It has been 29 weeks or 8 calendar months since we locked down our society to battle the scourge of COVID 19. Nationally, we are clearly in the third run of new cases. The graphs from the Atlantic’s COVID Project reveal escalating peaks with July higher than April’s, and this new peak already exceeding July’s peak.

Interestingly, there are also 3 peaks of hospitalization, though so far they are roughly equal in size. Considering the ratio of cases to hospitalizations, it appears that a significantly lower percentage of people require admission. There is a small surge in deaths, though nowhere near as many as in April (so far).

Here in Pennsylvania, the pattern is slightly different. We had a large peak in new cases in April and a comparatively tiny peak in July.

Cases are now heading upward again in Pennsylvania with daily rates roughly double that in the spring. There have been however roughly 3 times a number of tests done compared to April however suggesting a lower positivity rate. Despite doubling the new cases the rate of hospitalization remains about 40% of what it was in the spring. Deaths have not yet surged since the summer numbers.

As mentioned, 2 weeks ago, my hospital is seeing sporadic cases of COVID, but we now have an excellent treatment protocol including remdesivir, convalescent plasma, and when necessary, steroids. I think it’s worth saying that there is much less fear among the doctors and staff this time around. Other hospital systems in town are also admitting COVID patients once again. Unlike the spring, the hospitals are now better prepared, so that elective surgeries and other procedures are still going on.

There is also recent news of a COVID strain affecting mink populations in Denmark. This virus can apparently pass from humans to mink, and then back to humans. To my knowledge, this is the first mammal with whom there is a back-and-forth spread of the virus. Still, there is no evidence that this is a more virulent strain, or that the mutation, will render it resistant to vaccines.

Speaking of vaccines, of course, the big news this week other than the election, was the announcement by Pfizer that the preliminary results of their COVID vaccine suggest a 90% effectiveness, and that immunization might be available as early as late December. This is wonderful news.

One wrinkle in this however is that Pfizer decided to try to decouple vaccine from the Trump “Warp Speed” program, instituted earlier in the year to try to speed along vaccine development. It clearly was a part of that program as evidenced by Pfizer’s contemporary press releases.

Though it’s easy to accuse them of perfidy, especially if you’re a Republican, I suspect this was actually an attempt to decrease public resistance to the inoculation.  Both “anti vaxxers” and some Democrats, expressed concern about the safety of a vaccine produced so rapidly.

There is of course a related reluctance to give any credit to the president. In this vein, Andrew Cuomo actually expressed regret that the vaccine was released during the Trump administration, rather than presumably waiting till late January?

Forgive me, but what a callous, pompous ass.

 Pfizer clearly wants to sell doses, and not have the vaccine sink into a political morass. I think any reasonable person is hopeful that it will be effective, no matter who gets the credit.

Trying to look on the bright side, the end of this mess may be in sight, as vaccination begins, and as a large number of positive tests means even more immunity throughout the community. In the meantime, we need to continue with masks, distancing, and protection of the vulnerable.

Oh, and I’d avoid Danish minks.

 Just to be safe.

As always, I’d be honored if you would share this post.

Header image: Path through the Barberry (Sony RX100 III)

We have officially hit week 31 of curve flattening, infection prevention, disease curing, bizarro world. With the weather growing colder here in Pennsylvania there has been an uptick in positive coronavirus “cases”, meaning positive PCR tests. There has been a small increase in hospitalizations, but the death curve is so far flat.

Remember that the New York Times reported that by the current method of PCR testing, up to 90% of people who are PCR positive may be noninfectious. My fear about the rising case numbers is that our governor and health secretary will use the occasion to increase the restrictions upon us. Remember the severe “red phase” lockdowns in spring. All that misery and lots of people still got sick.

Of course, the big news in the last week was the fact that President Trump and a significant number of White House staff have tested positive for coronavirus. Although there have been allegations, that the president was cavalier about masking, the bottom line was that he has been tested frequently if not every day, along with apparently anyone who was in contact with him in the White House. This clearly was an extraordinary effort to protect him from the virus. Yet it failed. It did so for one reason: this virus is ubiquitous in the environment.

He was admitted to Walter Reed Hospital, not so much because he met the criteria for admission, but because he is the president. Though apparently never requiring oxygen, or getting particularly sick, he was treated with a very aggressive regimen of medications including the antibody preparation from Regeneron which is clearly experimental. After a 2 day admission, he was discharged.

Apparently, he is testing negative for coronavirus now and has been deemed “noncontagious”. The other “infected” staffers, including the first lady, have all done well. As I understand it, no one else was hospitalized.

The Pennsylvania new “case“ numbers are impressive. On October 7 there were roughly 1400 cases reported, roughly the same number, as were reported on April 23 for instance. The difference is that on October 7 there were roughly 700 patients admitted to the hospital with COVID, versus 2700 in April. Whether these patients are actually sick from the virus, or merely PCR positive is anyone’s guess.

It’s also was noting there was far less testing being done in the spring. Clearly, either the tests are oversensitive, or the virus has changed. Maybe it’s a little bit of both.

The search for a vaccine apparently is continuing at a rapid pace. Apparently, the Johnson & Johnson candidate may have provoked some unusual symptoms in one of its test subjects and for now hold has been placed on their efforts.

So now we have increasing cases and so far, God willing, little morbidity. Given the availability of more sophisticated care for those to become ill, I continue to believe that continued numbers of asymptomatic and mildly symptomatic COVID infections is actually good news about our journey to a helpful degree of herd immunity.

Remdesivir is also in the news. On October 8 a study comparing the drug to placebo in ICU patient’s revealed that the median time to recovery, defined by the study as either discharged from the hospital or to a custodial situation was 10 days in the treatment arm and 15 days in the placebo arm. This is a fairly significant result suggesting the drug is a useful part of our growing options for the treatment of COVID 19.

I continue to believe that given the persistence of the virus, it’s declining virulence, the improvements in treatment, that we should relax the regulations killing specific industries and small businesses. We need to react, not to PCR tests, but to actual illness, hospitalizations, and death from COVID, not PCR positives with other acute medical problems.

Finally this week, the World Health Organization seems to change its mind on the advisability of lockdowns. In an interview, Dr. David Nabarro, the WHO’s Special Envoy on Covid-19, warned against using lockdowns as the primary control method for the coronavirus, for fears that global poverty and malnutrition may ultimately result. He expressed concern that for instance, the suppression of the tourist industry has impacted many destination countries severely.

In other words… after eight months of masks and misery, people continue to be exposed to this virus. Time for plan “B”.

Hopefully, Governor Wolf is listening.

As always, I’d be delighted if you’d share this with your friends.

Header image: Maple in the Glen (Fujifilm X100V, TCL X100 II)

It is week 20 of the coronavirus lockdown. For a man of my age, between the pandemic, the sometimes illogical/irrational Government response, and the everlasting urban mayhem, this is clearly the most bizarre time period of my entire life.

Here in Pennsylvania, presumably due to a rise in cases in western Pennsylvania, our governor has re-imposed restrictions on bars and restaurants. The first version of this specified that there could be no bar seating, and customers had to buy food if they wanted a drink.

Understandably, many already struggling taverns created inexpensive food items for patrons who wish to have a libation while sitting at a table. Curiously, Governor Cuomo in New York, imposed the same rules on his state. This occurred despite the fact that the number of new cases in that state were minimal.

Apparently, New York bars and restaurants followed the Pennsylvania practice, and soon there were “Cuomo chips” made available to patrons.

For absolutely no discernible reason, other than perhaps pique, both Governors imposed additional rules requiring that A “substantial meal” be served. Andrew Cuomo made it clear that for instance “chicken wings” don’t qualify, undoubtedly endearing him to western New York voters.

All of this is ridiculous. I think of restaurants that I frequent in places like Sullivan County, Pennsylvania (5 confirmed cases), or Hamilton County New York (same statistics) which were forced to stay closed from March to June, only to have restrictions re-imposed once again for no good reason. No wonder that a recent Yelp survey reported that 53% of their member restaurants were closing for good.

I recently visited an establishment where I sometimes go for lunch on my day off. I usually sit at the bar, talk to friends, have a beer, and a single slice of sausage pizza (I love the crispy texture of re-baked crust). The slices are large and it’s more than enough food for me.

My waitress on that day was unfamiliar. I dutifully sat alone at a table, no friends around. I ordered my usual slice of pizza with a beverage and waited.

She came to the table with the pizza and beer and then informed me that although they would honor my order today, the slice of pizza was inadequate to be considered a meal, and they would not do this again. I was also told that I could not have another beer regardless of whether the pizza was finished. The restaurant, often quite busy on a Thursday, was minimally occupied. I can’t imagine why.

What kind of madness is this? Is the state now determining what I eat for lunch? And how does this protect anybody from COVID? Or is it just meant to add to the general misery? You decide.

I would be remiss if I didn’t discuss the surge in cases throughout the southern US. There are likely multiple reasons for this from the parallel surge in Mexico, to the loosening of COVID restrictions. Spring break activities may well have played a role.

The climate may also have something to do with this. While the Northeast in March April and May were “hotspots”, the South had minimal problems with really no “peak” like we experienced in April. It was a cold spring in the North and for most of us, we were trapped indoors, while people in the South presumably spent more time outside.

Now in summer things have reversed themselves, with those in the South, escaping the summer heat indoors with air conditioning, and those of us in the North are enjoying the outdoors. I do wonder whether HVAC systems are helping to spread the virus. There is some emerging interest in this possibility.

So, let’s talk about hydroxychloroquine. I’ve been writing about the pandemic since March 21st. In that first article, I already noted that there was some evidence that hydroxychloroquine, along with azithromycin might have some efficacy. I also noted that a research-based physician such as Dr. Fauci would culturally be uncomfortable recommending a medication without multiple double-blind studies. This is entirely understandable. But Dr. Fauci doesn’t treat anybody. Practicing caregivers in the middle of a pandemic are sometimes forced to innovate for the benefit of the patients.

Even in March, there was in vitro data suggesting that HCQ inhibited coronavirus replication, and since then, we have come to understand that there perhaps for other mechanisms on a cellular level where the drug may prevent viral contents from entering human cells. There were also non-blinded trials strongly suggesting that the drug was useful. In later articles, I discussed other papers that had been published with similar views. Finally, there was the controlled study from Detroit where HCQ halved the mortality rate of hospitalized COVID patients.

Unfortunately, when Donald Trump mentioned the drug in one of his briefings, all hell broke loose. I think I understood what he was trying to do, namely offer some optimism during frightening times. I honestly believe that another president, at another time might have been given the benefit of the doubt. Not in this case. Hydroxychloroquine became “Trump’s drug” and its use must not be allowed.

On Monday, a group of physicians calling themselves America’s Frontline Doctors held a press event in front of the Supreme Court. There they discussed their experiences using hydroxychloroquine in the treatment of COVID. The most prominent and controversial speaker was Dr. Stella Immanuel, who was apparently a pediatrician, born in Cameroon. She also claims to be a minister. She is convinced that hydroxychloroquine is effective having by her account treated 350 patients with it with minimal morbidity and no mortality.

What she seems to believe is that “Big Pharma” is suppressing information on the drug’s efficacy in order to boost profits from drugs such as remdesivir, as well as from vaccines to be developed. Having dealt with pharmaceutical companies for much of my career, I do not find this idea completely fantastic.

It was her opinion, that if hydroxychloroquine was used more often for prophylaxis and treatment, that no masks or other restrictions would be necessary. She was, to say the least, very fervent in her beliefs.

I saw this video on Monday night. It was interesting, but I’d never heard of the physician group and thus wasn’t sure what to make of it. Nonetheless, if her treatment claims are truthful, it is another data point. I couldn’t really figure an ulterior motive when the drug is off-patent for 40 years.

Tuesday morning, I was perusing Facebook when I noticed that multiple friends of mine had posted the video. They also were reporting that Facebook and YouTube were deleting it. I despise “Big Data” censorship, and thus I shared the video with the comment that I was posting this because it was being removed, but I found the video “interesting”.

I was then beset upon by a young lady of my acquaintance, who works in health sciences who was extremely offended that I would post what she considers to be essentially anti-science. She informed me that either I should take down the post, or undoubtedly Facebook would, as she had already reported the post to their “editors”.

Dr. Immanuel, as it turns out as a somewhat “colorful” online presence and holds some controversial opinions as part of her ministry. Websites like the Daily Beast, eschewing their usual love of diversity, quickly did a “deep dive” in order to debunk her. They claimed that Dr. Immanuel claimed that masks are not necessary, without the qualifier she provided.

Nonetheless, if her claims about her medical practice and her treatment of coronavirus are true, then the information may be useful. Again, it’s information to be processed and then believed or discarded. Information is generally helpful.

Given the significant number of articles that I have quoted in the past, some controlled, some anecdotal, but all supporting hydroxychloroquine as a COVID antiviral (here is a recent one from Newsweek), the virulence of opposition to this video would suggest that there are people who just don’t want to know if the drug works. Logically, it suggests that they may not wish for any chance to see the pandemic brought under control so that the economy can fully reopen. And why would they feel that way? Maybe it has something to do with the presidential election in 3 months or so?

I for one cannot imagine being such a nihilist- so politically driven that I would be willing to discard a potential treatment and prolong people’s physical and economic distress. I do not understand on an interactive forum like Facebook, why people who disagree with a viewpoint, would want to erase it, rather than just to make their case in opposition.

I just want to know what works so I can treat my patients.

And perhaps selfishly… sit at a bar with a beer and eat a piece of pizza.

As I mentioned in my last “Viral Post” two weeks ago, my local mountain laurels were in bloom, which signals to me that very likely they are in bloom elsewhere in the Poconos.

This includes several areas of nearby Hickory Run State Park, where there are areas where the laurels dominate the landscape.  In June the forest there is awash in pinkish-white blossoms as far as the eye can see. I have written about this before.

This is for me, a favorite time of year for photography. The blooming of the laurels is closely followed by the flowering of the closely related rhododendron which is also widespread in that location. In some years they bloom together which is particularly striking.

So, with the camera bag and a tripod on my back, I hiked up the quiet trail where I know from past dealings the display will tend to be lovely.

Unfortunately, perhaps symbolically for this year, this was not to be. For the first time, most of the mountain laurel had not flowered, and those that did had spotty blossoms.

Moreover, I found that the rhododendron was in the same state. I counted literally 4 to 5 flower buds on the whole trail where there would’ve been literally hundreds of thousands.

Not sure why this has happened. Perhaps the unnaturally cool spring we experienced is responsible.

There were blossoms elsewhere in the park, near to the brand-new park headquarters, but these were underwhelming and located on the border of newly cleared land, where the light was harsh and unflattering.

So a small event that I look forward to each year as once again failed to happen.

Whats next?

I’m thinking Murder Hornets

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 have reached week 11 of the suspension, by decree, of religion and commerce in the Commonwealth of Pennsylvania. Here in Luzerne County, we are scheduled on 5 June (Friday) to move into the “yellow phase” which means that the Wolf and Levine team will allow a tepid amount of additional business activity.

Whoopee.

This is occurring in the middle of a new crisis, namely the protests/riots in our cities caused by the universal outrage over the apparent murder of George Floyd, a black man, by a Minneapolis policeman who has been subsequently fired, charged, and imprisoned.

Scenes of large crowds of masked and unmasked protesters, provocateurs, and criminals, freely associating in our urban centers, to say the least, has been destructive to the culture of social distancing we have come to know over the past weeks.

Suddenly, coronavirus feels like yesterday’s news. With this new crisis, I suspect the caution and fear people felt about the pandemic will begin to dissipate.

There may be other reasons for this. Certainly, in most areas of the US, the number of new infections and deaths is clearly decreasing. No longer do we wait breathlessly for the state and federal coronavirus broadcasts for the most recent bad news. Drs Birx and Fauci seemed to have faded from the public view.

There was a report this week out of Italy (which appears to be the proximate source of our eastern viral strains) to suggest that the coronavirus there has become significantly less virulent in recent weeks. Based on basic virology, this would make sense.

First, it’s important to remember that this virus comes from a specific species of bat, where it infected large colonies with minimal deleterious effects. This is likely because the bats had a degree of “herd immunity” and the virus had evolved to maximize its spread by minimizing virulence. A virus receives no advantage by killing its host.

Then it spread to humans, whether from freshly slaughtered animals in a Wuhan market or more likely released by accident from the neighborhood virology lab. Humans had little or no immune defenses to this novel agent, and the virus had not yet evolved to avoid excessively sickening the new hosts.

Add in a little globalization and voila… a worldwide pandemic.

Now, if over time, there are multiple mutations of this virus (which there are), it makes sense that some of them will be more aggressive and some less. The strains that make people obviously sick, and/or dead, will tend to be more quickly diagnosed, and the patient isolated, impeding further spread.

Less symptomatic strains will be less likely to attract the attention of the public health system and thus have more opportunity to spread to and replicate in a new host.

At some level, the most successful viruses will be among the mildest ones. The virus has to be aggressive enough to infect the right tissues (respiratory ) to facilitate transmission by coughing and sneezing, but mild enough that the illness will provoke little concern from others and can spread freely.

Now consider a virus such as Ebola, with a horrifying presentation. In modern times an infected patient is quickly recognized and carefully isolated, reducing or hopefully eliminating spread.

In one of Dr. Fauci’s last publicized statements, he feels there is now hope that there will be no recurrence of the virus in the fall. I don’t entirely understand the data that this is based on, but it is undoubtedly good news.

With the good weather, and now obviously with the mayhem, the enthusiasm for social distancing is fading, and I think will eventually become extinct, rules or not. If there is no meaningful bump in cases around the country after all of the mass gatherings that have been occurring, then I suspect the sense of the coronavirus as a threat will reasonably ebb. The practice of masking, and spacing ourselves out, will likely then feel dated and unnecessary.

We are obviously living through extraordinary times. More than anytime in my life, I find myself praying for the welfare of our country and its citizens. I do believe that in God’s good time, there will be recovery and a return to a slightly different, but acceptable baseline.

I just hope this happens before there is more damage to our economy, our infrastructure, and our psyche.