By my count, it is week 18 of restrictions imposed upon us by the COVID-19 pandemic. It feels like “the new normal” has set in. Here in Pennsylvania, all of the state is in the so-called “green” phase, where the remaining businesses have opened, and we can now go to bars and restaurants albeit with masks and appropriate distancing. Our case numbers per day continue to trend downward except in Allegheny County (Pittsburgh). There the numbers are slowly increasing.

There is been great concern about the surge in new coronavirus cases in multiple states. Florida for instance has seen a significant increase in new cases over the last several weeks. If you look at the long-term graph of cases per day however, this surge looks like the state’s first true peak. Deaths are on the rise there. Interestingly there are reports out of Florida that a significant number of sites had an 80-100% positivity rate (our positivity rate in April was around 27% which is typical). This sounds like there are testing issues in the Sunshine State.

Georgia, which up to now had been fairly quiet, has seen its own increase, but so far deaths are flat. Another hot spot, Texas, new cases, and deaths are continuing to rise at this point. This is mainly centered in the cities and much of Texas remains quiet.

I should point out that the Texas hotspots of Houston, El Paso, and Austin were the site of significant protesting/mayhem in previous weeks. This is also true of Miami, Seattle, and Portland Oregon, where cases are also rising.

My concern about this situation regards the data on which it is based. Because it appears there are serious problems with the acquisition and reporting of COVID testing that could lead to bad decisions down the road.

There have been several interesting articles published in the last several weeks. Several sources I’ve pointed out that state by state, reporting of new cases uses different methodology. The CDC and apparently some states report both positive PCR tests (swab test), and positive antibody tests (blood test) as new cases (I understand this is true in PA). This is problematic.

First off, PCR test, or polymerase chain reaction test looks for pieces of the coronavirus RNA. This RNA can be present on your mucous membranes whether you’ve been merely exposed to the virus but not infected. The test detects segments of RNA that can either represent either intact virus actively spreading, or fragments of virus successfully destroyed by your antibodies or T cells. So, it may report a failed infection as positive.

Also, it is important to remember that we are reporting positive tests, not positive patients. If the patient has a positive PCR test, and weeks later has a repeat study and it remains positive, then that’s counted as another positive test even though it’s on the same person. And again there is the thought that the positive PCR in that situation may reflect the presence of viral debris at the end of the infection. So any way you look at it, it is bad data.

The antibody test, as most people know is geared to discover whether someone has been infected in the past. If we count these positives in the same way we count the PCR, then we can give the false impression of additional viral spread occurring in real time when that is not necessarily a valid conclusion.

Also, the dynamics of testing have changed radically in the last 3 months. It used to be that you needed to have very specific symptoms and be in a high-risk group to obtain a nasal swab test. Now you can essentially obtain testing on a whim. Thus, it is likely that many more asymptomatic patients are being tested.

We do know that the uptick in cases has also involved a roughly 10 years shift in average age downward. This means that the average person exposed is likely much less vulnerable.

 So, if a younger patient tests positive by PCR but has no symptoms is this really an actual infection or an aborted one? These are questions I don’t think we really understand. But we still count them as positives.

So, it would appear that the actual impact of each additional positive coronavirus test in July may be different than one in early April.

Need evidence of this? There is recent data from the University of Pittsburgh suggesting that the recent strain of COVID being encountered is perhaps less virulent than previous sprains. They note that only 2% of people who test positive now require hospitalization. And only 0.2% of cases result in death, far lower than previous statistics. Given the different profile of patients getting tested this might actually have been true all along.

There is another thing to consider. When we locked things down in March, we had little to no knowledge of how to treat these patients. We had shortages of hospital beds, PPE’s and of course ventilators.

Now, 4 months later, the healthcare system has adequate supplies and additional expertise in the care of these patients. We figured out how to reprioritize and add additional patient care units and negative pressure rooms. New discoveries in therapeutics are reducing the severity of illness and shortening the length of admissions. We are far more ready and capable than we were in the spring.

I should mention the hydroxychloroquine study out of Henry Ford Hospital in Detroit. They studied patients hospitalized with COVID. In one leg of the study, the patients were treated with hydroxychloroquine alone. These were compared to patients but did not receive the drug. The mortality rate for those in the treatment arm was 13% as opposed to roughly 26% in the nontreatment arm. There were negligible cardiac difficulties, which is the main concern over the use of the drug. This is a peer-reviewed study, the first significant evidence for use of the drug. So it is likely we can finally add this medication to remdesivir, and dexamethasone in our anti-coronavirus armamentarium.

There is also emerging information that many people may well have had some degree of both antibody and T-cell immunity to this particular coronavirus based on previous exposure to the “common cold” coronavirus that we have all encountered for most of our lives. This virus may not be so “novel” as we have been told.

I guess what I really want to say is this: We need to be careful about how we react to these surges.  In places where the healthcare services start to become strained, then we need to react strongly to avoid further spread. But in places where the numbers merely go up without much impact, then we need to remain vigilant,. We need to protect the vulnerable, but continue to go about our business with precautions in place.

As I am a compliant soul, I will wear my mask and observe the CDC recommendations. I will respect the businesses I visit, and obey the rules so they will not be penalized by the state.

So I wrote the words above between Monday 7/13 and Wednesday afternoon 7/15. I just needed a punchy way to end it.

I get home and turn on the news only to find that his Majesty the Governor has reimposed lockdowns?… on the whole state? He has targeted the bar-restaurant trade which I suspect he views as a more frivolous business and the least defendable (tell that to the owners and employees).

There is no justification for this in the state’s own data. First off, cases were bound to kick up a bit when we went to green several weeks ago. Then there is the fact that the increases are limited to a few counties in the west. Remember the announcement above from UPMC?

So I went to the State’s own COVID Early Warning Dashboard. In Allegheny county, the PCR positivity rate is 7.9%. The percentage of ER visits related to COVID is 0.9%. Pittsburg has multiple very large hospitals. There are 80 patients admitted with COVID, only 9 on ventilators. All of this in the State epicenter.

I’m sorry, but this feels purely political. It is tyranny in the Commonwealth of Pennsylvania.

What do you think…punchy enough?

It’s late June here in Northeastern Pennsylvania. Up here in the highlands, the mountain laurels in my yard are in bloom. I know from experience that the vast expanses of laurel in places like Hickory Run State Park, and in Sullivan County, on the Loyalsock Trail, will also have erupted. It’s time for some hiking and photography.

Here in Luzerne County, we are finally in the “green” phase of our coronavirus lockdown. Our benevolent overlords will finally let us live life in a quasi-normal state. Businesses can reopen, providing they attend to mask-wearing, and social distancing.

We can now sit at a bar, even one indoors, and enjoy eating in a restaurant so long as the capacity is properly limited, and the tables appropriately spaced. There are some quirky rules, like the requirement to wear a mask on entering a restaurant, but not after you are seated. People, I think, sense the illogic of this, which will ultimately erode compliance.

Of course, while we all politely comply with the state edicts, all sorts of people are out on the streets of our larger cities rearranging the statuary. I suspect their mask usage has less to do with protecting others and more to do with protecting their identities.

We are seeing additional cases of COVID reported. In our county, the numbers of new cases per day are generally in the low single digits. Hospitalizations and deaths also continue to decline statewide. There have been no changes in this with the phase changes, suggesting that perhaps a seasonal effect is indeed happening.

In reviewing the numbers from the various states, there are certainly curiosities. First, while it is true that daily numbers of cases in Florida and Texas are increasing, when you review the overall curve, you get the impression that they actually never peaked. This is true also of some of the Western states like California. There the curve has been slowly rising since March. Interestingly though deaths per day are flat or decreasing perhaps again suggesting a decrease in virulence of the virus.

Florida had a very minimal early peaking in early April, began to gently decline, and now has had a precipitous rise starting perhaps a week ago. Mortality, however, remains flat to decreasing. Deaths are obviously a late effect however so there still may be a bump there.

Georgia is also seeing an uptick in cases. They originally peaked in early April and were having a slow noisy decline in activity. Within the last couple of days, they had a second higher peak. Georgia as you may recall lifted its lockdown in late April, but still declined for weeks afterward. Another state with this profile is Washington which also peaked in April and now has had a higher second peak again within the last several days.

Given that Atlanta and Seattle have been the sites of some significant mayhem starting perhaps 3-4 weeks ago, I do wonder whether there is a relationship.

Another interesting detail is that the new cases are shifting to the young, which is probably explainable by the fact that they tend to be the ones most eager to take advantage of reopened social venues (not to mention the protests, etc…). It may also be why the death rates have so far not increased.

Perhaps I’m suffering from fear fatigue, but I’m at least personally not as frightened at the possibility of acquiring this infection. Other people still are though, and particularly of contact with me. This is hopefully because of my status as a healthcare worker. It is kind of ironic, because as the cases dwindle, I am largely confined to my office, and have not had any known COVID exposures in more than a month. I suspect there is more risk of exposure out in public than here at the VA, where we screen everyone who enters the building and test everyone we treat.

Anyway, it’s nice to be out and about, to catch up with friends and acquaintances, and to sip a draft beer (albeit from a plastic cup). And is nice to see my 94-year-old father be able to emerge from his quarantine and enjoy a restaurant (on an outdoor deck). Conversely, it sad to see those businesses could not tolerate the lockdown and will never reopen. I hope the owners and workers find other opportunities.

Still, it’s still worth being careful. The virus is still in the population, hopefully, weakened and decreasing in prevalence. I sincerely hope it fades away over summer, not to return.

In the meantime, I’ll be out with my camera and my tripod surrounded by the white blossoms of a Pennsylvania June (and probably the damn blackflies).

Enjoy your new freedom. I hope it lasts.

We are now in week 12 of the Wolfe/Levine coronavirus religious and economic lockdown. Most of the eastern portion of Pennsylvania is now in “yellow phase”. This does allow more businesses to open. It includes the so-called nonessential merchants, as well as bar/restaurants, the latter so long as they have an outdoor deck. “Personal-care” businesses such as barbers and hairstylists are still closed.

We found out yesterday that on June 19th, Luzerne County will be permitted to move into “green” phase. As great as it sounds, the rules for this phase are still very restrictive. I guess we should be grateful our benevolent overlords will permit us a little bit more of our rights.

Looking back on the previous weeks, I’m still puzzled by the whole question of nonessential businesses. Wouldn’t it have been smarter, for instance, to allow more retailers to stay open which would have the effect of spreading the pool of shoppers over a larger number of businesses?

Not that anyone cares about this in the governor’s office, but also wouldn’t that have been fairer?

Now that we are opening up, it would’ve been easy to rationalize some of the unusual precautions required by the new rules, such as temperature taking greeters, and mask-wearing waitresses. Hell, we’re all just glad to be out.

But then there was the vision of our governor, admittedly masked, but standing shoulder to shoulder with others in a large demonstration in Harrisburg (Dauphin County “yellow phase” no gatherings larger than 25 people). We watched as the ultimate zealot of pandemic propriety flouted the rules that he imposes on us non-protesters. No matter how worthy the cause, Mr. Wolf’s actions were hypocritical in the extreme. Kind of makes the “6-foot rule” feel silly doesn’t it? Remember, this is the man who called people protesting the unconstitutional lockdown “cowards”?

Want to protest and maybe do a little vandalism and looting? Apparently, it’s OK. Want to worship? Not so much.

 Almost as perverse was watching our health secretary, Dr. Levine using pretzel-like logic to justify the governor’s behavior.  Does anyone now doubt that the prolongation of the restrictions was purely political?

I don’t.

A couple of thoughts on the virus itself:

First, the WHO keeps changing its opinion as to whether asymptomatic people are likely to pass the infection on to others. First, they claimed that this is unlikely. Then they kinda backtracked. If the former is true, it suggests that taking one’s temperature on entering a business makes some sense, and there are technologies evolving that will allow us to do this automatically.

I do wonder however whether we should revert to the original CDC recommendations for facial coverings (only for patients known to have COVID 19, and their caregivers). I have certainly noticed as time goes on the people are getting more and more cavalier about masks, and I suspect their use will continue to decline.

The numbers of cases are certainly coming down. As I write this our local paper reports that there are no new cases in Luzerne County in the last 24 hours. This is likely the first time this is been true since mid-March.

When you look at the graphical data there is a clear decline since about mid-April. From March 15 to last Friday when we went into “yellow” phase, our county’s precautions have been in a steady state. If the virus had a constant level of infectivity, the curve should’ve leveled off at a roughly steady rate of increased cases/day, instead of steadily dropping as it has. To me, the continual decline suggests that something else is at work. it might be that the hoped-for warm weather decrease in the virus’s infectivity or virulence is real. Let’s hope this is the case.

There is talk of bumps in infection numbers in Texas and Arizona that some will blame on reopening. The infection rates in those communities are still very low and likely explained by significant increases in testing volume over time.

Though I am hopeful, I have no illusions. There is still COVID 19 in the environment, and if the wrong person ingests a significant amount of virus, then they may get sick and even possibly die. It will be some time for instance before I encourage my 94-year-old father to go out in public. It does not appear however that the average young or middle-age worker, or customer is at much risk. As long as the vulnerable are protected, we need commerce to resume.

I will be glad when we are finally allowed a more normal way of life.

Unless of course, our governor and his protesting friends cause another bump.

Who’s the “coward” now?

We have now reached week 10 of the Wolf/ Levine “2-week lockdown to flatten the curve”.

For my county, Luzerne, and other counties in eastern Pennsylvania, there is a tiny light at the end of the tunnel. On Friday, we are going to be allowed to exercise a slightly larger sliver of our former civil rights. We are moving into the “yellow” phase.

For many people, this will seem like thin gruel. Though the governor will allow us to open more of our businesses, which will undoubtedly help some to survive, he still refuses to allow restaurants, hair care professionals, athletic facilities, and shockingly, the almighty casinos to reopen. Schools also remained closed, even though children are minimally affected by this virus. Church services are still functionally forbidden.

He is finally allowing much of the Northwest of the state to move into the so-called “green” phase. Even this however is rather restricted with some businesses limited to 75% of capacity, and bars/restaurants limited to 50%. The governor likes to refer to this as “the new normal”.

He now apparently believes, that we cannot return to baseline until there is a vaccine (presumably one that is widely available). Perhaps conveniently for him, this is unlikely to occur before early November.

If I lived for instance in Tioga, Cameron, or Sullivan County each of which has low single-digit numbers of cases, and no deaths, I would be furious. These counties have likely had more influenza cases than COVID cases, yet they are only now being allowed into the “green” phase. Imagine owning a small business in say, Coudersport, and watching it fail, arguably for no good reason.

Germane to this, is new data out of the CDC suggesting that the death rate of this virus, based on the ever-growing number of documented asymptomatic cases, is down to about 0.25%. This is roughly what is seen during a bad influenza year.

,Another fascinating study has found that 40% of random blood samples collected from patients prior to the pandemic have immunologic cross-reactivity with COVID 19. In other words: some of us may have had full or partial immunity to this coronavirus all along. This helps to explain so many infected ended up asymptomatic or with very mild cases.

As I reflect on this, I think most everyone supported a short period of lockdown, especially given circumstances such as those in Italy, and of course in New York City. It was not unreasonable to think that such a dire situation could’ve happened here. It clearly did not, but despite this, the lockdown continues.

In fact, most of the severity of COVID 19 in Pennsylvania occurred because of the Wolf/ Levine decision to insist that infected patients be admitted to nursing care facilities. This of course occurred at the same time Dr. Levine insisted her elderly mother be moved from just such a facility, to a hotel. I don’t really want to fault a decision to protect an aging parent, but the sense of risk to the mother should have absolutely informed the decisions affecting other elders at risk.

If one looks at deaths per 100,000 of the population, Pennsylvania’s number is 40. Florida, early on did the opposite and prohibited COVID patients from admission to nursing facilities. Their death rate that is one quarter as large. As more than 2/3 of deaths in Pennsylvania involved nursing facilities or personal care homes, the numbers make sense. And remember, Florida locked down less severely, and opened earlier, than Pa.

Now to be fair, there was a concern at the beginning of the pandemic that hospital beds would quickly fill, and nursing homes would have to be utilized for convalescing patients. On the other hand, the first outbreaks in the country, occurred in Washington state where it swept in deadly fashion through nursing homes in the Seattle area. This might have been a clue as to what not to do.

At any rate, the disease statistics being used to justify our imprisonment were mostly the result of faulty decisions made at the beginning of this pandemic. And so far as I can tell the governor’s emergency powers have no time limit.

I was curious about what limitations different states place on their executive branch during times of emergency. It turns out that 35 states are like Pennsylvania, in that they allow the governor to change both statutes and regulations under emergency powers. Seven states allow Governors to only change regulations, and 8 states give the governor no explicit power under these circumstances.

While we need to our governors, to have flexibility during times of emergency, this should have limits.

We need to revamp the system. I imagine the law modified so that at some point, perhaps a month, any emergency authority should expire, which would relax all the restrictions that have been imposed. This would occur unless the state legislature voted to extend the time limits. Any extension by statute ought to itself be limited, requiring additional votes. This would force the governor to work with the legislative branch, rather than reject their input as Governor Wolf has done.

I have no wish to disparage fellow public servants who in the beginning, worked very hard to contain this pandemic. Happily they succeeded. As this drags on, it is not hard to believe that other factors are at play.

And they’re likely no longer about us.