19 June 2020 – Friday – #96

I have questions.

Seven months into the Covid-19 pandemic and there are still so many questions.

Three things seem unequivocal: social distancing is the best way to stop the spread of the virus; masks contain the virus reasonably well at the source; and, hand washing is an effective way to protect against contact with surface contamination. I write seem because current evidence is good for these, but experts could decide differently as they learn more. A recent meta-study in the Lancet confirms social distancing greater than a meter and mask usage reduce the spread of Covid-19.

There are attributes of the virus that have better measurements now than at the beginning of 2020. Covid-19 is significantly more deadly than the seasonal flu. The SARS-Cov-2 virus appears to have an initial R of 2 – 3 and an IFR on the order of 1%, although this seems to vary by region based on virulence of the strain, demographics, healthcare system, etc. Covid-19 mortality correlates to varying degrees with old age, blood type, baldness, comorbidity factors, and lower socioeconomic status. As with IFR, many of these correlations vary by region. Finally, the SARS-Cov-2 virus does not appear to mutate rapidly enough to thwart vaccine efforts.

From a public health perspective, it is clear that an effective Covid-19 response is not correlated with a country’s wealth. The most effective responses implemented testing and contact tracing to contain infections and avoid an outbreak. The next best responses used lockdowns and social distancing after an outbreak, presumably to be followed by test and contact tracing once infection levels drop. The worst responses have been in countries that have allowed Covid-19 to overwhelm their healthcare systems and shut down their economies.

Here are some unanswered questions about Covid-19.

  • Where and when was the first human case of Covid-19?
  • How is Covid-19 spread?
  • Can masks alone reduce R to less than one?
  • How much do children spread Covid-19?
  • Is there a common set of characteristics to superspreader cases?
  • Is a quick screen possible for Covid-19?
  • What is the complete pathogenesis of Covid-19?
  • What causes 5% – 10% of cases to develop severe or chronic Covid-19 symptoms?
  • Is Covid-19 a respiratory disease, a vascular disease, or both?
  • How strong is immunity after a case of Covid-19?
  • How long until there is a Covid-19 treatment or vaccine?

Many of these questions have partial answers, but are missing significant or useful details. Most of these questions become academic after a treatment or vaccine enable society to return to “normal.”

There are other questions that may help in the future.

  • What are the common attributes of countries with the best and the worst Covid-19 responses?
  • Why do countries with female leaders manage Covid-19 outbreaks better?
  • How did manufacturers and supply chains adjust during Covid-19 responses?
  • Are there economic institutions that would help navigate future viral outbreaks?
  • What international, national, and local public health institutions will help in a world of increasing viral outbreaks?
  • How did science change to respond to Covid-19 and how can it improve next time?
  • What government regulations will help manage the next outbreak?
  • Did reductions in carbon-based energy consumption during the Covid-19 lockdowns provide data that helps model climate change?

Those are my questions after three months of writing about Covid-19.

I want to cover two topics quickly. One is the role of children in spreading Covid-19. This is a constant conundrum for a few friends who have four and five year olds—Nicole in Barcelona, and Shane and his husband John in Berlin. They have lots of good questions. Should the kid go to school or childcare? Should the kid play with other kids? Is the kid a strong vector for Covid-19 into the home?

When I talk about this with my friends, I always say I don’t think there are any good answers for these questions. That doesn’t help my friends but, in fact, a recent article confirms that there aren’t good answers for how raise kids during the Covid-19 pandemic.

Covid-19 doesn’t cause many deaths or even symptomatic cases in children and that’s a double-edged sword. The good news is that it’s highly unlikely your kid is going to get sick, let alone die. The bad news is that, since it’s highly unlikely, no one is studying it. Well, there are a few studies, but not enough to provide good guidance to parents.

What’s worse is that the real world results are all over the map, as it were.

Denmark reopened schools in mid-April, without serious disruptions. But when classes resumed in Israel in May, infections among children and teachers flared. In China, where a cluster of cases in Beijing has everyone on edge, authorities moved quickly this week to preemptively close schools.

Stat, “How likely are kids to get Covid-19? Scientists see a ‘huge puzzle’ without easy answers,” 18 June 2020.

I wish my friends and all other parents the best of luck! Right now, there are no right answers.

The other topic I want to cover quickly is masks. I am a convert on this topic because the information changed and because the expert recommendations changed. Not everyone is a convert, however. In the US, masks unfortunately have become yet another partisan symbol.

American and United both started requiring masks on their flights this week. A conservative pundit delayed the departure of a flight yesterday, claiming he couldn’t be forced to wear a mask. He was removed from the flight, put on a later flight on which he did not wear a mask, and now he is banned from the airline.

In California, Governor Newsom ordered mandatory masks throughout the state. The Orange County sheriff, who refused to enforce the county’s mandatory mask order, also refuses to enforce Newsom’s order.

But masks seem to be working. Public health officials were concerned that the large BLM protests over George Floyd’s murder would create a spike in Covid-19 infections. Those spikes should have shown up by now.

The absence of surges in the cities with massive demonstrations but few other large gatherings has taken many officials and health analysts by surprise. However, as they’ve examined the data and the video footage, one thing has clarified matters, to an extent: A large percentage of the protesters wore masks.

Slate, “It Doesn’t Look Like the Protests Are Causing a COVID-19 Spike,” 17 June 2020.

So the question for Trump’s Tulsa rally tomorrow is: will Trump supporters wear masks? I hope they do, but if they make it a partisan issue, it also becomes a kind of Darwinian issue, too.

18 June 2020 – Thursday – #95

Two news items today. First, Barcelona is moving to Fase Tres! We’ve reached the New Abnormal!

Spain has reached the New Abnormal with not a small amount of controversy over its Covid-19 mortality reporting. Matthew Bennett points out the discrepancies.

Matthew Bennett on discrepancies in Spain’s Covid-19 mortality statistics, 18 June 2020.

Incorrect Covid-19 mortality reporting or not, things are better and people are ready to get back to abnormal. Walking past the packed outdoor restaurants along Passeig de Sant Joan yesterday evening, I didn’t have to read the news to know Barcelona was well into Phase Three before we officially arrived.

Since all of Catalonia is in Fase Tres, I believe I can take that day trip to Girona I’ve been contemplating. I cannot, however, travel to Madrid yet because it remains in Fase Dos.

Today’s second news item is closer to home. Brad got his visa no lucrativa! It’s a small miracle when it happens in normal times. It’s a gran milagro during the New Abnormal. For the record, if you need a Spanish visa, the consulates appear to be operating, but only by appointment.

If you think travel within Spain and within Europe is complicated, try travel between Barcelona and the US. It’s easy to buy a ticket for a flight. You can purchase surprisingly cheap ones.

The hard part is buying a ticket for a flight that actually will depart on the scheduled date. The flights from San Francisco to Barcelona haven’t taken off for months. It turns out there are no direct flights from the US to most European destinations. The best bet is to search for flights through London, Paris, or Frankfurt.

If you book round trip Premium Economy from San Francisco to Barcelona, as any sensible person would, you get two options.

Premium Economy options from San Francisco to Barcelona round trip, 18 June 2020.

If you pay the extra US$2,358, you not only can change your flights, but you also can choose who you want to die with sit near.

With things opening up, my European friends are ready to roll. It doesn’t look like we’ll be suffereing through a four-hour check-ins, but travel is changing the way it did after the September 11 attacks.

For instance, my friend David in Germany pointed out that each European country has a different contact tracking app and that the Google and Apple app stores are country specific. That creates a problem traveling across European borders. In each new country, it requires a traveler to set up a new account in that country, to switch his/her mobile so the app store thinks the device is in that country (which it may or may not be), and finally to download that country’s contact tracking app. Whew!

While the EU is developing a data sharing standard, every country is responsible for providing its own app with all the attendant data privacy issues. The devil, as they asy, is in the details.

In the US, Covid-19 has done to Amtrak service what Republicans have dreamed to achieve with legislation for decades.

“Due to the long-term impact of COVID-19 on ridership, Amtrak has made the decision to operate with reduced capacity through FY21. We are planning 32% fewer frequencies on the NEC, 24% fewer for our state-supported, service and plan to reduce most long-distance trains to three days per week, beginning Oct. 1, 2020.”

Christina Leeds, Amtrak spokeswoman, Trains, “Amtrak plans triweekly service for almost all long-distance trains as of Oct. 1,” 15 June 2020.

First world travel problems.

Be thankful you are not a refugee in the time of Covid-19. Refugees face life-and-death travel and relocation problems without great options.

“Refugee households are taking on additional debt and are not able to pay their rent anymore. Serious protection risks are also growing, including risks of child labor, gender-based violence, early marriage and other forms of exploitation.”

Andrej Mahecic, UNHCR spokesman, Voice of America, “COVID-19 Increases Economic Hardship for Syrian Refugees, UN Says,” 16 June 2020.

In first world countries, though, Covid-19 often starts as a disease of the upper classes who carry the virus across continents on long haul flights, only to become a disease predominantly of the lower classes.

A study of Covid-19 infections in San Francisco’s Mission District highlights the class disparities. As an example, people whose work required them to travel to work had more infections. They were disproportionately Latin and male.

Nine out of 10 of [infected] people said they could not work from home. That compares with 57% of the overall sample of workers and residents who reported not being able to work from home. Not being able to “shelter in place” at home may put people at greater risk of exposure to the infection.

Live Science, “San Francisco COVID-19 testing reveals stark burden on the poor and marginalized,” 5 May 2020.

The New Yorker published a great in-depth look at Covid-19 and homelessness. It’s a hard problem and it’s worth a read.

Sadly, I think Trump’s unconscionably poor Covid-19 management may be related to his disregard for the lower classes.

A couple of quick follow-ups on the recent Dexamethasone news. It appears the steroid provides significant benefit to severely ill Covid-19 patients. However, while the press release looks good, researchers haven’t released their data yet. We’ve seen that movie before.

Also, Derek Lowe makes two important points about Dexamethasone. First is that its application to Covid-19 isn’t actually an off-label use. It’s a steroid that reduces inflammation and immune system response, which is what it does for Covid-19 patients with severe inflammation and cytokine storms. Second is that Dexamethasone isn’t the only drug that’s been used to attenuate immune system response in Covid-19 patients. It appears that tocilizumab does the same thing, although it’s not clear yet which works better.

A few quick updates on Trump’s poor Covid-19 response.

US healthcare. A pre-Covid-19 rating of healthcare systems called Which Country Has the World’s Best Health Care? seems to line up well with Covid-19 responses by country. Germany and Taiwan scored well in the rating and also responded well to Covid-19 outbreaks. The US was rated the worst healthcare system and has, by far and away, the worst Covid-19 response of any country on the list. Trump is currently in court attempting to dismantle Obamacare without providing any alternative plan.

America First pharmaceuticals. Trump signed an Executive Order giving a company named Phlow nearly US$1 billion to create a complete Covid-19 pharmaceutical supply chain within the US. Experts say Trump’s America First effort cannot help with Covid-19 because not only will it cost tens of billions of dollars, but it also will take a decade.

Operation Warp Speed. Trump claims Operation Warp Speed will provide 300 million doses of Covid-19 vaccine safely this year. No one knows how to deliver this much vaccine safely in six months.

Hydroxychloroquine. The US now owns 63 million doses of hydroxychloroquine. That’s money that was not spent on PPE or other Covid-19 efforts. The purchases appear to have been made at the request of Trump supporters.

Those are pretty much the highlights of Trump’s Covid-19 response. The low light is over twenty US states with increasing Covid-19 cases. Also, the US is on track to pass 120,000 Covid-19 deaths today.

If you’re not worried about high infection rates because you’re betting on herd immunity, you might want to check this out. According to the Dallas NBC affiliate, a woman there has a second case of Covid-19.

17 June 2020 – Wednesday – #94

Last night Ana came over for dinner. It’s her birthday tomorrow (Happy Birthday, Ana!) and she’s waiting to hear whether she can travel down the coast to celebrate at a friend’s house. I offered her Casa Solar, of course, if Spain doesn’t allow travel down the coast. These kinds of social planning improvisations are standard as Barcelona prepares for Fase Tres of the New Abnormal. Everyone has to dance around where they can go and what they’re allowed to do.

The social improvisation comes with the feeling that life has taken on attributes of a horror movie. Everything seems normal, but it never feels quite right. Do you hug? Or go for an elbow bump? You have a sense in your life’s “based on a true story” drama that Something even more hideous than Trump’s hair is lurking just out of sight. You go for the elbow bump.

Still, we just might get out of this one alive.

An important advantage coming out of a lockdown is that the Covid-19 testing capacity developed as cases showed up at clinics and hospitals during the lockdown is freed up for test and trace programs required to keep the virus at bay after the lockdown. In fact, Spain is scrambling to apply its PCR testing resources to testing and tracing. The stakes couldn’t be any higher. “The efficiency of the monitoring measures will determine whether this spike in cases takes the form of small, contained outbreaks or a second big wave.”

In the US, the lockdowns are over. Hey, just kidding! Covid-19 testing resources aren’t available for post-lockdown testing and tracing programs because they’re still largely for confirming new cases showing up at clinics and hospitals.

In Florida, for instance, even though there isn’t a lockdown (hey, just kidding!), businesses are closing down anyway. As the state recorded two consecutive days of more than 2,000 new Covid-19 cases, “At least six bars in northern and central Florida have now announced their closures amid new Covid-19 cases, which peaked on Sunday.”

Which just goes to show that people don’t go out to bars and order a Grim Reaper with a twist. In Florida and many other US states, that Something more hideous than Trump’s hair isn’t lurking just out of sight. It’s right there on the bar stool next to you.

Which states are heating up besides Florida? Almost 20 according to rt.live.

Covid-19 R values by state, 16 June 2020.

That’s about twice as many states in R > 1 territory as there were in my first entry of June. Red lights should be flashing.

Trump, however, insists the lockdowns are over and everything is fine (hey, just kidding!). He is trying to pawn off higher Covid-19 confirmed cases on increased testing because if cases are really going up (hint: they are), then it looks like he pushed too hard to end the Covid-19 lockdowns.

Not so fast, buster.

Unfortunately, as Max Roser points out above, comparing the US to nearly any European country is all you really need to know about Trump and the US response.

Or compare the US to China. Trump loves to compare the US to China.

If Trump were brilliant he could make himself look brilliant by comparing his Covid-19 response to other countries in the Americas. Mexico, Brazil, Peru, and Ecuador have had poor Covid-19 responses, too. It makes me wonder what it is about the Americas that makes Covid-19 so happy. Maybe something the conquistadors left behind.

Covid-19 per capita mortality in countries in the Americas, 16 June 2020.

The US isn’t doing so bad compared to Brazil.

Brazil is on a trajectory to register more than 4,000 deaths per day and overtake the United States in both cases and deaths by the end of July, according to researchers at the University of Washington. But just as the pandemic is magnifying the similarities between the United States and Brazil – two continent-sized countries with extreme inequality and populist presidents – it is also revealing the chasm between them. Brazil has neither the world’s biggest economy, nor one of its strongest health-care systems, nor the U.S. Centers for Disease Control and Prevention.

The Washington Post, “Brazil on the brink of virus catastrophe,” 16 June 2020.

This US isn’t doing so bad compared to Brazil, except how did the US respond so poorly to Covid-19 when it had such a clear resource advantage.

I’m going to end with good news in the Covid-19 treatment front. The steroid Dexamethasone reduces Covid-19 mortality in severely ill patients.

The drug was given either orally or through an IV for 10 days. After four weeks, it had reduced deaths by 35% in patients who needed treatment with breathing machines and by 20% in those only needing supplemental oxygen. It did not appear to help less ill patients

Yahoo! News, “Cheap drug is first shown to improve COVID-19 survival,” 16 June 2020.

Reducing mortality by 1/4 – 1/3 with a cheap, widely available drug is great news. I don’t think it’s quite a game changer. We can’t let our hair down yet. Reducing the death rate by 80% – 90% makes Covid-19 a bit more like the seasonal flu.

Here’s a good ‘splainer on how Dexamethasone helps severely ill Covid-19 patients from Politico.