at high risk. Because we have vast experience in dealing with antibody injections or infusions, we expect side effects to be minimal.

Vaccines

My favorite sport these days is making up a list of how many vaccine candidates are in development. I have read numbers ranging from 120 to “more than 180.” For sure someone, whom I will call “Vaccine God,” knows what the exact number of vaccine candidates is, give or take 1%. But so far this “Vaccine God” has chosen to remain silent, so we depend on people who think that they know what they are talking about, and in good faith spread their own brand of gospel. I make light of this, because it does not matter if we have 120 or 180 candidates. My gripe is that there should be an international consortium that is given this task, and that we have failed; all of us; to grasp this golden chance that we had of finding ONE THING that we could agree to work on together.

Progress on the Moderna and Astra Zeneca vaccines continues. Large-scale testing is due to start soon. It is a bit disconcerting to hear that the US has agreed to pay Astra Zeneca four times as much per vaccine as the UK has agreed to pay. This after we have funded much of the research and the money needed to ramp up the factories. Also disconcerting to see that Moderna stock has tripled in value, thus making its CEO an instant billionaire, even though Moderna has never made anything that has been approved by the FDA. Although just about everyone has promised to keep the vaccine affordable for all of humanity, we have not heard a peep of promise as to what they will charge if a yearly, or biyearly, “booster” is needed. The commercialization of medicine in this country has reached the pinnacle of obscenity. I do not know what it will take for our citizens to begin to demonstrate about this matter with as much fervor as they have about income and racial inequality. The stakeholders have done an excellent job of convincing a majority of the population that they will be subjected to death panels, years of waiting to be seen for a sore throat, and emasculation of physician independence to diagnose and treat as best fits the situation. Hard to tell where to start fixing things because there is a lot to fix.

Keep wearing your masks. Be nice to essential workers; tip when you can.