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COVID-19 Update No. 18: Delta Variant- The Truth, The Whole Truth, and Nothing But…

7/22/2021

                So, now we are being told by Administration political leadership as well as the mainstream media there is a “surge” afoot of the Delta-variant COVID-19. The number of infections are rising, and there are hospitalizations and deaths. The COVID-19 vaccine is considered the answer and the president proclaimed that any anyone who did not submit to the vaccine is “killing people”. Pretty presidential, huh? Is he going to say that about influenza vaccine since it decreases flu infections and 20,000- 65,000 die yearly from flu, including children?

Yes, the Administration, its Surgeon General, and media commentators are accusing those who are not whole-hearted vaccine advocates of “misinformation”. How dare they! I will refrain from a political essay on their numerous and regular “misinformation” on just about every topic of the day, but instead speak within my expertise.

As you know by now (from prior COVID-19 Updates), I am a specialist in Infectious Diseases, with a particularly developed aptitude in pandemics. If you re-read some of those earlier updates, I think you will see I was very much on target about how this might and did play out, as far back as March, 2019.

The other comment to set up the context of this essay is that I am a committed Darwinist. The Theory of Evolution has no serious arguments against it. In a sentence, it holds that life is about more life, and the fittest survive. Those simple ideas tell you all you need to know about infectious agents, pandemics in general, and the truth of where we are (not what we are being told).

I wrote extensively about mutants and variant viruses on 2/5/2021 in “COVID-19 Update 17: Mutants! A Problem? No… The Solution”. Life forms replicate imperfectly, throwing off variants of the original version (in humans, we call them birth defects). Over incomprehensible periods of time (many thousands of years), such variants allow a species better chance of survival in case the environment into which it is born is changing in a direction that will not allow the original live form to thrive. “Variants” provide species variety so they are not at an evolutionary dead end, rigidly fit only for the current environment. So, the variant then becomes the new “original”, or dominant strain, best suited to the evolving environment. In the case of COVID-19, “the environment” is its human host.

So, with millions and millions of passages through human hosts, each individual infection accounts for millions of viral replications in each human host. Many variants result, many or most of which are too defective for continued survival; and so the variant is a dead-end and dies off. However, if  a variant has advantageous  characteristics for enhanced survival, compared to the parental strain, it will replicate with vigor to become the new, fittest strain. What would that look like? Exactly what we are seeing all around us and which I predicted months ago in “COVID-19 Update No.17”. The Delta strain is much more transmissible, human-to-human, than parent COVID-19 (SARS-CoV-2 virus). That’s good for the virus, right? Mother Nature at work. And, though it is not yet concluded by studies, the Delta variant is likely less virulent (ability to cause serious illness or death) than the parent. That’s good for the virus and for us. After all, a virus that kill its host is a kamikaze virus, a suicide virus… does not live to see another day. Charles Darwin would say that’s against Nature, unnatural. Remember, life is about more life… or over these past billions of years there would be no life on earth. Remember the 1918 Spanish Flu virus that killed 675,000 Americans and 20-100 million worldwide? Did it keep on going as a scourge of humanity… to end the human race? No. Thankfully, Darwin was right and it mutated to evolve to coexist with its human hosts, and to become just another seasonal flu virus.

Finally, the more variant infections, the more herd immunity– the virus becomes a vaccine.

Good news, wouldn’t you think? We’re out of the woods. Bring on the messages of optimism! The vast majority of COVID-19 deaths having occurred in the first months of the pandemic when we had little reliable information on the Wuhan virus (thank you, China) and had not yet learned who were at most risk for death (to quarantine), had not developed methods and medications for managing the seriously ill, and did not have the Trump vaccine. The virus was novel to humans, and that cost lives. It always will. Now, the virus is no longer novel. But, you wouldn’t think so to hear the alarm, hyperbole, and dire comments on the news and from the Administration. There are increasing numbers of cases– of course there are, as this Delta strain is a somewhat, but not completely, new virus. There are some deaths from the virus. Of course there are, there always will be. With our next flu season will we have such alarmist alerts because people are dying from flu? If there were not one more COVID-19 variant infection, there would not be one more death. Living in fear of COVID because of increased transmission of Delta Strain (with herd immunity now 72-94%; see below) is like deciding not to drive because there is traffic on the highways. When did you do that?

Oh, I forgot. Our standard now is, “One more death is one death too many.” So, guess none of us are driving tomorrow, since 9 people are killed every day in vehicles around Texas, and similarly around the U.S. about 4,000 children die annually in motor vehicle accidents. No more alcohol. No more eating out. Cannot have one more death. Mask everybody and do the lockdowns again– wreck the country and countless lives so we have not one more COVID death. I suppose our leaders require a risk-free life, or everyone stay at home. Irrational and ridiculous.

You know, we heard from “leaders” over and over that we must “follow the science”. That is, until the science and the facts got in the way of political agendas and their exercise of power and so our public health expert officials on the government payroll had to give their adjusted “expert” opinions; more opinions than science. Have you noticed the continual moving of the goal posts during the Pandemic Game?

Oh, but they’re experts and the public are illiterate sheep that will just follow anything they say.

Well, at the risk of losing some of you, we need to do some math, to get to the truth, but first a couple factual premises.

  1. COVID-19 deaths in those under 20 yrs-old are virtually non-existent; in all Western countries, such deaths have been rare. 93% of the deaths are in those 55yrs or older. In the U.S., so far, deaths in those 25 yrs or younger = 0.001% of COVID deaths.
  2. Most children with COVID-19 have little or no symptoms.
  3. Children barely transmit SARS-CoV-2 to adults; they have mild if any symptoms; so, meager tissue inflammation and viral particle shedding.
  4. Most of those who are unvaccinated are people at low-risk for serious disease or death, as the limited supplies of vaccine in its first months were given to “essential” workers and high-risk, mostly very elderly people. And, early in the pandemic, the virus claimed the lives of the weakest of the human herd.
  5. There are 400 deaths in U.S. children under 19 yrs-old from COVID-19 over a 17-month pandemic period. 188 children died from flu during the 2019-2020 season (only 7 months), and that is probably an under-count, per the CDC.
  6. COVID—19 Death Statistics and Reality: It has been a point of professional discussion that having a positive SARS-CoV-2 test and then dying are not necessarily cause-and-effect linkages. With such a high proportion of COVID-19 cases being asymptomatic, many “COVID deaths” may have been deaths from other causes with coincidental colonization with the virus. It is a fact that early on in the pandemic the federal government was expediting payments and at significantly higher dollar amounts than usual for hospital-based services for pneumonia and respiratory failure to incentivize taking on the risk of COVID-19 cases. COVID-19 was a cash-cow for hospitals and, with many physicians now hospital-employed and subject to employer pressure, it has been documented that cases were termed COVID-19 deaths when that was not the case. Many hospitals likely gamed this. Why mention it? Did 400 children die from COVID, or just some? Time for the well-known quote “There are three kinds of lies: lies, damned lies, and statistics”. Finally, a positive COVID test does not necessarily even indicate viable (infectious) virus- the test may be positive with just remnants of viral RNA from the prior complete virus; and such positive tests can persist weeks after infection has resolved. So, you have a heart attack and die in the hospital ER, but have a positive COVID test (as all patients presenting to a hospital are now screened with these tests)… just a sleep-walk for the paperwork to conclude “COVID death”.

If all of the above are true (and they are), why are we vaccinating normal kids and adamant that no one can remain unvaccinated? I am a big proponent of the vaccine for those at high-risk for serious illness and death, and any other adult who elects to take it, especially when the original strain was surging (most of 2020). There have been only 5,200 “breakthrough” infections in the U.S. who required hospitalization in those who had been vaccinated, with over 181 million vaccinees. So, efficacy is not in question. But, this is an FDA Emergency Use Authorization (“EUA”) vaccine, meaning it is still “experimental”. Should we be advocating it in people fitting the above premises when there has not been time to evaluate effects on those still growing and who will be childbearing in the future? Does the risk of the virus to children and the minimal risk of children as vectors of disease to adults justify exposing them to an EUA treatment? Seems all risk and questionable benefit. Shouldn’t we give more time to quantify vaccine-related myocarditis (heart inflammation), possible tendency to blood-clotting problems, and possible vaccine-associated autoimmune trigger reactions before promoting vaccination of children? The exceptions? Children with serious, underlying medical conditions putting them at COVID-19 high-risk for serious illness or death, and kids obligatorily living with adults who are in high-risk groups and unvaccinated.

All of this, of course, is contrary to the school teachers’ unions using COVID-19 as leverage for more full-pay time-off and “working” from home. This despite solid studies showing hardly any transmission of SARS-CoV-2 from students to teachers. Only 25% of teachers qualify as COVID-19 high-risk, for whom special accommodations might be justifiable. However, data show teachers get SARS-CoV-2 from other teachers. The hot bed for virus infection is in their homes! The safest place for them, based on the science, is in the classroom. Why this seeming digression? It is not. It is a black and white example of how this pandemic was used by manipulative operatives to pervert a public health crisis into personal power and financial gain by a messages of disinformation and misinformation, not the science. Propaganda, pure and simple. This is all perfectly relevant to what we are being told by media and Administration operatives about Delta variant. They want this to keep going as their grip on power tightens and permanent societal changes loom. I know many teachers who are professionals and appalled at not being able to practice their profession in the best interests of their students—held captive by their union and some opportunists in their ranks.

Now, to the math.  The statistics are about up-to-date and, though changing daily, the trends are valid.

COVID-19 (U.S.)

  1. 33 Million Confirmed Cases (positive tests)
  2. 607,000 Deaths (243/100,000)
  3. 40% (conservative estimate) of COVID-19 Infections= No symptoms
  4. Take #1 and #3= 55 Million Total Infections
  5. 181 Million= Vaccinated (by 7/4/21, 55% over 12 yrs-old had been vaccinated).

So, we can conclude,

  1. With a U.S. Population of 332 Million, If those vaccinated + infected (naturally immune) = 238 Million, then we have 72% “Herd Immunity”.
  2. If you subtract those under 20 yrs-old (80 million) out of the above numbers (since near no risk of death or serious infection and extremely low risk to pass SARS-CoV-2 virus to adults), then Herd Immunity= 94%.

As we were told we must “follow the science” (to not listen to President Trump, who was characterized as “anti-science”), Dr. Anthony Fauci, National Institutes of Health Director, said our goal was 70-80% herd immunity to indicate we had turned the pandemic corner, and then masks and other restrictions would largely no longer be needed. Did you notice they are no longer talking about herd immunity now that we’ve achieved it… moving the target and the goal posts, to keep “the crisis” ongoing and the public subjugated? Of course, anyone watching has seen that Dr. Fauci’s flip-flops are a pattern of behavior. He has the highest paycheck in the federal government to protect. Now, although our above figures and facts, which are “the science”, say we are well past Dr. Fauci’s originally stated goal, Governor Gavin Newsome (D), California, is re-imposing indoor mask mandates regardless of vaccination status with no substantial surge in COVID-19 deaths or ICU admissions, the key indicators of concern. Did anyone tell this guy the CDC said 2 months ago that masks are not needed once vaccinated? So, even the great protection of the vaccine does not alleviate their wanton exercise of power. Never ends, does it? Not if they can help it. They will have their way. COVID has been just too good an opportunity to change election rules, crush the middle-class, payback the teachers’ unions and other supporters, and accustom the American people to ceding their constitutional rights and power to politicians… all the while seeding the conditions for socialism. And, stay tuned to this channel regarding whether booster vaccinations will be needed. Remember, Pfizer withheld information that President Trump had succeeded at driving what was a miraculous, unprecedented delivery of a safe, effective vaccine to the American people in historically record time, by several hundred percent; withheld that information in the last week of the presidential campaign until after the vote. They did not need him getting credit for the single thing that can be said to have saved tens to hundreds of thousands of American lives and the American economy. Sweep him aside and have Biden try to make it his vaccine. Pfizer and Moderna are making many billions on this, so I am counting on the “need” for a booster, as payback to Big Pharma for helping deliver the White House. You ask yourself, “At this point, given all the facts, what is pushing this insistence on universal vaccination?” And, in the near future, booster recommendations? Big Pharma payback? Admittedly, I am a bit cynical.

By the way, where is President Trump’s Nobel Prize in medicine? Yes, a bit of political commentary here, but excuse my outrage at the perversion of science and human misery for political gains, since our profession has been entirely mute on these matters.

So, how bad has COVID been, comparatively?

If you take the 55 million U.S. infections with 608,000 deaths (243/100,000 population), the death rate= 0.24%, or 2.4/ 1,000. And, it is probably lower since population-wide testing has not been done to see if tens of thousands more were infected as symptom-free COVID-19 carriers, without disease (which some have estimated as possibly 6-8 per each test- confirmed case). If that is so, the number on true death rate and peril from the virus drops dramatically. For reference, seasonal flu has about 0.15% death rate. So, they may be about equal. Well, then why 608,000 deaths? That’s serious, right? Way past 20,000-65,000 annual flu deaths. Explanation is these pandemic numbers stretch over 17 months, versus the usual 7-month flu season. Secondly, this was a novel virus with likely many millions more infections than actual illness; and so, many more total COVID-19 cases than seasonal flu since many people have some immunity from prior flu season infections and vaccinations aborting many flu infections, while there is no historical immunity with the novel SARS-CoV-2 virus. In other words, total numbers of COVID-19 infections is probably much higher than our statistics and it is much less dangerous than being hyped.

Finally, compare COVID-19 to 1918 Spanish Flu. There is no way to achieve a completely reliable death rate for the 1918 virus since testing and epidemiological expertise was not set up adequately in the early 20th century.

However,

U.S. Deaths

COVID-19             608,000

1918 Spanish Flu      675,000

Total U.S. Population

During COVID-19: 332 Million

During 1918 Spanish Flu: 104 Million

No comparison. Yes, 608,000 deaths is 608,000 deaths, plus many thousands with serious complications and damage who survived. But, with most of those COVID deaths occurring in those over 55 yrs-old (93%), and the very most in those near or beyond their natural life expectancy of about 80 yrs. (60% of total COVID deaths), the draconian state-level lockdowns can never be justified beyond 1-2 months, March-April, 2019. Many thousands of lives were saved by the prior Administration fast-tracking of vaccines, medications, and monoclonal antibody treatments, in addition to creation of hospital beds, exponential manufacture of ventilators (previously unthinkable), and extraordinary increase in personal protective equipment (PPE) under Operation Warp Speed. However, countless businesses, careers, marriages, and lives were seriously damaged or ruined by the prolonged lockdowns. Looking at the science and the objective medical facts, public health officials and political leaders behind the long lockdowns should be fired or impeached.

If you haven’t figured it out by now, the strident demands that all remaining unvaccinated adults, regardless of age or medical conditions, be immunized (or be “killers”), masking be resumed, and other isolation measures be reconsidered are not congruent with the science. Then there are the door-to-door Gestapo visits by government operatives to query citizens on vaccine status and intent. Add this to the fact that a number of “medical authorities” and public officials deemed the George Floyd mass population demonstrations during the height of novel COVID-19 activity and hospitalization and deaths of more priority than COVID-19 containment, and you get the politicization of the Pandemic Game… and now the public’s distrust and disgust of “authorities”.

The American people see the hypocrisy of allowing illegal immigrants to invade our Southern Border without COVID screens, and then transporting the people across the country, exposing America’s citizens to COVID, while stringently screening U.S. citizen travelers to assure they are COVID negative before permitting air travel in and out of the U.S. This dramatically shows the Administration’s political interests supersede the welfare of our citizens. It is all about power, not principle or jeopardy to the populace.

What is this? Irresponsible demagoguery and manipulation at best. This started as 2021, but is fast becoming “1984”. At worst, a new norm… a dangerous attempt for a new norm, a reset of our American Constitutional Model.

Know these facts, then make a personal medical decision, possibly after consulting an experienced, knowledgeable physician– your decision, not the government’s. I took the vaccine. I am 71 and in excellent health. But, as an Infectious Diseases specialist I had a duty to stand “a-post” to serve our community and to do my job. My decision was fast and intuitively obvious.

But, now with the “novel virus” pandemic waning, deliberation is the operative word, as the risk-benefit calculus of remaining unvaccinated versus getting immunized is changing by the week.

Re-read this. Contrary to the drastic mis-messaging by politicians and media, there is a lot about which to be optimistic. This is not a time for acting on impulse. Sit on these facts, after you have carefully considered your social and medical situation. Yes, Delta is on the move, but most of those still unvaccinated are not at risk for serious illness or death–those groups have largely been covered with vaccine or have passed away, unfortunately.

My take-aways,

  1. Control measures, like vaccination, should be age (and so risk of serious illness) specific.
  2. Kids are near no-risk for anything serious from SARS-CoV-2, and so should not be vaccinated unless with serious, relevant, pre-existing medical problems or living with others who are at high-risk and unvaccinated, until the vaccine is FDA-approved.
  3. All adults should consider being vaccinated to increase herd immunity and so decrease further medical system costs, get the society up and running, and get the pandemic behind us.
  4. The Delta strain, with every new infection, is vaccinating the remainder of the herd.

My guess, given that virtually all those at high-risk or COVID-19 serious illness/death have been vaccinated or infected, is that, were we to clear the board of all the statistics due to the original, novel COVID-19 virus, the Delta virus sub-epidemic would be essentially like a seasonal influenza event, except with many more mild-moderate illness cases. The need for vaccination is no more or less than for flu. Masks only make sense for those who refuse vaccination and are at high-risk.

At this phase of the winding down pandemic there is no justification for any infringement on any individual constitutional rights. We are entitled to our own medical decisions and certainly our rights. The politicians are our servants and entitled to nothing but a clear message from an informed electorate. Mandates of any kind by government for universal vaccination have no place, by the science and The Constitution. Since the virus immunizes those it infects and is so highly transmissible, the emergence of the Delta variant was the signal of the beginning of the end of the COVID-19 Pandemic.
Edward R. Rensimer, MD

Infectious Diseases

Director, International Medicine Center

Houston, TX

Traveldoc.com

Copyright, E. Rensimer, MD, 2021, All Rights Reserved

 

COVID-19 Update No. 17: Mutants! A Problem? No…The Solution.

2/5/2021

Just banner “Virus Mutation” on your “Breaking News Alert,” and people will stop in their tracks, sit down, and get serious. The Hollywood version of that idea is zombies roaming widely and feasting on us. “Mutation” is a harrowing word. Indeed, charged with fright.

Maybe it’s time for a biologist, particularly a medical professional biologist, to explain why mutations are ordinary, good things…yes, good; in fact, necessary for sustaining life.

Viruses are living creatures, just as birds, fish plants, humans. They have DNA or RNA genetic material in the viral package. But, as opposed to other life forms, they are obligate passengers on other life-forms—virtual parasites. They need another living thing to “host” them since they cannot live on their own—do not have the equipment to replicate.

The next point should be self-evident, but all such things get lost in the blizzard of information that comes our way and, even though once upon a time realized, it gets sublimated as we go about our lives. What is that? Life begets life as its purpose. All else is biologically superfluous, off-point. If that were not so, there would be no living thing. It would come to an end. But, it hasn’t. To the contrary, the varied life forms everywhere we go, everywhere we look, are testament to the perfecting process of the machinery of life.

Ironically, it is the imperfection of living things and their progeny that is the essence of evolution that has sustained life, starting as a single cell, then colonies of cells, then organs and tissues, then highly complex interactive systems forming a bacterium, an ant, a fish, a frog, a snake, a sparrow, a dog, a human.

Each life form replicates—makes copies of itself. That’s reproduction. But, in countless cycles and generations of reproduction, every so often an offspring results a bit different from the parent, the rate depending on the specific life form—perhaps the order of amino acids in a blood protein, biochemical pathways, the shape of brain cells, hair distribution, heart size…changes in cells, tissues, anatomy. Most immediately, we are aware of a “birth defect” rate of 3.0% in humans. They are “defects” because we desire a perfect replicant of ourselves. But, more appropriately they are birth “variants”…or mutations. Certainly, such variants may not be as biologically “fit” as would have been a perfect copy…unless such changes in the offspring adapted the newborn to that environment better than the parent. We all know environments, usually over incomprehensible time, change. More hair for cold environments, hands and feet for land instead of fins and flippers, water-sparing physiology for arid climates.

Of course, I am vastly condensing the process for the purpose of simple explanation and comprehension. But think of such mutations occurring literally on a molecular level affecting body chemistry and structure (anatomy) over millions and millions of years, and billions of such changes in a single lifeform or species.

Let’s say there were no mutations. With time we would be highly limited as life-forms to extremely narrow environments and should a random ecological cataclysm occur, such as the meteor or asteroid that struck earth and wiped out all the cold-blooded dinosaurs with the sun blocked from atmospheric debris for thousands of years, we too would perish in the new conditions. The lesson? Variety and biological diversity is the insurance policy against the end of all life, extinction. Dinosaurs, highly specialized, were an evolutionary dead-end. They were “fit” (to survive) only in the narrowest ecological circumstances. Warm-blooded mammals fortunately had appeared over millions of years preceding the dinosaurs’ exit…through mutations! Mammals were mutants on an entirely different evolutionary limb, fortunately. All of this is basic evolutionary Darwinian theory. Environment perfects living things, but imperfection saves them. Nature’s elegant design—the balance of perfection and imperfection.

What has this to do with SARs-CoV-2 virus (COVID-19 agent)? Viruses mutate. That is, sudden changes in their DNA or RNA genetic code (the sequence of nucleic acids) occur, which are then inherited by the next generation if the mutant is fit to reproduce. These are random changes. And, they, like us, can mutate or change in any number of characteristics—surface spike (attachment) proteins, transmissibility, virulence (ability to provoke immune response, and so illness, from the host). And, any given offspring may mutate in more than one characteristic at any time. In this regard, mutations are Nature’s and Evolution’s slot machine.

What are we to make of this? Concern? Fear? Panic? I choose to understand.

I started out stipulating that, though philosophers may argue that life purpose and values as much define life as just living, the point of life is…more life—clearly a biologist’s perspective. Beyond that is metaphysics. What comfort is there in that regarding this virus and this pandemic? Well, if SARs-CoV-2 needs a host to live, killing its host is against its best interests. A virus that kills its host is a suicide virus. So, even if a random mutation or set of mutations can produce an highly virulent, killer variant, it cannot be around for long. Ever hear of Ebola virus? Ever hear of a worldwide Ebola pandemic? Why? It has a kill rate of at least 50% (overall, comparatively, 1.3% for the U.S. COVID-19 virus). It gets buried with its host, which relatively quickly ends any new outbreak. Ebola continues in monkey primates where it is adapted to reside, collaboratively, not in humans.

So, this novel (to humans) SARs-CoV-2 crossed over from the animal kingdom to humans in 2019 and now, as it passages and replicates in trillions of cycles through human hosts, it will spin off mutants. Those fatal for humans will die off with those unfortunate human victims.

Eventually, the virus will arrive at a model or variety that will co-exist with the human race synergistically. Just as seasonal influenza does which, because of its high mutation rate, assumes different forms virtually every year, such that new vaccines must be configured for each winter’s new strains. Actually, Flu mutates at a rate of 4X that of SARs-CoV-2. Some victims will die from these newer versions, usually those who are existing on the medical margins with advanced age and pre-existing conditions—a “natural” death. But, humanity will not be wiped out. The encouraging point is that SARs-CoV-2 appears to be more stable (slower mutation rate), and so may allow vaccines with enduring value. And, as a matter of natural law, viruses, if they are to keep humans as hosts, will gradually diminish as a threat to life.

And, finally, yes, certain, but not all, mutations can diminish the protective effectiveness of vaccines, which are static products directed at the virus variant available at the time of vaccine production.

In sum, mutations are desirable, no, essential, phenomena of all life forms. Without them, this earth would be rock, wind, and sea, and otherwise barren. Mutations are not to be feared. Rather, understood and monitored to adjust public health policies and medical weaponry to minimize jeopardy from a rogue mutant viral strain until it passes on to oblivion. For this reason, novel virus pandemics tend to play out over 1-2 years in several waves or surges as the virus adjusts and adapts to its new hosts. Proof of this is the exit of the 1918 Spanish Influenza virus that killed 675,000 in the U.S. when the U.S. population was only about 104 million.

Mutation is a life-critical feature of Nature—for all us living things. It is life-sustaining Evolution. Be not afraid. Rather, be amazed.

Ed Rensimer, MD
Director, International Medicine Center
Traveldoc.com

Copyright, 2021, E. Rensimer, MD, All Rights Reserved

 

COVID-19 Update, No. 16: The Playing of the American People and The Science

12/22/2020

 

Yes, America is starting to get it. COVID-19 is not a hoax. Over 300,000 dead say it is not (though more discussion on that number later under “SARs-CoV-2 Virus”). The dead are not to be dismissed or dishonored. But, COVID-19 is not the bubonic plague or the 1918 Pandemic Spanish Flu. In fact, the Spanish Flu killed about 675,000 in the U.S. in 1918-1919, when our population was about 103 million. With current population of about 328 million, were SARs-CoV-2 virus as virulent as Spanish Flu, we would have 2,150,000 dead. The recent overall U.S. mortality rate is estimated at about 1.8%, but that’s calculated on cases confirmed by a positive test. What about the CDC estimate that there may be 8-10x more people infected who have not been tested since up to 80% of COVID-19 infections have no or few symptoms? That brings down the fatality rate to around that of annual, seasonal influenza. Why so many total deaths, then? Because it is everywhere. It is extraordinarily transmissible and hides in the majority of people carrying it. It is largely a stealth agent of infection.

Yet, the American public has been fed and now is increasingly angered by persistent and recurrent authoritarian (probably illegal) public health mandates by political leaders, keeping kids out of school, small businesses closed, prohibitions imposed on gatherings on private property (parties, weddings, funerals). Their decrees proclaim, “The sky is falling!” while they are caught hypocritically dining in close groups, unmasked; having hair styled, unmasked; and engaging in leisure air travel—while their rules demand the general public can do no such things. And, it becomes real personal when it’s not just recreational or leisure activity—strictures on funerals, weddings, visiting a dying loved one in their last days and hours in an ICU. This is where the hypocrisy is chilling, in fact infuriating. Important personal freedoms are torched in the name of the public good, “supported by science.” But, the average American doesn’t need to be a physician or epidemiologist to smell something bad—that inconsistent positions on masking, business lockdowns, school attendance, dining out, and travel juxtaposed to the emerging information on COVID illness and the SARs-CoV-2 virus cannot be only based on hard science. If anything, established science, if nothing else, is consistent—unless it has been perverted by propaganda, misinformation, and political agendas. Just days after the Presidential election vote, Dr. Anthony Fauci then agreed (contrary to the prior position) that children could and should attend school. The science had changed, just after Joe Biden appeared to win.

So, before proceeding further, should a physician comment on political matters? Don’t we want our doctors and other medical professionals to be unbiased and non-partisan so they can provide our care dispassionately with respect to age, sex, religion, race, personal behaviors, and political affiliation? We want them neutral. The problem is political operatives have used a public health crisis to support their political agenda, and an authority grab, co-opting a society-wide medical crisis and the “facts” around it manipulated to impose their will and ideology on the American People. Only a knowledgeable expert can weigh in on what is true and what is not. To remain silent (to maintain the “neutrality” front) would be ethically irresponsible, especially when the patient at risk is America. Physicians must offer their opinions. What? Dr. Fauci has given opinions on COVID-19 policies. The New England Journal of Medicine (arguably the most esteemed medical journal in the world) has offered editorial essays on COVID-19 pandemic and the Trump Administration’s “mishandling” of it. Likewise, the American Medical Association. So, “the profession” has commented. Surely, the American public can rely on their pronouncements and opinions. However, most of the establishment of the profession leans “Left.” Many, if not most, who work and publish in academic medicine feed off government research grants and federal revenues and tax breaks as non-profit institutions. These medical leaders live off this. Dr. Fauci is a government bureaucrat, now over 35 years. The AMA fully supported the Affordable Care Act (Obamacare) and for decades has not represented the views of most practicing physicians (the people who take care of you), such that only about 17% of U.S. physicians are members. Are these examples of the political bias of the medical establishment? Just after the George Floyd death in late May, 2020 in Minneapolis, over a thousand medical profession “leaders” signed a letter proclaiming that the mass demonstrations, though potentially SARs-CoV-2 “supers-preader” events, were justifiable since they were being conducted in the name of social injustice. The imperative to protect lives from the virus just took second-seat to a liberal priority—unproven to actually exist systemically—yet, enough of a priority (to theur political ideology and agenda) to violate the Hippocratic Oath to first do no harm and to safeguard life. Apparently, the science had changed; or, the profession chose politics over medicine.

Another example of the politicization of these medical issues for political purpose (that demands physicians speak up) was when President Trump announced his belief that under his Vaccine Warp Speed Project there would be an effective vaccine available before the end of 2020, 100% of mainstream media and their “medical experts” decried this as fantasy and lies.

The narrative they had promoted and intended to make stick was that President Trump was a congenital, science-ignorant liar, buffoon, and illegitimate president. Another outrage by him. Do not listen to his false hope and irresponsible pronouncements. Well, now that the vaccines are being administered midway through December, not one media host or expert commentator has recanted and apologized for the insults leveled at the president last May. This was a political hit-job to undermine President Trump during an election year by a partisan press. So, politicizing this pandemic has been “the game.” It is time for physicians to step forward and speak up as the most credible advocates and protectors of the public good. We have taken a solemn oath to act in the best interests of our patients, who collectively are the community and the society. Arguably, physicians are among those most trusted by the public. And, the public must hear the truth. Remember, Benjamin Rush, Lyman Hall, Josiah Bartlett, and Matthew Thornton, all physicians, were 4 of 56 signers of the Declaration of Independence.

Let’s be honest. Virtually all of the most draconian authoritarian COVID-19 policies have been in Left Wing/Progressive leadership states and cities. That’s not an ideological position. It’s a fact. And, the underlying premise is that life is precious and the American People must be protected from themselves and from each other. But, these same leaders sat idle as U.S. citizens (and police) were threatened with violence by anarchists and looters. They would not intervene in the devastating social insurrection in Minneapolis, MN; Portland, OR; New York City, NY; Chicago, IL; Washington, DC; Seattle, WA; or Kenosha, WI, over the months leading up to the election. Many of them do not stand against late-term abortion. Yet, their justification for violating and removing constitutional rights is the risk of loss of life from a public health crisis. If these “leaders” believe in what they say regarding controlling the pandemic and protecting the public, why are they not closing our borders? Hypocrisy, inconsistency and lies.

Well, it’s time to reset on the apolitical science and what that means about the reality of COVID-19 and America—not the para-reality created by political despots.

1. SARs-CoV-2 Virus:
This virus, in the first months of the outbreak, demanded serious attention because of the mounting deaths worldwide and no science to understand the nature of its threat. It is now clear that from a virulence perspective (ability to cause tissue damage, and so disease), it is closer to seasonal influenza than to more deadly agents, like Spanish Flu, especially since it is a “novel” virus (never before experienced by humankind—which explains the total deaths being a multiple of the 25,000-60,000 from flu each year). Let’s look at the most important aspects of this agent and outrbreak.

a. COVID-19 Case Labels– You need to have a test positive for the virus; you are then a case. However, the U.S. “case totals” are near meaningless since we are not testing the hundreds of thousands out there walking around with the virus and no symptoms. How can you have an accurate death rate (percent people who are infected that die) when “you don’t know what you don’t know.” Yet, the media daily report alerts of “record” numbers of cases and deaths. Well, the first case of COVID-19 was a “record,” since there were no prior cases. But, the “new record” hype serves to fear-monger and to panic people into submission to government “emergency” policies. This is conditioning the American People to a new reality regarding the state and its authority over their lives and rights.

What are the important numbers then to appreciate the gravity (or lack of it) of an outbreak? When so many cases are undiagnosed, you must go by numbers of patients hospitalized and rates of death (as a percentage) of those, as well as duration of hospitalizations as an indicator of case severity (3 days or 3 weeks?). Since the first months, these numbers had been going down, until the surge of “new cases” (positive tests, not illness) in the last month or so.

Further, be aware that there is concern that the SARs-CoV-2 nasal swab PCR (polymerase chain reaction) amplifies simple molecules of genetic material to the millions and, as such, may be very prone to false positives since the test is exponentially amplifying the most meager biological material—and so, may cause inflated case numbers. PCR is not a culture—a test where the virus itself is grown. Even remnants of dead virus that can no longer infect can convert to a positive test. How might this affect COVID case stats?

However, though there are varying figures on hospital lengths of stay and ICU death rates, both have gone dramatically down as we have successfully quarantined nursing home residents and other high-risk individuals and we have developed effective treatments (Decadron, Regeneron, remdesivir, bamlanivimab, convalescent plasma) and expertise. Recent estimates were a reduction of ICU case fatality of 30% last Spring to around 3%. Overall mortality has also been estimated to have fallen by up to 20% in the U.S. This is a much less fatal disease than when it emerged.

b. Prevalence– Recent serum COVID-19 antibody data suggest that the virus may have been circulating for months in the U.S. before the first cases of illness appeared in January, 2020. This affirms the idea that the test-confirmed diagnoses are the tip of the iceberg, once again diluting and diminishing the “ominous” COVID-19 numbers being cited by media, to fear-monger and to justify restrictive public health policies in many places around the country. Positive tests (with no illness) are being called “cases” and added to COVID-19 case totals to emphasize an exponential pandemic explosion. Epidemiological statistics are extraordinarily subject to manipulation and misunderstanding. But, we are daily fed only the mounting totals on the nightly news—keep it simple, stupid, and just listen to the “breaking news alert” and obey the mandates.

Furthermore, the public is not aware that corporate consolidation in the business of medicine has forced many physicians to become employed by hospitals; private practice is now a medical profession dinosaur. Join that with the fact that hospitals are receiving extraordinarily high reimbursement rates and rapid turnaround times for COVID-19 case claims submissions to the federal government, and it is easy to imagine that there is an opportunity to increase profit-taking by having hospital-employed “diagnosis coders” working along hospital-employed physicians straining to call a hospitalized illness a COVID-19 case. This is all happening as hospitals are in serious financial distress because of postponed “elective” medical business (surgeries, diagnostic testing) with decreased patient traffic and COVID-19 shutdown of services. Every person admitted to a hospital is screened for COVID-19, for good reason regarding staff and other patients. But, if you were admitted with a stroke and no fever, so no illness reasonably attributable to SARs-CoV-2 virus, it would be simple to label it a COVID-19 case and put in a claim for reimbursement for this mislabel. Physicians have reported this as reality. What’s it mean? This is inflation of the extent of the epidemic as well as the death rate and risk.

c. Survivability/Mortality Figures

Survivability:

Age          Survival %
0-19          99.997
20-49        99.98
50-69        99.5
≥ 70          94.6

Mortality:

Age         Death %
< 1           0.006
1-4           0.006
5-14         0.2
25-34       0.07
35-44       2.0
45-54       5.0
55-64       21.0
75-84       22.0
≥ 85         31.0

*Almost all deaths in all age groups had significant pre-existing medical problems (avg=2.8 problems/patient) under 40 yrs-old. For a huge part of our workforce, survival rate is about that of seasonal flu; actually true for most up to about 65 y.o. if otherwise no medical problems.
Does it occur to you the significance that politicians and the media obsess over COVID-19 death totals, but do not emphasize how many have survived?

d. Children: They have a low number of ACE receptors (where SARs-CoV-2 attaches) in the nasal passages relative to adults. So, even when kids acquire the virus, they tend to shed only low amounts and so are not substantial sources of adult infections.

e. Mutations/Mutants: In just the past few days it was announced, in a rather alarmist tone, that the United Kingdom had detected a new, more highly transmissible SARs-CoV-2 virus subtype that was making its way through the population. No one has stated that this new variant virus was more virulent, that is more able to invoke tissue destruction or bring about death.

I had written about this months ago, that viruses, as with all life forms, including humans, inherently mutate. It is part of the evolutionary process that millions of replication events (reproduction) will every so often result in a defective product (birth defects). But, most of these “errors” do not result in a life form variant superior to the parent. However, over time, some variants (mutants) will have a characteristic that makes them more fit to survive longterm in the life form’s environment, which is always changing. Maybe tolerate heat or cold or desiccation better. But, a mutant (as opposed to that concept used in Hollywood stories) is not always, actually not usually, biologically malevolent or ominous. In fact, as I explained before, as SARs-CoV-2 mutates, it should eventually spin-off forms that make it less of a killer for humans. Any change to increased virulence will be short-lived in that it will not benefit sustaining the virus species—it will die off. Reproducing in humans without killing them gives it a host, or home. Otherwise, it is a suicide virus. If it kills its host in a high percentage (like Ebola virus), it is a suicide machine. That is not productive, evolutionarily. But, let’s see how the media and power-hungry politicians package mutation as a worrisome problem; that justifies more strictures on our behaviors and rights. Mutations are an expected part of biology and have been and will be occurring as SARs-CoV-2 settles into its biological symbiosis with humankind.

2. Lockdowns: The country is the patient. America is on life-support. Small businesses are failing (over 100,000 to never return). Mortgages are being defaulted at a rate of 60X baseline. Suicide, opioid use and overdose (up from 2,000/week a year before COVID-19 to 5,000/week), household violence, psychiatric illness (depression up 300%) are all on a sharp rise parallel with the pandemic. Kids are losing a year of education and social development. Marriages are breaking up. Life savings are being exhausted. As this proceeds, unemployment claims go up and those ex-workers are not paying taxes or healthcare premiums—putting at risk public services funding, Social Security, military defense funds, insurance company viability, and so medical practices and hospitals.

But, what about that science? Kids do not spread the virus to adults and they don’t die from it. Only teachers’ unions want the kids out of school as the teachers sit at home on paid vacation (of note, their unions are one of the biggest supporters of the Democrat Party). Yet, with kids at home, how does a family return to work? We are called “heroes” because those of taking care of the sick patients put ourselves at risk, yet traditionally teaching has been called a noble profession and the teachers are angels and heroes. Is that what we are seeing? Do they really care for the kids when they and their students are at minimal risk for serious illness and the kids are near no risk to transmit the virus to adults. We need to change the labels…it is an insult to those in our profession who have become ill and/or died from COVID-19 after putting themselves in harm’s way, to group teachers with medical professionals. Where have schools locked down the longest? Democrat strongholds (because teachers’ unions have the strongest quid pro quo relationship with the Democrat Party).

It has been clearly shown that the main source of COVID-19 infections is in the home—where co-habitors share closed ventilation airspace for hours a day. Not restaurants. Not bars. Not supermarkets. In New York City, studies show 70% of infections are acquired in homes, 2% in restaurants. Outside the home, most people wear masks when strangers are nearby and their “contact” is only glancing, not the at least 15 minutes CDC considers a significant exposure. And, it’s fair to assume that ill people are not out and about, mixing with others as they shed high amounts of the virus. The risk of infection from any infectious agent increases with “inoculum size”—the dose or concentration of infectious particles imparted with a sneeze or a cough.

If there are 8-10X the number of COVID-19 carriers as there are “diagnosed” cases (positive tests), then SARs-CoV-2 is everywhere and everyone will get it. Hopefully, those at high-risk for severe disease are vaccinated or improved treatments are available when that happens. But, we cannot otherwise escape this inevitability unless each and all of us get on individual rafts and launch out to sea for at least 2 weeks, all at the same time. Once a virus this transmissible was out of the bottle, we were never going to stop it. Lockdowns, by the science, cannot work to eliminate the outbreak, only to slow it. Lockdowns won’t save us. They kill the country in a way that will remain long after this virus is gone or has become a usual virus. Lastly, the longterm, inevitable effect of a lockdown is to hide people from the virus such that, as the lockdown is removed, those bodies return to exposure and a possible tsunami of cases (which is what we are probably seeing now from the Spring Lockdown-the virus has not changed). Severe lockdowns will lead to severe pandemic relapses, potentially overwhelming the healthcare system’s resources and staff.

Finally, this lockdown scheme was started by a public health official (not a physician) in Santa Clara Country, CA as a model for response to grave bioterrorism infectious agents, not for a virus of the nature of SARs-CoV-2. It is way overkill and is effectively killing the country. Lockdowns are a luxury of the rich—they keep getting paid, have assets to live on, hire tutors for their kids. The poor and financially marginal are most impacted—lost jobs, savings, homes. Drug overdoses, alcoholism, domestic abuse. And, pay attention. Despite all this financial and social devastation, Nancy Pelosi , Democrat Speaker of the House in Congress, would not pass a COVID-19 stimulus bill to get relief money to small businesses and families in distress last August because she feared it would help President Trump get re-elected in November. She said this. She was willing to see middle-class lives permanently ruined to gain power by sustaining misery that would be seen as “Trump’s America.” Also, be clear that during this time many died alone with strangers holding their hands in hospitals, funeral attendance was restricted, and weddings also were constrained because of the lockdown. A lucid, appropriate and rational statement on lockdown policy, The Great Barrington Declaration, is displayed at GBDeclaration.org.

3. Schools: For all the reasons stated, the children must be 100% in school immediately. If a child is found positive, immediate contact tracing with respect to their families is in order.

Teachers at high-risk for serious disease can be offered temporary disability until vaccinated. However, recent data suggest it is rare for teachers to acquire SARs-CoV-2 while teaching.

4. Vaccine: The first vaccines available in the U.S. (Pfizer and Moderna) are both based on messenger-RNA (mRNA) technology. This is a nucleic acid strand that directs the recipient’s cells to form anti-spike antibody protein to block SARs-CoV-2 virus from attaching to mammalian cells at the ACE-receptors in respiratory passage and eye lining tissues.

The mRNA is not a life-form. This is not a live vaccine. Yes, this vaccine has been created in unheard of record time. Though no serious reactions have been seen in significant numbers, it will take 6 months to a couple years to have a reliable safety profile on the vaccines. However, the effectiveness of these vaccines are unquestioned—94-95% antibody production, even in the very elderly, which is not usually the case. The best flu vaccines are about 60-70% effective, much less so in the aged.

Be clear. Anything we put into our bodies has risk. Alcohol, medications, vaccines. The decision to take them is a personal risk-benefit decision. In Texas, every day that you get into your car you wager you will not be one the 9 people a day who die in accidents. If we require no risks (such as with lockdowns and the vaccine), then we need to stop alcohol sales, lower the speed limit to 5 mph (about 40,000 deaths per year), and have a complete society-wide lockdown every flu season from September-April (25,000-60,000 annual deaths).

There is a point where, if we are rational and intelligent and choose to live our lives, we calculate and accept risk and do not obsess over it; or, we have an emotional disorder.

It would seem sensible that with an infection that is worldwide and affecting literally every human being, their families, and their lives and livelihoods, a pharmaceutical company would be at great risk for exposing a huge number of people to an ineffective or dangerous product.

CONCLUSIONS

1. Masks: It is inconclusive whether they protect us from getting the virus. It appears they mostly help in decreasing someone shedding SARs-CoV-2 from giving it to others. Cloth masks are probably worthless, and the small surgical masks not much better. Otherwise, it is a positive civic and ethical behavior to wear an effective mask when close-by the public.

2. Distancing: This is the most useful preventive for COVID-19. But, 6-feet is a minimum. 20-feet is more advisable in closed ventilation with someone with respiratory symptoms. And any airspace where someone who may have been COVID-19 positive should be unpopulated for at least an hour.

3. Quarantine: Anyone 65 or older is best advised to tightly control their exposure to others. Assisted living facilities and nursing homes should regularly screen their staff several times a week for SARs-CoV-2 as a condition of employment.

4. Lockdown: Should not be done unless hospital bed capacity is approaching full and then where lockdowns should occur should not be unilaterally mandated by governing or public health officials. Instead, such measures should be done in collaboration with medical and public health professionals, government authorities, business owners and leaders, the general public, and any other stakeholders in such policies. Decisions can then be made by consensus on what businesses, services, and workers are “essential” and whether the onus of a lockdown can be rotated such that it is not imposed across an entire industry, sector, or service center. Again, the “patient” is the entire community and the country, not just those individuals with COVID-19 illness. Lockdowns and other very restrictive policies must be PROPORTIONATE to COVID-19 scientific data and other societal, collateral risks, or people will not comply. The public and leadership must work together, in trust. Right now, the trust is gone. The bottom line is that general, severe lockdowns have not worked. Case surges have occurred anyway, and will as this extremely transmissible virus steadily makes its way through humankind, only possibly short-circuited by vaccination and herd immunity of 60-70% from prior infections.

5. Schools: Open (see above).

6. COVID-19 Illness: We are quickly moving toward focus on the moderately ill cases to now prevent hospitalizations (previously treatment was centered on inpatient cases). We will see more and more of this going forward with treatments given earlier and outpatient.

7. Vaccination: Obviously, healthcare professionals and first-responders must receive vaccine first, as most exposed to those who are shedding the highest amounts of virus in the acute onset of serious illness.
Current policy intention is to next vaccinate the very elderly as most at risk for death. I disagree with this. Most of the very elderly are fairly sequestered and relatively immobile socially and so not really practically exposed if focus is put upon keeping them relatively quarantined (and screening their caregivers) until the COVID-19 surge relents. It makes more sense to get herd immunity up (and so safety and confidence) in workers who we need to return to work. Once done, the elderly can be vaccinated. Lastly, the kids (at least down to 16 yrs-old for Pfizer and 18 yrs-old for Moderna, by current vaccines’ criteria).

8. Travel: Again, this is a personal decision. But, airlines are equipped with high-efficiency particle filters (HEPA) in their ventilation systems and exchange the entire cabin air about every 2-3 minutes. If the flights are screening passengers for recent COVID-19 symptoms or known exposures/positive tests, if you wear a mask, if you are not seated next to someone with respiratory symptoms, and if you clean your hands before and after the flight, air travel should be very safe. So far, there has been no report of a super-spreader event related to an airflight.

I hope this has been of value. But, unfortunately, the medical profession has not voiced objections enough over the politicization of this pandemic, at times complicit (saying public demonstrations for social justice were more important than COVID-19 “super-spreading” concerns), and otherwise mute on the perversion of public health policy for a political/social agenda. It has been a disgraceful year for the profession, other than the COVID-19 caregivers and the vaccine.

We cannot afford medical and public health myopia, ignoring managing our “ill” American society, lest we sacrifice our country and our way of life.

I think I have made the case that our current dilemma is political and medical, inextricably bound. I personally have no question that the handling of this pandemic in the U.S., at odds with data, can only be ascribed to an exercise in political power and an agenda to re-order the society. All this in the context of Leftist leaders’ failure to enforce law and order over violent anarchists and property destruction from May through September, joined with their tone deafness for their constituents’ protests and desperation over lives falling apart from decreed public health policies, can only lead to a conclusion that all this mayhem has been an opportunity to subdue the middle class and create an environment where socialist, statist America is an achievable reality out of economic devastation—something the Left knew could never be achieved by vote. There really is no other rational explanation for the incongruity between “the science” and the extreme actions of progressive leaders on the pandemic “to protect lives,” yet their inaction to govern as anarchy raged. Of course, during an election year, creating a terrible vision of “Trump’s America” was the immediate goal, but the longterm aim has been an undoing of the American model and a “re-imagining of America” and a new order. At least, that’s one doctor’s take.

“The worship of the state is the worship of force. There is no more dangerous menace to civilization than a government of incompetent, corrupt, or vile men. The worst evils which mankind ever had to endure were inflicted by bad governments. The state can be and has often been in the course of history the main source of mischief and disaster.”
-Ludwig von Mises

Bolshevik Russia/Soviet Union, The Third Reich, Communist China, Venezuela…America, on the brink.

Finally, as always, these are my personal, professional opinions.

 

Edward R. Rensimer, MD

Infectious Diseases

Director, International Medicine Center

traveldoc.com

 

COVID-19 Update No. 15: Vaccine-Take It Or Not?

12/4/20

                Let me start out by clearly stating I am obviously a science-based guy, entirely. Vaccines are one of the great miracles of modern medicine, saving millions from damage and death from communicable diseases. However, they can and do cause harm. That is not the rational argument (against them). If a vaccine kills one person but saves 1,000, what is the issue for anti-vaccers? U.S. cars kill 40,000 annually. You going to start walking everywhere? But, motor vehicles take people to hospital emergency rooms, transport food and medicines, make travel possible. As a society, we agree that it is OK if 40,000 people die each year, many of them young, because we want the benefits of rapid, economical, and individual transportation.

Vaccines need to be considered the same way. Risk v. benefit. Of course, in the middle of a pandemic with over 250,000 deaths and uncertainty on the future course and stability of the SARS-CoV-2 virus, that balance is disturbed. How do we decide whether and when to take a new vaccine? It needs to be given some thought, especially by those at low-risk for death from the infection. Unless you don’t know much, it is not a straightforward decision. Remember, all vaccines are relative not absolute protection.

So, here are some facts,

  1. m-RNA Vaccines: The Pfizer and Moderna vaccines, those most likely to get EUA (Emergency Use Authorization) approval from the FDA, are vaccines using this first-time technology. This method uses a SARS-CoV-2 gene to provoke specific antibody formation against the virus’s spike protein. This gene is not able to replicate itself and so constitute a risk of infection. It is not a “live virus” vaccine- not even a virus. There is nothing to suggest the m-RNA aspect conveys any particular biological risk for recipients, although, since this is novel technology, it remains an open question.
  2. Efficacy: Defined as “the ability to produce the desired effect”, this is a tricky issue, yet. These two vaccines have shown clear ability (over 90%) to produce high levels of virus spike-protein (attachment protein) antibody levels. Is that the same as preventing disease? That has not been resolved. The numbers of study recipients so far are low and the claimed efficacy of over 90% may not hold up as the number of recipients grow. Vaccine manufacturers typically turn out the most optimistic numbers when launching a new product, later to be revised. This is often so with any vaccine (as well as the safety profile). Even if the rate of antibody production turns out to be 60-70% (that of the best flu vaccines), it still is worth it–that effect spread across the entire society would profoundly down-regulate the pandemic, if the antibody is the key aspect of immunity to the virus.

Furthermore, the human immune response needed to stop or minimize the bad effects of infection may be far more complex than a single antibody type, and these vaccines are developed to generate an antibody. It may be helpful, but not enough to impact infection, and so illness. Other parts of the immune system may be as or more important than any single antibody.

Another aspect is duration of immunity. The SARS-CoV-2 virus infection may only generate effective antibody levels lasting months to a couple years. Vaccines may not be as effective at doing this as the virus itself. Remember, these vaccines have been so fast-tracked in development (record time) that it is unknown how long their antibody production will endure. There just has not been enough time to study it.

Furthermore, vaccines may be less effective across different patient groups, especially the elderly. Although there is obvious intention to protect those at most risk for death, those over 65 yrs-old, it is usual that advancing age weakens everything, including our response to vaccines, such that antibody production from these COVID-19 vaccines may be much less than in younger subjects, importantly those who most need the immune protection. Again, not enough time yet to know what is the truth for these vaccines.

Lastly, these vaccines are very targeted at a specific, narrow function- to produce antibody that will bind the “spike proteins” on the surface of the SARS-CoV-2 virus (which make it look like a submarine mine), to interfere with its ability to attach to human cells. What if the virus, as all viruses do, mutates to devise other ways to attach to our cells? Possibly, a geometrically altered spike protein. Viruses, by Darwinian principles, through millions of reproductive cycles passaging through human host cells will generate mutant or altered forms that may be “defective” compared to the origin virus, but actually adjusted to the current environmental threat (antibodies from the current vaccines) to the virus’ ability to replicate and so to survive, so that the mutant becomes the dominant new, more fit (survivable) strain, and so another surge of cases. We are familiar with this phenomenon with annual, seasonal influenza, which requires a new vaccine formulation every year. So, a narrowly targeted vaccine could become obsolete or much diminished in its protection fairly quickly, depending on the virus’ ability to mutate. This also is an open issue.

So, what are the latest results from trials involving about 40,000 people.

Pfizer: The study group developed 170 COVID-19 infections.

Infections: 170                  Placebo: 162 (9=Severe)                               Vaccine: 8 (1=Severe)

Pfizer claims its vaccine is as effective in over 64yr-old recipients as in younger subjects. 95% effective.

Moderna: The study group developed 196 COVID-19 infections, (30 severe),

Infections: 196                  Placebo: 185                       Vaccine: 11

Moderna states the vaccine has been effective across all ages, races, ethnicities, and sexes. 94% effective.  Both vaccines caused these side-effects: fever, headache, bodyaches, fatigue, injection site reactions, but more severe. But, follow-up for adverse effects after the 2nd dose (both vaccines are 2-dose) has only been 2 months.

  1. Safety: As stated above, in general, the risk/benefit for vaccines approved for use generally has favored the vaccine. These vaccines have been developed in about 10 months, versus the usual 2-20 years. Also, the m-RNA technology basis is cutting-edge and new invention. All of this is commendable as a miraculous achievement in a crisis.

However, substantial safety data will take at least 6-12 months more, with much larger numbers of recipients, to accurately assess this issue. Again, this is usual with new vaccines. It takes millions of recipients to get a complete picture, although the FDA would not issue a EUA unless fairly confident about relative safety. However, the urgency to do something to impact the pandemic’s effects on the American people and on our society and economy is pressuring granting of a EUA.

Safety and efficacy appraisals will be moving targets, evolving over time to a more reliable position.

So, what are the specific factors to consider in making a personal decision to take the vaccine?

  1. COVID-19 High-Risk
    • Exposure: “essentials workers” such as healthcare professionals, first-responders, food-handlers, etc.
    • Over 64 yrs-old
    • Pre-Existing Conditions: Obesity, diabetes mellitus, hypertension, asthma, immune deficient, etc.
  2. COVID-19 Disease Incidence: If the virus activity (new cases) is leveling off in the months ahead because of increasing herd immunity (from those previously infected or vaccinated), it may be reasonable to not take a vaccine, especially if serious vaccine-associated ill-effects are being reported in substantial numbers. Of course, as with annual flu shots, there is the consideration of taking a vaccine as “civic duty”, as part of a collective community’s effort to minimize extent of a casually communicable disease. The answer to all this, on a personal level, is nuanced by what is going on at the moment and by one’s principles. It also must take into account all that has been so far stated about the specific vaccines’ risks and benefits, and how those are changing (again, a moving target during an epidemic outbreak).
  3. Safety: This must be considered and re-considered as vaccine experience and data develop and then factored into disease incidence at the very time the vaccine is available to you.
  4. COVID-19 Illness Treatment Efficacy: We have seen substantial decline in the hospitalizations, ICU admissions, and deaths as a percentage of all positive tests. That is, the rate or percentage of bad outcomes. The total number of cases (defined as positive tests) has been reported in panic tone by the media, but they have not emphasized the success the medical profession has had in understanding the virus, the nature of disease at a cellular and tissue level, and the timing of medical interventions that have dramatically improved the outcome of any individual COVID-19 case. For example, it was recently reported that U.S. ICU case mortality was about 30% in March-April, 2020, and now is about 3%–the worst of the worst cases.

Along with this is the fact that about 90% of COVID-19 positive individuals are without symptoms or only moderately ill—not requiring hospitalization or specific treatments. Yes, there are increasing death totals because there are many, many more positive cases, but for fewer deaths per thousand than early in the pandemic.

All of this colors the decision on taking vaccine or not, as well as when to do it.

  1. COVID-19 Disease Risks: I will not restate the mortality rates for various age-groups, readily available at cdc.gov. Obviously, the high-risk groups have been well-established and those individuals almost certainly should be vaccinated (unless they can indefinitely avoid substantial exposure to the virus), if incidence of new cases substantially continues (large surges). But, the improving death rate should be factored into the decision, particularly until the relative safely of these novel vaccines becomes established. That may well be the case by the time the vaccines are available to the general public, likely in the 2nd quarter, 2021. It is a more problematic for someone like me, 71 yrs-old and with front-line exposure as an Infectious Diseases physician.

Vaccinating people under 19yrs-old, given the near absence of deaths from the virus, is not about protecting them. It’s about decreasing the total protoplasm in the community available to grow and spread the virus to high-risk groups.

Finally, we still do not fully know the long-term effects of SARS-CoV-2 virus on some people. It will take another year to evaluate those who have had the illness to assess what damage has been suffered, and to what degree recoverable or permanent. Heart damage, lung damage, kidney damage, cognitive impairment (dementia), peripheral nerve damage, are all on the table, having been seen in patients some months after illness (but not asymptomatic patients). All of these problems are likely to be found, but, given the huge numbers of infections worldwide, the very high majority of COVID-19 patients will have complete recovery. And, any long-term damage will most likely occur in those with the most severe (hospitalized) illness and with underlying pre-conditions for higher death rates.

Conclusion

You can factor all this into your decision on whether to accept vaccine or not, according to your personal circumstances. I started out saying this is not straightforward, but now you are at least informed.

The data from Pfizer and Moderna are encouraging and, at least in terms of efficacy, should incline high-risk individuals toward taking the vaccine if SARS-CoV-2 virus activity is substantial when the vaccine is available. For most Americans, by that time, more data on safety and efficacy should be available. It is fair to be concerned about the unparalleled speed at which these vaccines have been brought to application. So, we all must pay close attention in deciding what to do.

But, what about personal principles around the idea of vaccination for communicable diseases? Should it be mandated that we receive it? Don’t we have individual rights and isn’t mandatory vaccination an infringement of such rights? I mean, we are Americans and live by a Constitution and Bill of Rights, right?

Well, first, just because we can cite our basic rights as statute protecting some of our behaviors does not make it right, ethically, to decline immunization. I am now articulating a personal, professional point of view of immunizations and the decision to receive them. This is within the context of there being no such thing as a no-risk position, vaccinated or un-vaccinated. We all live in a community, governed by laws. We are part of something bigger than ourselves, for our benefit, those we care about, and for all others. So, we agree to not drive intoxicated, not run red lights, not discharge firearms in public, etc. We give up some personal freedoms and, though given broad rights under our Constitution, with such freedom comes responsibility to act properly, to do no harm to others. So, we concede to laws and to abide by them. In addition to these communal rules, properly The Golden Rule is foundational to ethical behavior toward others. In medicine, a corollary of this is, “Primum non nocere”: First do no harm. The core of the Hippocratic Oath physicians swear upon receiving their medical degrees.

Putting all this together, the case is made that receiving immunizations for communicable diseases is truly a civic duty… exercised beyond your concerns for yourself as an expression of duty and caring for others in your family and, more broadly, your community. When I have encountered people who obstinately refuse the flu vaccine saying they are willing to risk getting the flu, and it’s their right, my response is that that’s fine, but what about getting it to decrease risk of flu illness and death to their friends, grandchildren, co-workers? As part of a community, we are compelled to be selfless. Certainly, we have a personal obligation to not harm ourselves. But, our lives are replete with risks: driving, eating out, drinking alcohol, and on and on. There is no absolute safety. I would challenge any one to show statistics wherein any FDA-approved vaccine may be rationally declined, though medically indicated, based on the risk/benefit calculation.

What it comes down to is our decisions on vaccination have potential serious negative impact on others, not just ourselves, and vice versa. We do not live in isolation. There should never be a need to mandate a vaccine in a responsible, functional, civilized society. The right thing to do is intuitive.

Whether by SARS-CoV-2 virus infections or vaccination, once we reach 60-70% herd immunity of the population, the epidemic will cease. There may be sporadic cases, even reverbatory smaller waves of infection, but hospitalizations and deaths will decline (as with seasonal flu). And, our society will be able to reclaim its life and vitality. And that is something of which we should all want to be a part. So ends my lecture on medical ethics.

Of course, the longer you wait to move forward with the vaccine, the more accurate information you will have on safety, efficacy, and relevancy to the COVID-19 virus community-wide activity at the time. Please notice in the Pfizer and Moderna preliminary trial numbers there were 170 and 196 infections, respectively, despite vaccination. So, as with all vaccines, the protection is relative and imperfect. Holding any vaccine to a standard of perfection has always been medically ridiculous. Even after vaccination you will need act responsibly until the epidemic is gone. Lastly, the further along all this goes, the more weapons and expertise we will have to apply to any case and to turn the situation around. On the other hand, there will never be a guarantee that any individual case will not proceed to physical damage, death, and collateral non-medical losses, like lengthy time off-work.

If these vaccine statistics and facts hold up after the FDA’s Advisory Committee reviews them in mid-December, and COVID-19 community-wide activity is still vigorous (likely, I will almost certainly take the vaccine as soon as it is offered, and advise my family and patients to do so; first those at high-risk for severe disease and death. Remember, I am 71 yrs-old and an highly exposed physician specialist– that’s my risk/benefit calculation.

I hope this information will be of value in your consideration of COVID-19 vaccinations. These perspectives will be true for any future COVID-19 vaccine products.

Edward Rensimer, MD

Infectious Diseases

Director, International Medicine Center

Houston, TX, USA

 

COVID-19 Update No. 14: “Trump’s Pandemic Performance”/Politics

10/26/2020

Just weeks away from Election Day and, if the polls are to be believed (not a given), President Donald Trump is behind. Since he fares better than his opponent on the economy, now and into the future, it must be that personal dislike of him and the public’s inclination to blame him for the state of the COVID-19 Pandemic account for the poll deficit. Of course, all this occurred on his watch, but a review of the facts will clarify what is and is not reasonable about all this. In order to arrive at proper conclusions, we must revisit the beginning of COVID-19 in the U.S. Starting there, the questions to answer are,

1. How might all this have gone, at best?
2. What was done?
3. How has it gone?

Recall that the first U.S. COVID-19 case was Jan. 21, 2020. It had clearly come from China. Despite a widespread outbreak with many deaths in China at least the prior 2-3 months (very possibly longer), with the arrival of a novel virus on our shores, the first priority was to get information from the Chinese experience with haste. China would not cooperate. They would not allow our CDC experts access to their high security biological lab (much of which was funded by U.S. taxpayers) in Wuhan where SARS-CoV-2 (COVID-19 virus) had been under study, virtually the epicenter of the Chinese epidemic. So, from the outset we had no helpful information. We were starting at zero (and we now know the virus was spreading here exponentially, but silently). We were already behind. In addition, the Chinese misinformed us, suggesting human-to-human transmission was not a serious issue. By that time, SARS-CoV-2 was already showing up outside China, in other parts of Asia, India, and Western Europe.

Further, the nature of novel, pandemic viruses is to spread quickly and in rolling waves over 1-2 years after their first appearance. So, the cat was out of the bag with the first U.S. case and no one could have stopped it. No one. We now know that up to 20% of infections have no symptoms, and 60% are mildly ill. And, we had no test yet to detect the virus. So, we would spend a couple months just to collect actionable information allowing policies and protocols to contain spread. And we had no idea who was at most risk for serious disease and death. We were entirely in the dark for the first couple months on what we faced.

The President did what leaders do. While trying to develop information, he announced the problem to the country with a calm, optimistic tone. Should he have then been grim and worried, leading the country to panic- a rush on supermarkets, home supplies, banks? No. That is not leading. But, on Jan. 31, 2020 (10 days after our first identified case), he made a bold decision to stop travel from China, anticipating the worst. He was immediately criticized by Joe Biden as being “xenophobic” (racist) against the Chinese. Nancy Pelosi, Democratic Speaker of the House, smilingly told the country to go to Chinatown to eat Chinese food, as she did so on camera. This was the “anti-Trump” strategy. Whatever he does, do or say the opposite and find a way to label him. So, from the start, some Democrats worked this pandemic for political advantage. As Jane Fonda, a lifelong Democratic Party darling, recently said, “COVID-19 was God’s gift to the Left.” … but not to the over 215,000 COVID-19 U.S. dead.

He then shut down travel to and from Europe on March 12, 2020. Leadership.

1. How might this have gone? What was done?

With what we know about pandemic viruses’ behavior and the SARS-CoV-2 virus specifically, no one could have contained this. Infectious Diseases specialists and public health experts know this. President Trump’s COVID-19 Task Force, which he formed immediately, came out with the most reasonable approach. The goal was not to stop the virus. It was to “mitigate” it. The idea was to break an expected tsunami of cases into many smaller “surge” waves, so that the healthcare system had sufficient workers, facilities, and equipment to optimally treat the afflicted. Italy failed at this and so choices were made by its physicians of who would get the ventilator and who would be made comfortable to die… rationing care. This never happened once here, despite a horrific hotspot outbreak in New York City. Why? Because the President and his Task Force mobilized the military and private sector business to go into wartime mode to outfit two U.S. Navy hospital ships for expanded bed and intensive care unit capacity in a matter of weeks… record time. The ships were deployed to New York City and Los Angeles. Both the Democrat Governor of California, Gavin Newsome, and New York’s Democrat Governor, Andrew Cuomo, were effusively grateful and complimentary of the president’s time-critical effectiveness and speed in getting the job done for these governors and their constituents.

In parallel, the president had the biotechnology companies develop an accurate diagnostic test for SARS-CoV-2 within the first month, and then ramp up production and distribution of test kits as soon as possible over the next couple months. This was essential to success, to have a tool to detect the enemy and to track its behavior and extent. Only with this could we develop a containment strategy while working on the currently ill. Likewise, personal protection equipment (PPE) of facial visors, masks, gloves, gowns, and cleansers were urgently needed, especially for frontline medical workers, and the president pushed manufacturers to retool their factories for massive production of all this and ventilators that were sorely needed for survival. All of this activity was initiated and coordinated by the president’s Task Force. But, its work also included mobilization of the U.S. basic and medical science communities to study the virus in detail and to start clinical studies on patients and patient groups to start to define methods and standards of care for the clinicians charged with care for these patients—an ongoing process to continually re-evaluate new data and to optimize care, the goal being to minimize the death rate. So, the death rate and intensive care occupancy by COVID-19 patients has dropped radically.

Finally, the CDC also daily and weekly produced guidelines and protocols as new information was collected real-time for the medical profession, first-responders, and hospitals and the general public (schools, restaurants, bars, sports venues, etc). There was a necessity to address virus exposure across the society with the goal of mitigation to limit further spread. And so, to bend the building huge wave of new case numbers downward, all of this had to happen at virtually the same time. President Trump’s Task Force, under his leadership, got this done.

Sure, there were some shortfalls in production and distribution of supplies in the early months, but this was unavoidable with an unprecedented biological catastrophe (at least since the 1918 Spanish Flu Pandemic). And, President Obama and Vice-President Biden had exhausted the supplies of PPE with the 2009 H1N1 Influenza Pandemic from the national stockpiles and never replaced them. Nevertheless, everyone received the best care available in the moment.

To diminish the first, huge wave of cases, a “lockdown” of the country was done under the advice of public health experts, such as Dr. Fauci and Dr. Birx—to be managed by each state’s governor according to their state’s density of population, total population, rate of new cases, and many other factors. And, now that more was known about those most at-risk for serious COVID-19 disease and death, strict quarantine of the most vulnerable was effected. It was clear that any lockdown was a double-edged sword. The more severe and longstanding any lockdown, the more societal paralysis and collateral COVID-19 damage: ruined businesses, defaulted mortgages, exhausted savings, mental illness exacerbation, alcohol/substance abuse incidence rising, broken marriages, physical violence, diminishing tax bases threatening government and public services breakdowns, closed medical practices, and financially tenuous hospitals, and on and on. Knowing the peril to his white-hot economy and the potential political fall-out in an election year, President Trump called for sweeping lockdowns in outbreak hot-spot areas in the best medical interests of the American People, per the discretion of governors and local leaders.

One important point about lockdown that has not been discussed. The longer and more severe they are, the more people are not exposed to the virus and so not developing immunity. So, when strict, long lockdowns are terminated, it is a set-up for massive resurgence of infections—creating the tsunami that mitigation was designed to avoid. That is what is happening in Europe now. Lockdowns were over-done there. Lockdowns are supposed to be managed to slow down and, so to spread out, new cases. President Trump did that.

Finally, President Trump had the Food and Drug Administration (FDA) streamline its ponderous, inefficient approval process so that promising medications and other therapeutics could be fast-tracked in what was a public health cataclysm. This innovation also is relevant to what appears to be a record-breaking development of a COVID-19 vaccine, expected to be available by the end of 2020, an unheard of 8-9 month timeline, compared to the usual 3-5 years. This could only occur with the lightning fast mobilization of U.S. basic science companies and academic institutions by an expert leader and manager to develop the science on the nature of SARS-CoV-2 as well as its interplay with human immune systems (immunology). This had to start up back in March in order to meet a vaccine target arrival date in late 2020, or early 2021. Fantastically ambitious and unprecedented.

Finally, it appears likely we will have a vaccine that will enable us to return to our usual lives understanding that a new vaccine is never a given possibility. Do we have a vaccine for HIV/AIDS, Herpes simplex, Zika virus? No.

How has it gone?
Well, cases continue to appear and deaths continue to occur. But, again, that was always expected. It could not be otherwise. We had to open, or sacrifice the country’s economy, and so America. With that, more people would be moving about, and so, with increased testing as well, there would be mounting case numbers. Many of these are positive COVID-19 tests without illness, though the media does not explain this critical detail when announcing panic “alerts” on “surges” of new cases, which fits their aim to exaggerate and to sensationalize. But, the focus should not be on the media’s alarmist “alerts” on new case totals as people re-engage in their lives. The focus should be on several facts,

1. The public is, by far, more used to the need to “social distance” and to wear masks, where appropriate. It is not the “new norm”; rather, a new norm for a while…probably another year (depending upon the effectiveness of the anticipated vaccines).

2. The medical profession now has methods and tools to deal with the worst cases. So, COVID-19 hospital admissions, ICU cases, and deaths are all way down the past 3-4 months. Most of the deaths occurred when we were COVID-19 ignorant and inexpert. This will only continue to improve as more medications and other therapeutics (monoclonal antibody and convalescent plasma infusions) become available. Many are in the pipeline and will be available in just months because of the mobilization of private enterprise, the healthcare system business and scientific communities, and military and public health sectors—all done immediately and in parallel by President Trump’s Task Force from the outset. An apt analogy would be America’s all-out, full-societal response to entering World War II after December 7th, 1941, Pearl Harbor.

3. Children are increasingly back at school. That is necessary as they have been hit hard in their development in crucial years of their lives. Long-term life success is highly correlated with the elementary school years’ experience. There are next to no deaths in people under 19 yrs-old who are otherwise healthy. Recent studies show in 1 in 1,000 school children acquire SARS-CoV-2 at school; 1 in 2,000 teachers. And, children are now known to not likely spread SARS-CoV-2 to adults. Adults get COVID-19 from other adults.

4. With easing or cessation of lockdowns, we will see more cases. But, the great majority of those new cases are in people in their 20’s, not a risk for serious disease or death more than seasonal influenza. The more of this that happens, the more “herd immunity,” until finally, between those previously infected and immune and those who have been vaccinated, we will see this all in our rear-view mirror, much as any virus that is part of the human condition, such as influenza. The president is correct when he says we have “turned the corner.” Case counts will continue to register, but death rates and hospitalizations will go down and the virus will gradually mutate to a weaker form. Anything that suggests otherwise is misrepresentation to create panic. Walk away from that.

MASKS

One other topic should be discussed…masks. Politically, the failure to religiously wear a mask or to insist on it has been used as a “virtue signal” for social irresponsibility, and wanton disregard for others, in fact, gross negligence. This has been a drum loudly beat by President Trump’s adversaries. And, they have used mask wearing, virtually every time in front of a camera, to create political theater over the issue as a negative signal on President Trump’s alleged personally unethical behavior and incompetency, as well as an ever-present reminder that we have a pandemic and it is on Trump’s watch; so, he owns all its negatives (or so they assert).

No one can argue against wearing a mask. If it allays anxiety in an individual because they are “doing something,” then, so be it. But, it is clear that the data on efficacy of masks having a reliable impact on the risk of acquiring COVID-19 are conflicting. Likewise, the opinions of experts on the matter. The CDC just turned out data on patients who were so COVID-19 sick that they were admitted to the hospital. Of those, 71% had worn a mask all the time; 14%, most of the time. Seems like the mask did not provide much value. The U.S. Surgeon General, some months ago, doubted their value. On March 8th, Dr. Anthony Fauci (NIH) said masks were not needed. He since then has seemed to advocate them, but he has vacillated on his position, like on other pandemic issues, many times during this pandemic. But, before we take a political party’s condemnation carte blanche, we should examine an issue, the facts of which are still evolving, ourselves. The Democratic Party and Joe Biden’s opinions on this are just perhaps not entirely motivated by established science. The bottom-line on masks from the CDC is that masks may decrease the risk that someone ill with SARS-CoV-2 will spread it to others, but it is less clear whether masks protect the wearer.

Note, just last week, the World Health Organization pronounced COVID-19 quarantine lockdowns no longer advisable because any value with respect to COVID-19 prevention were negated or even outdistanced by the severe collateral damage of societal isolation, economic damage, and non-COVID-19 medical morbidities and deaths from the lockdown as people delayed or avoided medical attention for serious problems out of fear (from the media) of acquiring SARS-CoV-2 while seeing a physician or going to a hospital. And, until this, lockdowns were written in stone, COVID-19 dogma, as necessary, even to the point of many Democratic Party governors over-reaching their legitimate legal authority to bring to bear almost COVID-19 martial law on their constituents as they restricted their constitutional rights. Yet, the lockdown issue is still open to debate by qualified experts.

You want to end COVID-19? Put every person on a private raft at sea for 3 weeks. Done, virus gone. The only fool-proof anti-SARS-CoV-2 intervention is strict social distancing. And now, knowing it hangs in the air in minute, aerosol particles, everyone must be at least 20-feet apart. As for masks, jury’s out.

The Election/Trump/Biden/Pandemic: Conclusions

Lexicon: Propaganda, misinformation, disinformation, political theater, exploitation, manipulation, mistruths

All of the above.
Well, if you’ve gotten here, you have the picture of all that went into, over a very short time, orchestrating a comprehensive public health, medical, and societal response to this unprecedented crisis, without the benefit of any collaboration with those who originated the outbreak. Really astonishing by anyone’s measure. I won’t say unprecedented. FDR, likewise, mobilized all needed expertise and resources with our sudden entry to WWII.

Nevertheless, Joe Biden, Kamala Harris, and the Democratic Party leadership seem to have gotten away, in this age of sound bites and partisan social media edits, to misconstruing President Trump’s leadership and effectiveness in confronting the pandemic for the American People. They claim President Trump has been asleep at the switch, fiddling away while Rome burned.

Joe says he would have done (in fact, will do) it differently. He’ll let us know (just like with Supreme Court “packing”) what groundbreaking solutions of his would have turned all this around, after the election. Funny. What happened to the telephone? To email? I am sure the Administration would have welcomed a message from him with his prescient wisdom to impart on ending the COVID-19 Pandemic from a former vice-president. Certainly, no one committed to the welfare of the American People (and the country) would withhold information that would save lives until after an election. That would be a pre-requisite for a would-be president.

Had Biden been president in January, he would not have stopped travel from China. Remember, China had a wobbly economy and would not take well to such a lockdown of travel between the U.S. and China. Besides, they needed the SARS-CoV-2 to spread broadly across the world—a receding tide to lower all ships. They needed the U.S. hurt, badly, without firing a shot so that their timeline for becoming the Number One Super Power of the 21st Century was not derailed. And, the Bidens are tightly entangled with them through under-the-table business schemes when Joe was VP, more evident every day.

According to Joe Biden, President Trump is personally accountable for all the COVID deaths. Any competent president would have prevented all of them, according to Biden. Well, the pandemic modeling in February suggested about 2 ½ million U.S. deaths with what was known. That’s 6X more than so far. Had Biden been president and not stopped China travel, there would be tens of thousands more deaths. Parenthetically, tens of thousands of these deaths were mass-murder actions by several Democrat governors defying (New York, New Jersey, Pennsylvania, Michigan) CDC guidelines and sending recently infected elderly patients back to their nursing homes to pollinate thousands of doomed residents (about 11,000 estimated deaths by Gov. Andrew Cuomo, alone, who still does not take responsibility and still holds office; says a lot about their real concern for all those deaths about which they decry President Trump).

When Biden does offer up a sampling of what he would do, it is everything President Donald Trump already has done. But that’s just like Ole Joe. Once a plagiarizer, always a plagiarizer (the reason for his two prior failed runs for the presidency).

But, we don’t need to speculate. Joe Biden was charged by President Obama with managing the 2009 H1N1 Influenza Pandemic. In the U.S., 61 million were infected (compared with 5 million with SARS CoV-2). There were about 12,500 deaths with H1N1 compared to over 215,000 so far with COVID-19. However, the SARS-CoV-2 virus is 6X more lethal than seasonal flu and 30X more lethal than the 2009 H1N1 flu strain. If SARS-CoV-2 had been the virus in 2009 with 60 million infected, Biden would have presided over 360,000 deaths. Joe Biden is in no position to criticize President Trump. Yet he does. Politics. Trump has been a master, given the unprecedented circumstances. His virus is a killer, more like the 1918 Spanish Flu with a death rate of 2%.

His chief of staff, Ron Klain, said, “It is purely fortuity that this isn’t one of the great mass casualty events in American History,” in commenting on Biden’s management of that pandemic. The fortuity was that, though the virus spread prodigiously, it was much less lethal than SARS-CoV-2. Joe lucked out. However, not so for the 12,500 who died, who were mostly between 15-40 years old. SARS-CoV-2 deaths are about 50% in nursing home patients, well past their life expectancy. 80% are over 65 yrs-old. So, Joe Biden was tested on a pandemic and did not fare so well, relatively.

So, in closing, just to get this right, first, Trump did too much, too fast, because he’s a racist. Then, he did next to nothing (and he doesn’t wear a mask in the shower!) and so mass-murdered over 215,000 people, which would not have happened with a President Biden. Guess we can all relax because all this will be over and we can return to our lives when he’s sworn in. At least that’s the Trojan Horse they’re selling to the American People. Maybe the Democrats will be charitable and at least take 25,000 off the death totals due to Democrat governors’ gross negligence, so as to not hold them against the president. Nah!

It is also essential to understand that from the outset the president was clear that COVID-19 was a pandemic, which is defined as a number of individual, contemporaneous epidemics, each one with its own particular expression according to the geography of each state as well as other characteristics particular to each locale: number of large cities, total population and population density, use of public transportation, number of medically vulnerable individuals, etc. In other words, the pace and extent and severity of the pandemic would be highly variable, state-by-state. Some needing total lockdown, others gradual or partial shut-downs. For example, at the start of the pandemic, the states and cities on the coasts were hit hardest because of their extraordinary exposure to international travelers. With all this in mind, the president plainly stated that each state governor should determine what measures were needed and when, to match their healthcare system resources to the nature of their specific COVID-19 epidemic that they were experiencing. President Trump said the federal government stood ready to provide whatever was needed by each state, upon request. He did so. Most notably, Governor Newsome of California and Governor Cuomo of New York, both Democrats, praised him unequivocally for his immediate and exuberant response to all their needs. President Trump overwhelmed them and anywhere else requested with sufficient supplies, equipment, and hospital bed capacity. So, this always was a multi-centric management strategy to be overseen at the state level by governors with the full support of the federal government. Nothing else would make sense or would be effective. To now try to lay all blame entirely at the feet of the president is preposterous.

If you say President Trump failed, you need to say what he did not do that should have been done and when, with the information available at the time, it should have been done. And, if so, where were you with these ideas when all this was playing out? You don’t get to be Monday Morning Quarterback with no facts, only criticisms, to claim you would have done better.

The best benchmark of success is a decrease in death rate (deaths per total cases), decrease in hospitalizations, and opening up of the economy. All of that has been happened about 6 months after the inception of this nightmare. The media panic us with “surging” new case numbers which mostly reflect more and more availability of tests…the vast majority are minimally ill, or not at all. Beware of this messaging. It is cynically perverse politicking the pandemic in an election year.

As for President Trump, as a specialist in these matters, I cannot see how anyone could have done better. Thankfully, we have had an expert business manager/developer executive as the Chief Executive when COVID-19 arrived. Biden, who has never created a job or a service, never been an executive manager, and never started and run a business would have been a tragic failure, with unimaginable losses for our country. If elected, he’ll get the benefit of all Donald Trump has done and President Trump will get no credit from the partisan media.

Edward R. Rensimer, MD
Infectious Diseases

 

COVID-19 Update No.13: Being A Low-Risk Patient

6/29/2020

How long will this go on? Well, we had the worldwide 1918 Spanish Flu Pandemic, which cycled continuously, with about three major surges of disease and death more than two years. It is a fair guess that 1-2 years of COVID-19 will be prominently in our lives. However, we are physically interconnected across the globe in a matter of hours with air travel. And, this is a below-the-radar SARS-CoV-2 virus that is spreading most vehemently in the 48 hours prior to the onset of illness symptoms, when the unsuspecting host is shedding virus profligately and that person is going about their life with abandon, unaware of the danger they pose to family, friends, co-workers. So, the features of modern civilized society make predictive models of COVID-19 behavior and pandemic timelines tenuous at best.

The best thing has always been to avoid doctors and hospitals by maintaining your health and physical conditioning. More so now, with the extraordinary communicability of this virus as every place in the healthcare system is a trafficking funnel that concentrates the sick, medically infirm, and elderly… those at most risk for COVID-19 fatality. The healthcare system is the worst place to be, the frontlines.

What are you to do? You are not a habitual medical care seeker (there are those). But, you have blood in your urine, unexplained weight loss, fever, extreme new-onset fatigue, or cryptic chest pain. Problems that cannot wait-out COVID-19. And, the collateral damage of COVID-19 contagion is yet to be tabulated- people delaying seeing a physician or going to the Emergency Department because of COVID-19 fear- and die of a stroke, heart attack, septic shock, ruptured appendix, etc.

How do you balance the risk-benefit of being evaluated timely in the context of COVID-19 exposure risk? Below, I will give you practical ideas and actionable points that should provide a template for your medical care until all this is way in our rear-view mirror.

1. Telemedicine Appointments: Many medical offices are offering at-a-distance visits that may be effective for the problem (we do). Most certainly, the physician should lean strongly toward this type service for those over 65yrs and/or with underling medical conditions. Whether an in-person visit is in the patient’s best interests, and so necessary, is a medical decision by the physician. Ask your physician if they are set-up for this.

2. Minimize Time in Medical Facilities: This is intuitive on its surface. There are creative ways to do this aimed at infection control. It is all about pre-emptive communications, personal preparations for the appointment, and operational flexibility of your medical professionals. To limit your exposure time to other patients and the medical staff,

a. Complete all forms and provide all documents (updated insurance, prior medical records) prior to arrival.
b. Inform the office staff you will wait in your car until they call you to enter the facility so that you can be showed directly into an exam room, with no time among others in the waiting room.
c. Wear a mask (consider a double-mask, like I wear) and rubber gloves.
d. Have your story (onset, timeline, encounters with other physicians, medications and their impact on the problem or lack of it, prior diagnostic test reports- blood, urine, imaging) written out to present the physician. Optimal if this can be forwarded pre-visit (FAX, secure email).
e. Have your questions and concerns defined and written for the encounter.
f. Try to physically distance (other than the actual physical exam) during the visit (6 feet or more from others, including the physician and staff).
g. Do not be seen by medical professionals who are not wearing masks.
h. Clean your hands when exiting the medical facility, in a building restroom if needed.
i. Most of these measures are also relevant to an Emergency Dept, laboratory, imaging facility, physical therapy, pharmacy, and other medical service locations.
j. Wash your hands thoroughly as soon as you arrive home, touching nothing else (consider keeping hand cleanser in your car, as well).

3. Potential COVID-19 Illness Case: It is medically irresponsible to have a person who has an illness consistent with COVID-19 come into a medical office, potentially exposing staff and other patients to the virus.
a. Your physician’s staff should be asking each person trying to come in whether they have recently had symptoms consistent with COVID-19, exposure to a confirmed COVID-19 case, or themselves been found positive for COVID-19? These patients need to be turned away from an in-person office visit. The physician can arrange a phone or telemedicine (computer) visit. What if that person is really sick, with ominous symptoms, such as shortness of breath? They must be directed immediately to the hospital Emergency Department, with the doctor and the patient calling the ED staff to forewarn them of an arriving COVID-19 illness so they can sequester the patient into areas designated for such cases, protect themselves, and give directions. Such patients are not welcome at outpatient labs and imaging facilities- they do not want to be shut down because their staff have been compromised and/or infected. The rest of us do not want them closed down either, nor physicians’ offices. We need them up and running out of self-interest.

4. Conclusion: Stay away from medical professionals and medical facilities, but, with any problem that would normally bring you to contact your physician, do that and let them decide how to address the issue. Do not sit on something you normally wouldn’t. COVID-19 isn’t the only thing that can come to a very bad outcome.

Lastly, if your physician and staff cannot work with you in line with the aforementioned principles or they seem apathetic, dismissive, and/or ill-prepared, maybe it’s time to look for another physician.

Edward R. Rensimer, MD

COVID-19 Update No.12: “Surging” Case Numbers, Media Alerts, and Reality

So, COVID-19 “lockdowns” were eased and new COVID-19 case numbers “surged”? We should all panic. The pandemic is roaring back and we can do nothing but lockdown again. Texas’ governor, Greg Abbott, is giving that serious consideration. This, even though we know further, significant societal lockdown carries dire consequences for our economy and all Americans, while COVID-19 poses a death risk now approaching a small multiple of seasonal flu, and that for a small group of people, mostly the very elderly and medically infirm. The average age of COVID-19 death is 82 yrs, about the U.S. life expectancy for other causes. But, with the alarmist nature of the media and of breakneck, reflexive 24/7 “Media Alerts” and “Breaking News”, we don’t deliberate on the situation… we emotionally react with dread and borderline hysteria.

Lets’ try something new. Let’s calm down and think through the facts, like scientists, like physicians.

1. The Pandemic Goal: It never was to stop the virus. The cat was out of the bag in January and it was spreading with unprecedented speed and ease across the globe. Based on prior “novel” virus pandemics, we knew this would play out over 1-2 years until the virus slowly changed (mutated) to partner better with humans biologically, rather than kill them (which is against its own interests- a suicide virus). The virus would become the vaccine; eventually, once about 60% of the human herd had been infected and had immunity, the potential human hosts would be radically reduced, and so the pathway to those at most risk for death. The virus would become just another background occurrence in the human condition- like influence, West Nile virus, head colds.

So, we took measures to slow down the outbreak pace (“mitigation”) and to spread it out over many months, rather than over the initial 2-3 months, to allow us time to learn more about the virus and how to deal with it. More medications and management techniques. Maybe a vaccine (but don’t count on it). And, with the concern that the Fall season brings people to congregate more in close-ventilated spaces, as well as the certain annual rise of flu cases, the chief goal was to spread COVID-19 over months so the healthcare system could have staff, supplies, and equipment so no one received less than optimal care when both viruses hit.

Conclusion? Once we re-opened we knew there would be more COVID-19 spread, more hospitalizations, more deaths. It was acceptable, balanced against the sure devastation of lives and of the country with continued lockdown. So, what is happening was expected to happened, yet there is anxiety all about, fanned by the media.

Leadership needs to monitor COVID-19 hospital admissions and ICU occupancy, and adjust infection control measures to match the case numbers to resources. This is analogous to Harris County officials “bleeding off” water in phases threatening to burst the Addicks Dam during Hurricane Harvey to minimize flooding. Some property would be lost, but not all property.

Finally, despite increasing COVID-19 cases, the fatality rate has decreased, suggesting more of the cases may be in those under 65 yrs-old. If that continues, we could be moving toward the 45-60% “herd immunity” that will dramatically decrease the size of future outbreak “waves”.

2. Case Increases Across the South: It is unclear why this is so, but possibly the cases were at such a low number because of intelligent, effective lockdown measures initially such that we did not have the outbreak disasters seen in New York, New Orleans, etc, due to major errors in management (public transit, nursing home errors, Mardi Gras), and so less infections. As we eased lockdowns, COVID-19 is now getting to more people, but in the intended, measured way. Further, with increasing outside heat, people in Florida, Texas, and Arizona are naturally driven more indoors to air-conditioning, much like the effect of winter’s cold air arrival in the North. We know most COVID-19 infections are acquired among household members in close, prolonged contact, not people out and about.

3. COVID-19 Case Labelling: There is an incentive for hospitals and the medical profession to label a medical case as “COVID-19” diagnosis. Why? The government and insurers are processing payment for testing and care quickly and at good rates in order incentivize the system to prioritize care for COVID-19 cases as this has been termed “a national health emergency”- analogous to FEMA dollars for floods, hurricanes, tornadoes. The uninsured are even covered, where hospitals would normally eat the bill for them, other than a tax write-off.

So, I arrive at a hospital from a serious car wreck. Now, all patients arriving at the hospital are screened for COVID-19 to protect the staff. But, once that test is positive, I am labeled as a COVID-19 case. If I die from my injuries and was only carrying COVID-19, but not ill from it, I may be labeled as a COVID-19 death. There is a financial incentive to over-diagnose. There is also a political incentive. Make this a bigger, more ominous epidemic, governors, mayors, county judges are given more room to exert power. Be clear also that this is a presidential election year and many politicians have a big stake in not seeing the economy recover for fast and in making this natural disaster the result of mismanagement by current leadership to influence elections.

4. Social Distancing/ Politics: Somehow, over a thousand medical professionals disgracefully issued a letter stating that the specter of COVID-19 transmissibility during huge public protests across the nation took backseat to the cause of “systemic social justice”. I suppose the COVID-19 virus threat to individuals, which previously required draconian isolation measures by political fiat, now was not so much. I guess “Black lives DIDN’T Matter”, since many of the protestors were black and it is well-established that black death rates from COVID-19 are substantially higher than other groups. Even if mostly younger blacks were protesting, they could take virus to their families.

So, many medical professionals took a political position against their professional oaths to protect the health and medical interests of patients. This put people at risk for serious injury and death, in the name of a political protest movement which was based on a questionable, yet unproven, premise of “systemic social injustice”. Moreover, just weeks before, medical leaders advised and insisted on tight, protracted COVID-19 infection lockdowns with absolutely probable devastating effects on the lives and health across our entire population. It is unequivocal that “social distancing” is the most effective measure against COVID-19 propagation. You put yourself on a single-person raft in the middle of the Gulf of Mexico the next 2 years, you don’t get COVID-19.

Did anyone but me note that the incubation period for acquiring the COVID-19 virus to onset of illness is up to 14 days, and the uptick of cases in Houston occurred 1-2 weeks after the local mass protest gathering and funereal crowds for George Floyd in Harris Country? Yes, what was predicted and speculated is happening. But, the media has no interest in making this association, as apparently they are all-in with the “social justice” movement.

This must be stated. It will be remembered as a low-point for the medical profession and leadership who advocated against the public good, resulting in loss of “precious” lives (“Every life is precious” is, I think, what had been the mantra) out of political self-interest. A disgrace. Disgusting hypocrisy.

Edward R. Rensimer, MD

COVID-19 Update No.11-2nd Wave or Expected Blip

Recently, in some parts of the U.S., including here in Houston, TX, we have, just weeks after businesses have gradually re-opened, seen an uptrend in COVID-19 new cases. Think back to March. At that time there was a strategy of containment and mitigation of the pandemic curve’s upward tack. It was felt too late to stop COVID-19. Rather, the aim was to “flatten the curve”- to turn the new cases curve to horizontal and then gradually downward. That “mitigation” occurred by dramatic lockdown of human interactions and wearing masks, hand cleansing, and social distancing. The curve was bent and new cases as well as deaths declined.

As we saw the resulting economic devastation, a deliberate decision to re-open was made and it was presumed that with people out and about, COVID-19 activity would pick up. It had to. But, we had, for the country’s greater interests, to re-open and expect an increase in new cases.

That’s where we are. We are seeing an uptick in COVID-19 cases. Further, keep in mind that 100X more COVID-19 tests are being done than 2 months ago. This naturally will detect cases that before would have gone unseen. The result? An appearance of increased disease activity, which might actually be an increased detection of cases that were already there, all along.

In the month ahead, look to hear new information showing far more COVID-19 cases than before, many more subclinical or asymptomatic “infections”. Further, we should see the COVID-19 total case denominator grow substantially, which will decrease the mortality rate a good deal, perhaps just above seasonal influenza- say, 0.2-0.3%. If you have 10 deaths in 10 cases, the death rate= 100%. 10 deaths in 1000 cases is 1%. The denominator is everything.

Finally, if there really is some true increase in COVID-19 cases, the long-term benefit is “herd immunity”- much fewer people available to be infected for a large 2nd wave in the Fall.

So, don’t panic, even if the media have a political agenda in keeping this thing going. Wear your mask, wash your hands, and socially distance. Enjoy the gradual re-opening, but continue to be smart in playing your role in continuing to “bend the curve”, until we are told we can go back to “normal”, which I believe is 1-2 years away.

Ed Rensimer, MD

Director, International Medicine Center

Copyright, 2020, E. Rensimer, MD, All Rights Reserved

Coronavirus Update Archives

COVID-19 Update 10: Re-Opening v. Continued Lockdown and Pandemic Politicization May 15, 2020

This is an opinion piece, so it is critical to know about the source of the opinions. I am a board-certified Infectious Diseases specialist, med school graduated in 1975 and full-time in practice 39 years. I was fully engaged in the HIV epidemic since it started 9 months after I opened my practice. For the first few years, we did not know what caused the illness and even after we did, with only one effective medicine, it was a virtually 100% fatal illness if you acquired HIV. At the time, we were unclear for years on whether we were at substantial risk, as we managed the sickest people you can imagine with pneumonia, bloody diarrhea, and multi-system organ failure on whom one performed spinal taps, bone marrow procedures, and other sampling procedures that exposed us to their blood and other body fluids. We were in this “at risk” exposed position for years, not months, as with SARS-CoV-2. Some physicians refused to see such patients. We were not called “heroes”. During COVID-19, I have maintained an open office, even performing SARS-CoV-2 diagnostic testing. I suppose all of this qualifies me as a first-responder. I am uncomfortable with the “hero” label being thrown about, as I am sure are most military people. We do what we do out of duty and sense of mission. With respect to COVID-19, I am 70yrs-old, and so in the “at risk for death” group. Enough about me, other than that COVID-19 is a daily part of my reality, not just a “News Alert” banner on TV.

I think it is time for the medical profession to comment on the facts and to not allow politicians to manipulate a public health crisis for their political power self-interests. Our profession cannot stand by silently on this, though we are trained and so, inclined, to stand neutral on all things that would in any way bias us (gender, sexual orientation, race, etc.) in rendering care and performing professionally. However, there is a point where silence is agreement. If the messaging by the media and public policy leadership appears to distort or exploit facts, medically, economically, and societally in ways inimical to the public’s best interests, then the profession is obligated to join in the conversation. This is the spirit of this communication.

The Facts

In earlier COVID-19 Updates, I made it clear that our biggest problem was that we were in uncharted territory. We had a novel virus with incredible transmissibility; rampant, multi-focal worldwide outbreaks; and the only data from China, with their track record of disinformation, misinformation, and oppression of free speech. Could it be worse?

Well, we have now had our own epidemic with our own data. What can we say about COVID-19?

  1. The overall death rate is probably 0.6% or less (we cannot know until we have tested a large part of the population, since up to 80% infected have little or no illness); that’s 6 per 1000 infected, or less (seasonal flu is about 0.1%).
  2.  48% of deaths are people over 65, almost all unhealthy prior to infection. The average age of COVID-19 death is 82 yrs– a little higher than normal U.S. life expectancy.
    Most deaths have been in extremely old people in nursing homes, most of whom are “existing”, if we are honest. Between 25-44 yrs-old, about 1.25% death rate; 45-64 yrs-old, about 8%
  3. There is virtually no death risk to medically normal people 18 yrs and younger; less than 1% are hospitalized.
  4. For about 80% of COVID-19 infected people, it is a non-event.
  5. This is more than likely the worst of the COVID-19 phenomenon, even though there will surely be several more waves of outbreak over the next 2-3 years, until the virus is no longer novel. The only exception to this statement is if the virus mutates to a different form. The mutation rate of COVID-19 is several fold less than seasonal flu. And, mutation tends toward less formidable forms of a virus for its host– humans in this case. Why? A virus that kills its host kills itself- a suicide virus. So, it is in the biological interests of a life form, such as a virus, to grow to a symbiotic (collaborative) relationship with its host.
    As the virus passages through more and more human bodies, those humans should acquire immunity, so less humans to infect. So, subsequent virus outbreak waves should be less severe. And, as time goes by and better diagnostic testing is readily available; the healthcare system has a rapid, organized response to new case hotspots; and treatment options have been found, time is on our side to manage COVID-19 without drastic societal containment measures like lockdowns.
  6. Most COVID-19 infections are likely acquired in the household, not when we are out and about.
  7. Herd Immunity: It is likely that if a population can have been vaccinated by infection with COVID-19 (the virus as vaccine) such that 60% or more have protective antibodies, COVID-19 will no longer be novel and humanity and the virus will have reached a balance of co-existence, as is the case with many infectious diseases. Our entire current “crisis” is due to the biological “novelty” of COVID-19 virus.

When the above facts are appreciated, it is impossible to justify putting our entire country and way of life at risk to deal with it. Currently, we seem to have lost the original goal of the mission. We were never intending to do the impossible- eliminate such a highly transmissible and widespread virus. The cat was out of the bag when it reached the U.S. It was getting here from China, or any of a number of countries, and there were thousands of Americans infected before the first case of illness was recognized. Our aim was to “flatten the curve”; to slow the rate of increase of new cases to match the population’s illness burden to our hospital beds, ventilators, medications and supplies, and medical professional staff. We wanted to never have to ration care – to need to choose who would live or who would die based on limited medical equipment, supplies, or facilities, as happened in Italy’s socialized healthcare system.

Well, we flattened the curve, even in the worst epidemic hotspots of New York City and New Jersey and elsewhere. Yet, there are continued assertions that we must stay locked down, else be labeled cold-hearted murderers of the elderly. Moralistic rhetoric is used to intimidate the US citizenry into conformity and compliance with governors’ executive orders (but not laws). Weaponized morality is at play. I will discuss this further toward the end.

Let’s look at the likely picture of continued lockdown versus controlled, responsible re-opening or our society.

Lockdown

  1. Jobs lost, possibly permanently, as some businesses cannot restart. If only 25% of the over 33 million newly unemployed, that would be just over 8 million people dependent on government entitlements and impoverished indefinitely (and soon accustomed to ongoing checks from the rest of us).
  2.  Major lost tax base of the population, and so funds to support Social Security, Medicare, Medicaid, military services, etc. What happens when the Treasury is empty?
  3. Hospital and medical practice closures, with a much lower quality and accessible healthcare system. Employer-based health insurance policy losses now are projected to be 27 million. Where do they go? What about those non-COVID-19 medical emergencies that could cost a life?
  4. Major disruption in the education and career development of our children and young adults-our future.
  5. Homes, vehicles, and lifetime savings lost.
  6.  Collateral loss of lives– due to suicides, substance abuse, alcohol abuse, criminality, violence, decreased access to emergency medical care (strokes, heart attacks, trauma care, etc.). In the last year of the Great Depression, there was a 28% increase in yearly suicides; would be about 8,800 extra deaths with today’s population (about 46,000 total).

When public officials assert that opening society will cause deaths from COVID-19, they never mention the collateral damage and deaths from extreme, protracted containment efforts. Why? See below.

Those who insist on lockdown moralize that “every life is precious” and one life lost is too much. Such language is crafted so you cannot disagree with it (or be labeled “murderer”), and so with their agenda. It is the same game played with the “racist” label. Well, then, if every life is precious and invaluable, we need to immediately stop all smoking, go back to alcohol Prohibition, make the speed limit 5 mph (40,000 vehicular deaths/yr.), and lockdown every flu season (average 25,000- 62,000 deaths, annually). They are selling “risk-free” living propaganda. There never has been such a thing. And each of us, living in a community, among and dependent on others, subconsciously accept risk to ourselves and our children- whenever we are in a public gathering, go to school, enter a vehicle, dine out, take a swim. Communicable viral and bacterial respiratory illnesses, food poisoning, vehicular trauma, violence, undergoing medical/surgical treatment and on and on… with serious illness or death always in the background. We just subconsciously suspend reality (as in watching a movie) because it is not a functional way to live, always in dread or anxious about risk.

Further, we sent 405,000 young people, many of whom had never really started their lives, off to World War II, never to return, to defend and save our way of life and our country. My uncle Jimmy died at 20 yrs-old and is buried in a military cemetery near Anzio, Italy so that Axis Powers would not occupy our country. Because of him I am free to write this piece. Were Americans murderers for offering up those lives?

Controlled, Responsible Opening

  1. COVID-19 will spread, gradually. There will be new cases and there will be deaths, mostly in high-risk groups.
  2. Herd immunity will be established over the next 1-2 yrs. In fact, the more locked-down and quarantined, the larger the group of COVID-19 susceptible (not yet infected) people for the next viral disease waves– so they will be more severe and medically costly and societal disruptive.
  3.  New case hotspots will be rapidly identified with testing and contained to stop spreading, without generally disrupting the society and economy.
    It is too late for severe lockdown to work. SARS-CoV-2 is widespread across the population. Lockdown will just increase death tolls, “deaths of despair”. The focus should be on containment of flaring new case hotspots (positive tests with or without illness), distancing, targeted quarantines, cleansing, and masks. We can be careful and prosperous; it is not an “either/or”.
  4. We will have a healthcare system expertly trained and experienced to deal with the minority of cases needing hospitalization, and possibly new drug treatments for those seriously ill.
    Parenthetically, do not count on a vaccine, which may never happen or may take years to arrive. National leaders should move away from this misleading idea. If it happens in the next year, it is a godsend and a medical miracle.
  5.  We will reach a natural co-existence with COVID-19 in the next 2-3 years, with this pandemic a stark memory of our vulnerability to Nature, but only a memory. No one is offering this message of realistic optimism and hope. Only dire warnings and admonition on “extreme caution”, to serve the political agenda. (see below) Fearful people are controllable.
  6. People will continue to mask, cleanse, and distance where appropriate until COVID-19 becomes a usual infection.
  7. Continued rigorous infection prevention and containment measures will focus on those at high-risk for death and those working obligatorily in very close quarters.
  8. Routine, regular COVID-19 screening tests of elderly in nursing homes and assisted care facilities; healthcare workers; and those in large gatherings, such as schools, until there are no significant COVID-19 disease waves.
  9.  Re-opening pace and extent must be determined at the local level, depending on the community’s disease activity, population density, concentration of high-risk groups, and numbers of essential businesses. Correctly, there will be myriad different proper models.
    Rational review of what we already know and what we can project from it leaves us with only one choice: responsible, intelligent, controlled re-opening.

Media, Messaging, and Pandemic Politicization

On May 11, Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, said we must proceed with “extreme caution.” He also said that our schools and colleges might need to remain closed next Fall. Really? When there is near no risk of fatality in those age-groups and we need to move toward herd immunity (by deliberate, controlled infection of as many low-risk-for-death people as possible)?

The media reveres Dr. Fauci’s positions. He seems to have been elevated to Pandemic Chief Executive. However, in January, he said COVID-19 was not a major threat to the U.S. In March, he said we need not wear masks (now reversed that). On April 7th, he said we should drop handshaking as a social behavior, forever. On May 10th, Dr. Deborah Birx, White House Coronavirus Response Coordinator, his colleague on the COVID-19 Pandemic Task Force, said she cannot trust what the Centers for Disease Control and Prevention (CDC) says. Both of them are responsible for vehemently insisting that President Trump impose a national shutdown based on a pandemic model suggesting up to 2.2 million U.S. dead. Current epidemic models now estimate 90,000-150,000 deaths. Not a small number, but many-fold off the prediction that caused measures that have devastated our economy and threaten to wreck it if we do not act decisively and fast.

Dr. Fauci, before the U.S. Senate, on May 12th, suggested we need a COVID-19 cure and/or vaccine before we can safely re-open our society. He just moved the goal-posts. There is no place for his “extreme caution” rhetoric if you consider all the facts. Dr. Fauci and Dr. Birx are accomplished and esteemed public healthcare leaders and physicians. They are bona fide experts. And, they are fallible and have been wrong, and critically wrong in matters that not only can result in individual deaths, but also many COVID-19 collateral “deaths of despair” and the ruination of our country. Like any who are experts in a narrow discipline (like me), they can have a natural myopia and tunnel vision for things outside their narrow expertise. The President and his Administration and other political leadership must limit the scope of influence of these individuals, taking their counsel in a most limited and measured way. Dr. Fauci and Dr. Birx are over their heads. The problem is, I believe, their language and positions have been influenced by their sudden, unanticipated celebrity.

So, what is really going on? Let’s look at a list of things that may help us understand how we got to where we are and where some wish to take us

  1. “Blue” (Democrat leadership) states have been the most autocratic in their imposition of lockdown and its unrelenting continuation.
  2. Blue states (many of which were heading for bankruptcy from government mismanagement prior to COVID-19) are petitioning for federal money to avert bankruptcy – so, they get to continue in lockdown with no productivity and saying their people need to remain safe at all costs, while Red (Republican) states go back to work and pay for Blue states’ protected, safe time-off: California, Illinois, Michigan, New York, New Jersey, Maryland. And, Blue states propose using money from all the states to correct their books from years of financial insolvency.
  3. Speaker of the U.S. House of Representatives, Nancy Pelosi, delayed at least a week on a vote to pass the original stimulus bill to provide emergently needed money to small businesses and individuals. She kept the House unadjourned while the country was heading over the cliff and working people and business owners were frantic about pending insolvency.
  4. Speaker Pelosi only allowed the stimulus bill to pass after Democrats coerced funding appropriations for their self-interests, such as $35 Million for the Kennedy Center for the Performing Arts in Washington, D.C. What did that have to do with people not able to make their mortgage payment or to meet payroll? What did that have to do with a pandemic? The Democrats held the course, willing to allow the middle-class working people take the hit, so they could use the desperation of citizens to milk the bill for Democrat agenda items.
  5. There has been a push by Democrats to go to mail-in election ballots, more open to fraudulent voting without photo I.D. verification, based on alleged COVID-19 risk going to the polls.
  6. Democrat state leaders and judges are releasing violent crime prisoners en masse, but then non-sensically threatening COVID-19 jail time risk for non-criminals defying their lockdown edicts (such as the hair salon owner in Dallas, TX).
  7. Democrat bill being put up for a vote on May 15th is a $3 Trillion stimulus bill liberal bonanza which includes $1200 checks for each illegal immigrant (up to $6,000 per family), plus amnesty (which will become permanent) for all illegals; work visas for immigrant healthcare workers (more Third World future Democrat voters); while American medical workers are being laid-off or fired because of financial failures of hospitals and practices prisoner releases (mostly minority Democrat voters); and many other programs directing money toward Democrat Party donors. All of this during a national medical/economic crisis. This is disgraceful exploitation.

This rush to raid the U.S. Treasury must be directed at essential, business and life-preserving financial priorities, not Left-Wing and socialist agenda items. After the earlier, $2 Trillion, pandemic stimulus bill alone, it was estimated that each American would have a $37,000 tab to be settled eventually- surely through future taxes on our kids and grandkids, and maybe even levied against our Social Security, Medicare, and IRAs/401Ks. And, this crisis is being seen, by Democrats, as an once-in-a-lifetime chance to fund their supporters and voters to assure their hold on power, irrespective of the long-term financial fallout on everyone else.

By the way, many of the small businesses going under (estimated to be 100,000 at this time) are largely owned by conservative voters and funders — no loss to Democrats, in fact a gain.

Look all this over and you must be disgusted by profane exploitation of a public health and economic crisis and vulgar and dangerous politicizing of the situation. The same bipartisan divide in this country since President Donald Trump was elected is playing out in the COVID-19 epidemic. Be clear that we are just 6 months from a presidential election with an incumbent who is an outsider who had an unbelievable record of accomplishment until January, 2020 and COVID-19, while under unrelenting assault and resistance by his adversaries. A President the Democrats still do not consider legitimate, though duly elected. The Democrats had no agenda but to “get Trump”. No vision for the country, other than Senator Sanders’ socialism, which was rejected by the Democrat Party as a deal-killer for winning the White House. Now, they think they have a godsend… a pandemic to blame on him and to destroy his unparalleled economy. They are not locking down COVID-19. They are locking down the economy. No concern for the working people for whom they claim to advocate. Democrat leadership advocates for itself, despite its propaganda and rhetoric. Their acts lead to no other possible conclusion.

You need not be “conspiratorial” in nature to see the facts before you. Nancy Pelosi’s unprecedented tearing up several copies of the State of the Union Address in a pre-planned, staged performance on camera, just behind the President, tells you all you need to know. Nothing but vile contempt for this duly elected President and resolve to take him down. Be clear, all the extreme and wrongful behavior is being done by progressive Leftists. The record speaks for itself.

Why does a physician comment on all this? Because there is a reality to this pandemic that is not an unparalleled horror, or even unique. Yes, there is death. There always is. It’s part of living. We need to minimize it. We will never eliminate it. Just like COVID-19. We don’t trivialize it. But, those like me who have devoted their lives to saving lives of others and minimizing suffering and death (walked the walk, not talked the talk), are appalled, no, enraged, at opportunistic politicians; self-absorbed, ego-inflated medical leaders; and extremist ideologues who are conspiring to create hysteria and conformity out of fear by propaganda and misinformation. It is perverse and dangerous. Moreover, the media are in on the fix. And, it is a lie.

I was for serious COVID-19 mitigation and lockdown when there was a paucity of information on the SARS-CoV-2 virus and the dynamics and direction of the outbreak. But, we are beyond that now. We can now re-open prudently and responsibly by,

  1.  Continued social distancing, masks, and personal cleansing until there is a consensus that SAR-CoV-2 activity is acceptable.
  2. Opening schools and colleges.
  3. Sequestering high-risk groups not in essential jobs if they wish and until disease activity is minimal. They have a right to put themselves at risk, at least the last time I looked.
  4. All businesses continuing to follow distancing protocols and trying to segregate high-risk clients.
  5. Where appropriate and practical, in the near future, working at home and using “tele” services (telemedicine).
  6. Regular COVID-19 screening tests of healthcare workers, elderly care workers, workers in close quarters, etc.
  7. Rapid response public health containment of new COVID-19 case hotspots.

Focus on the goals of “flattening the curve”, not eliminating COVID-19; minimizing death, but not “no deaths”; rescuing the economy and restoring our way of life and country.

Dr. Anthony Fauci’s testimony before the U.S. Senate is most revealing in how he crafts words, despite the facts of the epidemic, to adamantly push a point of view. Under questioning he said, “I don’t give advice about economic things. I don’t give advice about anything other than public health.” So, he demures on counseling on “things” outside his expertise, all the while posing before the media as the nation’s expert and authoritative voice on the pandemic. A federal employee at the highest levels of government for decades and he pulls back from any responsibility for the dire ramifications for our society and country for his recommendations and mistakes. Then, he insisted that schools and colleges likely need to remain closed in the Fall, employing language like acting with “extreme caution”, particularly when it comes to the children… If we don’t accept his position there will be “needless deaths and suffering.” “Needless” means that unless we do as he says, people will die who needn’t, but for we murderers. He further says, “I think we better be careful [that] we are not cavalier in thinking that children are completely immune to deleterious effects.”

So, after throwing out a litany of alarmist words…”extreme caution”, “cavalier”, “needless deaths” and “suffering”…he closes with the fail-safe emotional hot button, “the children.” To slam home his position, he used the safety of the children. This is what he tells the US Senate. Despite the solid stats showing healthy youth under 18yrs-old almost never die from COVID-19. No one asked him about that. Despite clear errors on his part over the past 2 months, reliance on pandemic models that were astoundingly off in their predictions by hundreds of percent, and his public reticence to accept any blame for any collateral damage to the society from his recommendations, he again asserts continued lockdown as his expert position. And, he now invokes the safety of the children as the ultimate weapon, with contradictory facts staring him in the face. Disingenuous, anyone?

Well, let’s look at COVID-19 and the kids. In the U.S., by April 2nd, there were 2,572 cases who were 18 years-old or younger (out of a total 150,000 cases). 5.7% were hospitalized, with only 3 deaths (I said “virtually” no deaths). China had the same type of pediatric stats. By May 2nd, in the U.S., there had been 174 pediatric deaths from seasonal influenza. And, note, this is 174 deaths when most children have received flu vaccine. So, do we conclude that COVID-19 as a risk for children (when there have been near no deaths from it unless a child is inherently unhealthy) is due cause to make ominous pronouncements before Congress and upon which to base another year of school closures? Talk about “cavalier”! To that, I would add, flamboyant and histrionic language doubling down on his alarmist, myopic position. There is another aspect to all this. The best defense is offense. Instead of finding himself painted into a corner of acknowledging and owning his mistakes and their results, he doubles down his position more resolutely, while covering his back saying he’s only a doctor and public health expert, certainly not a political leader and policy maker; so not accountable for policy results. Whatever happens bad, he didn’t make policy; above his pay rate.

Finally, he created more room for excuses for any further errors by saying the COVID-19 deaths total is “almost certainly higher” because in the first months we didn’t have enough tests to diagnose it. Of course, not having enough testing for the 80% of all COVID-19 patients that have minor or no symptoms, we cannot know the true risk of death because we don’t know how many tens of thousands were infected that did not die. It is estimated that there 12X the COVID-19 infections than those actually diagnosed. The virus may be far less fearsome, because its prevalence is much more extensive, and so the percentage of deaths much less. Statistics can always be manipulated to a purpose. “There are three kinds of lies. Lies, damn lies, and statistics.” (Mark Twain)

He also acknowledged there could be some “flare-ups….because it’s a highly transmissible virus. It is likely there will be virus somewhere on this planet that will likely get back to us.” So, Dr. Fauci is saying more outbreak flares will occur, just based on the biology of novel virus pandemics, the fault of no one. But, I thought he said we need to be extremely cautious and keep pretty locked down, like the schools… for the children. But now, it’s coming back anyway. What?

We cannot stay locked down indefinitely. This flies in the face of the serious policy errors of interminable lockdowns happening mostly in “blue” states, and justifying their continued lockdown based on the cautionary language of the national medical experts.

Why is all this important to examine in detail? Because Dr. Fauci has positioned himself as the medical face of COVID-19 Pandemic leadership and the media and political Left take every word of his that suits their agenda to criticize and undermine undermine the President’s and his Administration’s performance and pandemic policies. Remember, election year. Dr. Fauci wants it both ways—authority and celebrity, but no culpability. And, he is the Left’s justification for their draconian measures. I think the word is “demagoguery”. By the way, so desperate are the Democrats to get President Trump out that 90% agree with continued lockdowns irrespective of the risk to the economy and the country. But, what about all those “working folks” on Main Street they always fight for? Well, they just need to fend for themselves until they are back in power as political leaders with their privileged, entitled lives. After that… ah, the workers, yes.

The proper words that should be used regarding the outbreak are what is and is not reasonably probable and what is extremely low risk, rather than possible. Those are the words that define how we usually consider risk/benefit in every other aspect of our lives. Whether to drive or walk. Whether to go to a public event. Whether to pass through a dangerous neighborhood. Whether to undergo a medical procedure or to agree to a treatment. We do not require a guarantee of safety and no possible harm. Yet, the Left has concocted a narrative, no, a standard, of “no deaths acceptable.”

So, we need to ask how there can be such a divergence in approach to an infectious disease outbreak…along political party lines? I have only seen Democrat judges and governors threatening or imposing jail for anyone exercising civil disobedience in defying unlawful lockdown mandates. A biological process should, based on scientific facts and principles, lead to a fairly uniform and inarguable policy consensus, except for pockets of exceptional disease activity. The only way to explain this divergence is one side seeing the virus as an opportunity to disrupt the country, create “crisis”, foment panic/fear, impose authority, and emergently drain money (taxpayers’) from the U.S. Treasury. Can this all be off the rails “conspiracy” delusions, or, maybe, the truth? Too oft-quoted Democrat Chicago Mayor and President Obama’s first Chief of Staff, Rahm Emmanuel: “Never allow a good crisis to go to waste. It’s an opportunity to do the thing you once thought impossible”. Says it all. He thought this was funny, but he was sincere. What do these things below that Democrat Party Leadership have solely promoted or enacted tell you?

  • Release of prisoners (mainly racial minority Democrat voters)
  • Devastating the rampantly ascendant Trump economy of January, 2020, in a presidential election year; an economy that would have guaranteed President Trump’s re-election
  • Create uncertainty about the future
  • Grab power and limit rights to accustom the people to a new “normal” of centralized governing authority
  • Ruin the middle class; having lost homes, jobs, careers, and savings, a mandate for a socialist model to support the masses with nowhere to turn but to the federal government
  • Use the risk of COVID-19 infection to stop voting at polls; to justify mail-in ballots, more subject to voter fraud
  • Diminish political adversaries’ funding support base—by ruining small business owners
  • Amnesty for all illegal immigrants and taxpayer dollars to support those families, hardwiring a majority Leftist electorate for the indefinite future

And, all of the above is occurring while the U.S. House of Representatives is held in adjournment by Speaker Nancy Pelosi. But, while others have no pay, no jobs, no prospects, the House Democrats have their protected world,

  • Continued full-pay
  • Guaranteed retirement pay
  • Private healthcare (not Obamacare)

Sort of reminds you of the Soviet Union Politburo or China’s Central Communist Party.

But, they are truly concerned about “the people” and “even one death is unacceptable”, at least so they say. Now, what’s for lunch? They are ecstatic.

In a word, the ends justify the means, even if countless lives are ruined. But, throughout history crises have been used to push radical societal change—the Russian Bolshevik Revolution, the collapse of the Weimar Republic making a way for Adolf Hitler, and “911” creating the currently dangerous Deep State Intelligence operations and the intrusive Transportation Safety Administration that disrupts and impedes our travel. A new permanent imposed “normal” from a temporary crisis.

Democrats are seeing their opportunity to get done what would never have happened in our pre-pandemic, normal country. In fact, they were losing their grip as racial minorities were going middle-class and unions getting disempowered. They were losing their “victim” base, so had to go shopping South of the Border and in the prisons. Next was going to be 16 yr-old voters. You think they’d exploit a major epidemic? They have exaggerated a public health crisis (this is no 1918 Spanish Flu Pandemic; with 675,000 American and 50 million worldwide deaths, mostly between 20-45 yrs-old) to attempt social engineering and permanent political power. No other conclusion can be reached if all the facts are carefully considered. By the way, anyone see the American Civil Liberties Union (ACLU)? Are they on strict lockdown?

In closing, at 70 yrs-old, if someone said to me I needed to die or have the lives of my children and grandchildren ruined, I would get my papers in order and kiss my family goodbye. I cannot imagine a person in their latter years with a heart and any sense of values and virtue who would do otherwise. Older people get it. They know what’s right.

We are not in a unique moment. We have been here before. The question is how many lives are we willing to concede to save our country and our way of life? To preserve our rights and freedoms? It is simply a matter of acceptable losses. We have the facts. It is a risk/benefit decision we make when we drive a car (or take our kids as passengers), drink alcohol, smoke a cigarette, walk the streets, go shopping, attend work or school during flu season, have a medical procedure or treatment, or go to war.

Let’s not make this more than it is. Let’s consider it carefully, then live with our decisions and take responsibility for them. They should be re-evaluated as new information develops and conditions change. This is a marathon, not a sprint. It is our decision, not that of elected public servants. Remember, they serve the will of the people, after providing their counsel. Remember, the goal was “flattening the curve” of case growth to spread out the illness burden over time to match our healthcare system capability. It was not to eradicate the virus. We do not move the goal-posts to suit a political agenda, absent legitimate reasons for the overall good of the country. We stay on mission.

The decision to do a controlled re-open, managing problems as they occur, is a life and way of life affirming decision. It is the pragmatic and right decision.

Edward R. Rensimer, MD

Infectious Diseases

International Medicine Center

Houston, TX

Copyright, 2020, E. R. Rensimer, MD, All Rights Reserved

 

COVID-19 Update 9

Why Should I Do It If “Essential” Workers Don’t?

We are pounded on incessantly by medical experts, by government leaders, by media, from every video screen we stare at, from notices on doors, from the radio… exercise The Golden Rule and be part of something bigger than yourself… stay apart! The more SARS-CoV-2 spreads, the more it kills. Yes, the old people. Yes, medical workers and first-responders who put themselves at risk. And, at times, even someone in middle age. Someone’s wife, husband, brother, sister, father, mother, grandparent… a best friend. It gets real when it isn’t just a number. It’s that person 2 months ago with whom you were planning a dream trip. Or, grandpa whose only remaining life’s desire was to see your child, his coming grandchild, be born next Thanksgiving. Or, just your buddy you meet every Tuesday for some coffee, and a sandwich, and a piece of chocolate pie, to make sense of what your life was and is, now that you’re both retired. Plans, dreams, memories, hopes… lives.
So, for the most part, many are making a reasonable effort to keep to themselves, to be part of the solution.

Yet, Sunday, I stop by Kroger’s Supermarket to load up the fridge for the week. I’m 70 and I’m wearing a mask and using hand cleanser on the way out of and into the car. As I stroll toward the entrance, the majority of people entering and exiting this human funnel have no masks. Haven’t they TVs, radios, mobile phones? Have they not heard the message? Worse, as I get my cart inside, I see a few supermarket workers with masks, many askew, but clearly not more than 50%.
Geez, the aisles don’t allow 6-feet separation of shoppers passing each other. At checkout, you are maybe 4-feet from the cash register guy. Maybe 3-feet from the bagger.

Then it comes to me. I get it. Because this is an essential service (food delivery) COVID-19 knows this and doesn’t come in here. That’s why, when I suggest to the register guy that he needs to shave off his goatee and tight-fit a mask, he has a “caught-in-the-headlights” frozen stare.

I can see the white-space bubble over his head, like in the comics, “What the hell is that your business?” I pull my trump card, “I am an Infectious Diseases expert. You look like you’re about 70 and are probably exposing yourself to 100 people a shift. You are at serious risk to die if you catch this virus. If you don’t care about yourself, care about somebody else, like us,” I assert through my muffling mask. He stares an annoyed stare and hands me my receipt. See you.

Just considering, is the supermarket putting USDA failed, spoiled food out on the shelves? Might as well seeing how they run their show in a pandemic. We all need food, so, the one place you would want to have the highest infection control measure would be where the close-in traffic is. How about putting signs up to dissuade those 65 and older or with medical conditions to not come in; have a surrogate pick up the milk? Or, at least supply them with a mask if they must shop for themselves. How about one-way traffic down each aisle, enforced by monitoring staff? Hand cleansers at the entry-way.

I mean, these essential businesses get to stay open and rake in the cash while other businesses don’t know if they’ll ever reopen and people are buying groceries off savings or debt. Yet, market management is so arrogant as to ignore what everyone else is doing for the greater good.
Where else? Hospitals. Walk the halls of a hospital floor and you’ll see their staff chatting, unmasked, several feet from each other. No social-distancing here. We’re special. We’re healthcare professionals. When we enter this special building, we are exempt from the biological reality all those schlemeels out there follow. Well, we actually do it at home, but not here. We have uniforms, we’re different. Well, it is different, we think, because the hospital Administration doesn’t require us to be tested every 2 weeks to prove work-fitness, so we don’t pass SARS-CoV-2 to the patients. Oh, the patients- – forgot about them, because we do work under special rules. Let’s see. A hospital is a place where such people go. Really sick people. Old, serious medical conditions, weakened immune systems- with their bodies physically handled hourly by nurses, therapists, blood drawers, physicians. I mean, is this COVID-19 heaven or what? Masks for everyone? Are you kidding? Nurses have been fired and doctors threatened for insisting on such measures since it might upset patients and families that there is a contagion afoot. What’s more important, infection control or public relations?

However, hospitals got serious a couple weeks ago when they limited visitation to one person a day per patient. I’m still trying to figure out how they were sure which patients were COVID-19 clean? Oh, that’s it. They set up a table with several staff at the single entry point allowed. Taking your temperature with an unreliable forehead thermometer got it done. Except, what if I had a fever an hour before or an hour after they spot-checked me? You must know that no infection causes continuous temperature elevation. I asked the hospital nurses manning the screening workstation. Blank stares. Just doing what they’re told. Others must know what’s right or we wouldn’t be doing this. After all, they’re doing it at the airport with international travelers. Most usually, infections cycle fevers up 2-4 times in 24 hours. All of them… malaria, TB, typhoid, AIDS, pneumonia, COVID-19.
But, at least it “looks” like they’re serious. This is what “leadership” hands down as policy. This is written as if this is comical. You have to do that to avoid being preachy and to compel the reader to stick with it. But, far from humorous or entertaining, this is a criminal disgrace. And, I never thought I could join a hospital and a grocery store into the same class.

The point? How do you get the regular guy in the street who half suspects a lot of this is just an exercise in wielding power to create hysteria to comply with public health policy?
He looks at these societal “essential” services and what their take is on the true threat of the situation. He sees no consistent or serious measures taken. He sees these as places where bodies are concentrated, yet they’re sure not distancing and masking. Ah, it’s just a bunch of malarkey. I’ll go my own way, carve my own path through this, he thinks.
And that, my friends, is how you fill graveyards.

You have more time on your hands now than you have ever had. Contact management at the essential services centers and raise their awareness that you are watching and that you will not patronize them if they don’t get with the program, don’t join the team. If you don’t sense intent to change, call the media and see if you can get a reporter to put it on air. Post it on social media.
Where our lives and those or our loved ones are at stake, there are no exemptions, especially for the essential services.

Ironically, they should be held at the highest standard by the community.

Graveyards.

 

Ed Rensimer, MD

 

 

Michael Berry Show Clip

Please listen to this segment on the Michael Berry Show, KTRH 740 radio, 4/3/2020. Michael thought so much of my discussion of COVID-19 that he replayed the entire piece on his second show of the day to a national audience. I am sure you will benefit from the content.

Ed Rensimer, MD

CLICK HERE FOR THE RADIO CLIP

 

COVID-19 Update 8: What’s THE Critical Next Step In Return to Normalcy?

Answer: A SARS-CoV-2 Serology Test

What is that? A single test? Are you kidding? Let’s first discuss what such a test is. Once you understand it, you will see it is a game-changer.

Serology is the area of medical laboratory science that refers to the markers in our serum (the liquid fraction of our blood) from reactions of our immune system cells. After an infection such a footprint is an antibody (like an “anti-missile”); a protein in the serum that our immune system cells made to attach or neutralize the invader, to kill it and/or clear it from our body- like a sticky glue made to inhibit further replication of the pathogen invader until other weapons and support troops (cells) can arrive as part of the overall immune response.
Once the infection is resolved, most often these protein antibodies stay around for a long time, often times for life. The antibodies are entirely specific to the invader. So, having had measles or chickenpox, there would be measurable antibodies in the serum that could show that you had had that viral infection decades ago.

Wow, lots of basic medical science. Where is this going? What’s it got to do with my currently miserable life and this COVID-19 mess? We already have a test for the SARS-CoV-2 agent, why are we talking about this?

The current COVID-19 screening test is for the genetic material of the virus itself. It is positive when an individual is infested with the virus or clinically ill from it, and shedding the virus. But, you’ve heard that up to 80% of COVID-19 infections may have no or minimal symptoms. So, a huge number of infections will not be diagnosed – they are below the radar screen. Are they important if no one is sick and no one harmed? Yes, it is critically important to identify these people. Once you do that you understand the true nature and extent of the pandemic; where the virus has been, and is headed.
The data we have now are on actively ill cases. So, if 5 of 100 ill people die, the fatality rate is 5%. But, if 80% of COVID-19 infections are minimally ill or without symptoms, then the group the 5 deaths came from was 500, and the death rate is 1%. These real numbers can be found out once COVID-19 serological testing is applied to the entire population. 1% (usual flu is 0.1%) or lower fatality rate makes it much more acceptable for people to return to work (especially when we continue to shelter high-risk people until widespread infection abates) when comparing the true risk of death to losing your livelihood, your home, your retirement savings, your business or your country. We do not close down the country for a severe seasonal flu epidemic, which can kill 40,000-60,000 per year. We make a decision to concede that. Just like we conceded 406,000 mostly young lives to World War II to save our way of life.

If a large number of patients are not counted because they are barely or not ill, then the fatality rate would be much higher, which would increase the sense of pervasive anxiety and dread and reluctance to approve rejoining society, a by-product of incomplete information.
The value of such accurate information is undisputed, but where is the impact right now of serological test results of the population showing all who have been infected? What’s the practical benefit?

1. If you know who has and has not been infected and, in keeping with most viral respiratory infections, cards could be issued to those who are “post-COVID-19” and who would likely be partially or completely protected from infection, or at least severe disease, allowing them to go to work, go to school, congregate in public places like restaurants, visit hospitals, proceed with pregnancies, and on and on.

2. Personal protection equipment, like masks, would be conserved and directed to the highest need- -medical professionals and first-responders exposed at work.

3. A pool of people able to donate plasma with COVID-19 antibodies for treatment of extreme illness cases would be identified.

4. Medical workers with positive antibodies could attend their duties with impunity, allowing antibody negative individuals to stay on work-leave until the intense phase of the epidemic waned.

5. If and when a vaccine became available, surely in limited supply at first, it could be targeted to those not yet infected as indicated by a negative serology test.

6. Should there be resurgent waves of infection over the next 1-2 years, usual with novel virus pandemics, those identified as never yet infected could be advised against social contact and to continue quarantine, without mass evacuation of schools and businesses. The suppressive-mitigation infection control measures would be applied to a well-defined much smaller population, without the profound social and economic disruption.

Yes, this one type test, currently under development, applied broadly would change every aspect of dealing with this pandemic, minimizing loss of life (by concentrating resources on those at true risk) while restoring our societal order and economy. This, of course, assumes that COVID-19 confers significant protection against re-infection and endures past the 1-2 years of usual infection resurgence. This is an important detail, but it is reasonably probable that COVID-19 antibody gives some, if not complete protection. SARS virus, the brother of SARS-CoV-2/ COVID-19 produced protective antibody that lasted at least 2 years, long enough for COVID-19 to no longer be “novel” to the human race, just another virus, like flu.
Let’s keep our eye on this and hold it as reasonable position of hopeful optimism. We’re due.

Ed Rensimer, MD

Infectious Diseases

COVID-19 Update 7: Infectious Diseases Specialty Overview

FRONTLINE CONCEPTS

SARS-CoV-2 vs. Influenza 3/17/2020

Statements have been made that Coronavirus-19 (SARS-CoV-2) is just like the flu- that too much is being made of it. To compare them,

1. COVID-19 and influenza are both respiratory illnesses caused by viruses.
2. Virus Shedding,
a. Patients ill from flu shed virus (and so may infect others) for 24H prior to onset of symptoms and for 5-10 days after.
b. COVID-19 virus shedding has been seen 2-3 weeks before onset of illness (persons who are not sick, asymptomatic), and then for possibly 2-3 weeks after illness onset.
c. COVID-19 death rates are anywhere from 10-50X that of influenza (numbers subject to change as virus detection testing is more available and the extent of infection across the entire population is defined).

So, these are very different viruses, probably mostly because SARS-CoV-2 is “novel” – crossed over from the animal kingdom to humans with no immunity, whereas many people have at least partial immunity from prior flu infections or vaccinations. In years ahead, once SARS-CoV-2 has passage through millions of humans and there is broad immunity across populations, this virus will likely resemble other respiratory viruses in its behavior.

The Pandemic

The biology of SARS-CoV-2 and its behavior in interacting with humans will not be known for months, maybe a year or more. However, looking at the experiences of individual epidemics within the pandemic provides valuable information, useful for dealing with the US outbreak as it is accelerating at exponential speed.

1. There are dozens of countries with exponential growth; all of Western Europe, Scandinavia, SE Asia/ Malaysia, Africa, and S. America.
Italy: A model for us, as a western society. 3 ½ weeks ago, there were only 3 cases; now has the highest number of cases outside China- 15,000 cases and 1,000 dead by 3/13/20. 25,000 by 3/16.
By 2/20/20, all healthcare workers were on continuous work shifts.
By 2/23, there were 76 cases.
By 2/25, there were 229 cases. Officials were behind in testing 7-10 days.
By 3/3/20, 10% of medical workers in Lombardy were infected.
From 3/1-3/11, between 9-11% of hospitalized patients went to the ICU.
On 3/8, the extraordinary measure of mandating quarantine of 60 million citizens was imposed. On 3/16, the decision to not offer ventilator support to anyone 65 yrs-old or older was implemented.
In Italy, COVID-19 cases have been doubling each week.

Asia: China’s extreme societal lockdown stopped exponential growth by the end of January. Japan, Singapore, Thailand, Taiwan, and Hong Kong were hit by SARS in 2003, and so learned about exponential growth; so they did lockdown earlier with COVID-19, holding the epidemic below exponential growth.
Note, when Wuhan, China thought it had 444 cases, it had 12,000 (27X more).
With COVID-19, the case numbers are always far under-estimated because of asymptomatic incubation pre-illness onset.
80% of COVID-19 cases are mild. 20% will be hospitalized and 5% of cases will go to the ICU.
Average doubling time for SARS-CoV-2 is about 6-7d; meaning after 11 doubling times (about 2 months), 500 cases would become 1 million. We must appreciate the explosive nature of this virus over a short time.
With the average time from illness onset to death being 17 days, and if there is a 1% mortality rate, then when 1 person dies, he probably was infected 3-4 weeks before- during that time there were 99 other cases (as he is the 1%). With a COVID-19 case doubling rate of 6 days, the numbers compound and that one person’s death suggests there are 500-1000 cases along with him.

Containment/Mitigation

Containment is impossible. COVID-19 now is endemic to America- “community-based” cases, unrelated to travel or exposure to travelers. With the entire country involved and the Italian COVID-19 track-record, we can only POSSIBLY SLOW the inevitable progression through our populace.
Slowing the pace of the outbreak is the strategy of “mitigation”. It is described as “flattening the curve”- the graph of new cases emerging. An analogy would be taking a 50-ft high tsunami and breaking it up into five 10-ft waves, hitting the shore in spaced apart succession. The idea is to allow an orderly processing though our healthcare system within the staffing, hospital bed. and medical equipment limits of our medical system. Should the illness load hit over a short period, say a month, as in Italy, rationing would be the dreaded necessity- deciding who gets admitted to the hospital, access to an ICU bed, or placed on a ventilator… or dies. That has been happening in Italy.
This is why what seems like overreaction and drastic measures across our society are being put into action. The tsunami is visible on the horizon and the near beach water is being sucked out to sea. Leadership realizes to hesitate or equivocate is likely an incomprehensible disaster.
If people are separated (“social distancing”), infections will occur, but at a much more controlled rate as they return to their normal lives, spreading out the case load over 2-3 months. There is hope that SARS-CoV-2 will be harmed by higher ultraviolet light levels and warmth as we head toward April, as is the case with some other respiratory viruses. Also, some such viruses that spread by airborne aerosol droplets (coughs, sneezing) do not spread as easily with high humidity that carries the droplets to the ground in a shorter distance (6 feet for SARS-CoV-2). We can expect such humid Gulf of Mexico air to move into Houston by April.
If the transmission rate decreases by 25% by social distancing, the case curve would flatten and delay the epidemic peak by 14 weeks; decrease by 50%, and the peak delays by 3 months and is much smaller.
Social distancing used too late with the 1918 Spanish Flu in Philadelphia caused 260 deaths/100,000; used early on in St. Louis, 50 deaths/100,000.

Healthcare System

We have about 160,000 ventilator machines in the U.S. As a novel virus, if SARS-CoV-2 paralleled the 1918 Spanish (Novel) Flu Pandemic, about 740,000 would need ventilators to have a chance to survive the illness.
The U.S. has 2.8 hospital beds/ 1000 people-less than Italy (3.2), China (4.3), and S. Korea (12.3.) … all of which struggled with SARS-CoV-2.
The U.S. has about 45,000 ICU beds. A moderate epidemic, would require about 200,000 beds; a more severe outbreak, it could be 3 million. US influenza deaths avg 12-60 thousand per year. But pandemic flu in 1957-1958 killed 116,000 and in 1968 killed 100,000. Both of these epidemics would have needed 65,000 ventilators to rescue people from likely death.
And, with COVID-19 cases taking up all these beds and ventilators, there would be collateral loss of life (not counted directly in the epidemic mortality statistics)- others who need the ICU management and/or ventilator: evolving strokes, heart attacks, severe bacterial infections, vehicular trauma, etc.
As we all know, because of the economics of the medical business, our healthcare system is streamlined with only a bit of extra capacity; hospitals are often at full occupancy in normal times. You can see where a crisis across the society could require rationing of care as the existential reality. It is no different than medical professionals choosing who will live or die based on medical futility and best chance of survival on a battlefield.
Currently the U.S. has an estimated 1% of the respiratory masks needed to cover all healthcare workers. And, remember, 10% of Italy’s medical workers have become infected (some fatally) partly due to insufficient protective equipment supplies.
I think you now get it. We are not prepared and cannot make up for it in time to contain this outbreak- only spread out the contagion over time to more closely match medical need to resources–mitigation. Social distancing can show positive effects in 2 weeks.

Conclusions

We must realize what we face. Actions that make sense now (and for continuous review as circumstances change),
1. Serious Social Distancing
a. Schools out
b. Public entertainment and other large group gatherings delayed
c. Stay at home, except for life essential activities.
d. Minimize human contact with those at or above 65yrs-old and/or with serious underlying medical problems.
e. Minimize visitors to elderly care facilities and hospitals.
f. Minimize visits to any medical facilities-physician offices, labs, imaging centers, etc; only appointments out of critical medical necessity for the next 1-3 months.
g. Pharmacies should provide extended medication supplies and consider home delivery.
h. Only essential services open: grocery stores, transportation, pharmacies, medical offices.
i. All medical care providers to adjust workflow communications and operations to achieve rapid access and egress for patients- the goal little or no waiting time in common areas with other patients.
Ignorance and risk uncertainty are the parents of panic and anarchy, primed by unrelenting media exaggeration and, at times, misinformation.
What are the elements of coming through all this with the best possible outcome?

Concern: Yes
Attention/Focus: Yes
Compliance: Yes
Flexibility (course corrections): Yes
Information: Yes
Action: Yes

I am confident that this country can manage its way through this. But, it will be with credible leadership; information transparency; timely, targeted action; trust and resolve; and always, always focus on those for whom we are responsible, while also seeing ourselves and our families as part of and stakeholders in something bigger than ourselves. The Golden Rule always works.

Ed Rensimer, MD
Director
International Medicine Center

 

To Dine or Not to Dine? What to Consider Amid Coronavirus Concerns

Take a look at this article for which I was interviewed on aspects of eating out during a pandemic,

Ed Rensimer, MD

https://houstonfoodfinder.com/news/to-dine-or-not-to-dine-what-to-consider-amid-coronavirus-fears/

 

 

CORONAVIRUS UPDATE 6: FOR THE PROFESSION

Re: Medical Facility Procedures/COVID-19 Containment 3/11/2020

Colleagues,

There appears to be no commentary or direction for those of us on the front-lines of what is a US epidemic within a novel virus pandemic. Aside from my office’s protocol for my staff (attached), I suggest that it therefore is on us to think this through.

Operative word: proaction. Your patients and their families will see you taking measures to protect them as well as your practice’s viability while this outbreak runs its course, and they will be grateful. It is time for the profession to engage.

So, consider the following,

1. Limit all appointments to only those that are time-critical from a medical point of view, i.e. standard of care required and unavoidable in the interests of the patient.

2. Workflow Change: Though this will impact the business, consider the impact if a number of your staff require quarantine. At the intake of a call for an appointment, tell the patient to call your office on arrival so your staff can approve entry to your facility such that there is little or no waiting time in your lobby, shown quickly into an individual exam room. If they are not in acute medical distress, have them wait in the building common areas or their vehicle.

3. Upon entry to your facility, provide a respiratory mask and require hand cleansing with soap and water or hand cleanser with over 60% alcohol.

4. As much as medically advisable, try to keep those 65 yrs and older away from your facility; elective appointments to be put off until we see if the COVID-19 pace and pattern of spread diminishes with warmer weather.

5. Wipe with appropriate cleaning solutions surfaces of likely patient contact after each visit: arm rests on chairs, exam table edges, door knobs, stethoscope diaphragms, BP cuff, etc.

6. Staff to cleanse their hands after each patient encounter.

7. Check-Out: Staff to cleanse their hands, pens and counter areas after each check-out financial transaction and appointment re-scheduling encounter.

8. Staff to wear masks.

9. Advise patients to avoid crowded elevators, or to cover their nose and mouth (?handkerchief) when in one with others, on their way to see you.

Previously, the focus for isolation/distancing measures was on anyone with respiratory symptoms and/or fever. Now, knowing the incubation period from time of virus acquisition is up to 14 days, and that many will not be ill but shedding virus (as well as post-illness shedding of virus for another 10 days, or more), everyone is an exposure risk. Now that there have been “community-based” cases, travel history is irrelevant with respect to COVID-19.

The basis of these ideas are the facts on the biology of COVID-19 as they are emerging as well as the nature of our practices and how they interact with the community. From an epidemiological view, physician offices and other medical facilities (diagnostic laboratories, hospitals, surgery centers, elderly living facilities), congregate and concentrate the most at risk protoplasm in the society and those at most jeopardy for serious illness and death—those 65 yrs-old and up. How much and what you decide to do will be customized to your practice environment and services.

We need to be thinking this way and we need to look at our patient populations, our services, and our physical plants, and then be the professionals and leaders our patients and communities expect and rely on us to be. We treat patients, but, cumulatively, we treat society. Inarguably, measures taken by the medical community to diminish spread within their workplaces will be the most impactful on this epidemic because our clinics are where the rubber meets the road on contagion. We do not want to become Italy.

Feel free to share this and anything else I have written with your friends and colleagues and even patients (who might bring these ideas before their other healthcare professionals). My email list is limited,and I hope this information is disseminated. It is all posted on my websites:

traveldoc.com

rensimer. com

Call me anytime with questions or ideas that I would be glad to consider as part of future bulletins.
I hope this has been useful in getting all of us thinking about our personal professional circumstances. Cliché though it may be, we are all in this together.

Ed Rensimer, MD
Infectious Diseases
Director, International Medicine Center
Houston, TX

Coronavirus (COVID-19) Update 5: 3/11/2020

The epidemic is accelerating, as expected, and it will do so over the next 1-2 months, at least. We will find hospitals over-burdened, even possibly without enough equipment and other resources to treat the deluge of seriously ill patients if community-based containment measures fail.

The only thing that will after this trajectory (note what is happening in Italy), will be investment by each citizen and every medical professional in conscious awareness of and action on containment efforts.

Things for you to do,

1. Every family member cleansing hands (soap and water for at least 20 seconds of all hand surfaces, or a hand cleanser with at least 60% alcohol) every hour if possible when outside the home.

Even without human-to-human contact (within 6 feet of a coughing individual or direct physical contact), COVID-19 can be picked up from contaminated surfaces—elevator buttons, phones, credit cards, chair arm-rests, steering wheels, you name it.

So, we should all be carrying hand cleanser with us.

2. Avoid touching your eyes, nose, or mouth with your hands.

3. Avoid visiting elderly people or those with serious pre-existing medical problems or on immune system-compromising treatments.

4. Medical Appointments: See my piece on “Medical Facility Procedures/COVID-19 Containment”, 3/11/2020. Take action, as a patient, to follow the “Workflow Change” principles with your physicians’ offices.

In fact, copy and share this commentary with your medical professionals, or direct them to these updates on our websites, traveldoc.com or rensimer.com. Disseminating this information as widely and quickly as possible and putting the recommendations into action are critical to containment, the only game in town for the foreseeable future.

5. Respiratory Masks: Consider any mask you can get, optimally an N-95 mask, for any closed-ventilation spaces, when gathering with others is unavoidable, such as airline flights, business meetings, school classes, etc; certainly if anyone in your group exhibits respiratory symptoms (cough, runny nose, sore throat) and/or fever.

Note: Children, by the Chinese experience, comprised only 2.4% of all the COVID-19 cases, so they appear naturally resistant to infection. However, as with hepatitis A, they very well may not be usually clinically ill when infected, but may be an exposure risk for adults from their asymptomatic virus-shedding. With respect to hand cleansing, children need to be included.

Edward R. Rensimer, MD
Infectious Diseases
Director, International Medicine Center
Houston, TX

 

COVID-19 Update 4: 3/9/2020

Prudent Personal Actions

Well, as had been apparent, coronavirus (COVID-19) is here, in most US states, soon to be in all. The experience in other countries indicates we will see exponential spread and many who are not clinically ill are shedding and spreading the virus now.
So, what should you do? Listen to all your personal “wish-system” that it is really nothing? Listen to political leaders who always and in every country, including ours, withhold communicable outbreak information or spin it to soften the impact in order to keep public order and economic stability?
What is known?

1. COVID-19 is highly transmissible, both before and up to 2 weeks after clinical illness.
2. Risk for a deadly outcome is mostly in those over 65 yrs-old, especially with pre-existing medical problems.
3. Transmission is by aerosol (coughing) up to about 6 feet and acquiring the virus off contaminated surfaces with self-inoculation of the nose, mouth, or eyes.
4. It is unclear what is COVID-19’s ability to mutate—into worse or less worse form—but, as with all viruses, the more passages through humans, the more chance for mutation.
5. It is unknown whether seasonal warming will diminish COVID-19 activity and so its spread.

So, our goals should be to avoid the virus and to be part of killing this outbreak.
Common sense measures,

1. Become a homebody for at least the next month.
2. Wash your hands with any public exposure or activity at least several times a day, if not every hour—soap and water, thoroughly, or with a cleanser with 60% or more alcohol content.
3. Spend no time with anyone with respiratory symptoms and/or fever—runny nose, sore throat, cough.
4. Try to have business or other meetings by phone or other “distancing” methods.
5. Medical Appointments/Procedures:
Avoid them. Re-schedule unless an appointment is absolutely medically necessary. There should be no “wellness” exams.

Medical facilities, particularly physicians’ waiting rooms, are shared ventilation spaces where ill people congregate, sometimes for long periods. Obviously, the elderly are disproportionately present, often moving from doctor office to doctor office, through emergency rooms, through medical testing facilities—they are an intensely medicalized subculture. All of this, when you think of it, magnifies the risk of cross-pollination with COVID-19.

Our office has patients don respiratory masks and clean hands upon entry. Patients with respiratory symptoms or fever are shown directly to an exam room, not to sit in a public area.
a. If elderly, call your doctor’s office ahead so that you can go directly to an exam room on arrival (wait outside until they call you on your mobile phone).
b. Wash your hands on entry and at departure from the office.
6. Avoid visiting elderly people. Call them or see them through FaceTime. If it is necessary to physically visit, avoid physical contact, and wash your hands on entering their physical space.
7. Respiratory masks are probably overkill, except in medical facilities or in prolonged, close quarters in close-ventilated spaces, such as an airliner.

There is no reason to panic. But, that is not permission to disregard what is happening before our eyes around the world and which is about to rapidly escalate here. Denigrating concern, anxiety, and responsible action in an evolving, widespread epidemic is just a form of condescending arrogance, willful ignorance, and blowhard bravado in a situation about which there are serious gaps in important information. If we all take part in pro-action to thwart the spread of COVID-19 and it turns out to have minor impact on the US, then we acted responsibly for our community, our loved ones, and ourselves. For that, we should be commended, not criticized.

Edward R. Rensimer, MD

Director

International Medicine Center

 

Coronavirus (COV-19) Overview/ Update 3: 2/28/20

It’s Here. What Do I Do?

Yes, COV-19 is now in the U.S. Do I deal with the information, or just duck it and go about my life, obliviously? The immediate answer is based on your life’s pragmatic philosophy on how you choose to deal with the inevitable “rough water.” For me, information is everything. It allows me some sense of control and to assume my natural optimism – that I have always and will always get the best possible outcome for the circumstances. Maybe not what I had wished, but the best that could be had.
So, what’s the overview and the bullet-point facts?

1. In a totalitarian society (China), where people can be forcibly locked into quarantine, beaten and imprisoned for not wearing face-masks, and entirely restricted from public assemblage and getting around, COV-19 has spread at breakneck speed. So, it is highly and casually (no intimate contact) transmissible.

2. Though we think the time of exposure to onset of illness is about 2 weeks, we don’t know, because we are basing our conclusions on Chinese data, subject to the propaganda filters of that regime.

3. COV-19 infected individuals who are not overtly ill can spread it.

4. We have no idea how long people shed the virus after the illness subsides. Ebola virus has been found in survivors’ tissues months to a year after being well.

5. We yet have no idea whether having had COV-19 immunizes a person against future infection.

6. Again, we have no idea of the real death-rate from COV-19, because there have not been enough cases outside China to compile statistics on deaths vs. the total number of diagnosed cases that are reliable.

7. We do not know if COV-19 mutates or changes to weaker or stronger ability to cause disease (virulence) as it passes through more and more human hosts (as does flu).

Think about it. We are an open, free society where we take for granted our mobility and rights to congregate. However, in an highly controlled and restrictive Chinese societal model, COV-19 could not be contained.
Some are saying it is not inevitable that we will have a widespread outbreak, a U.S. epidemic inside a worldwide epidemic, i.e. a pandemic. With all the facts to date, this seems implausible, though I hope to be wrong. At least, if COV-19 is heat-labile, perhaps it, like influenza, will wane as we get to mid-April and warmer days. However, that is yet unknown. A rational person should count on at least an abbreviated, but serious, epidemic over several months.
So far, those at most risk for death are 65 yrs and older, usually with serious, pre-exisiting medical problems. Not so comforting for those of us up there.
Alright, I’ve given my overview. It should be apparent that, now that there has been one U.S. case not directly associated with or imported from an affected country, the cat is out of the bag. There must be a number of unsuspecting U.S. citizens incubating the virus, and then more and more. There is no public health measure that can effectively stop propagation through the populace when you cannot always know who is carrying and shedding the virus. And, without entirely closing entry to the U.S., COV-19 will be imported from France, Italy, Brazil, Russia… from everywhere and anywhere.

But, though we cannot prevent it, we can minimize it.
What, right now, should you do?

1. Keep up on announcements on COV-19 based on developing information from western societies (from which we will develop factual information on transmissibility, virulence, and mortality rate); but always be aware that public officials (regardless of political party) are prone to censorship in war and other national crises, to allay panic and societal disruption.(cdc.gov)

2. Minimize exposure to large groups of people.

3. Avoid anyone, family, friends, neighbors, co-workers, classmates with a respiratory illness.

4. Have no contact with anyone who has traveled overseas, for at least 14 days.

5. Wash hands frequently and thoroughly.

6. Avoid casual physical contact with others (handshakes, etc.)

7. Do not send your child to school or other group settings if they have a respiratory illness.

8. If you develop a respiratory illness, warn your healthcare providers that you wish to be seen, but tell them you wonder if you should and/ or their staff should be “masked” at the outset of the encounter, before entering their facility; that includes urgent care and emergency facilities- protect the healthcare professionals by “The Golden Rule”. We’re going to need them alive and working.

9. Focus on activities away from others- be more a homebody the next couple months.

10. Emphasize exposure avoidance, awaiting the possibility of anti-viral medication treatment possibilities and potential vaccine development.

11. I have been asked whether public venues, such as fitness clubs, should be screening arrivals for fever. It can’t hurt, but the COV-19 problem is all those walking among us shedding the virus for days or weeks before they become ill, if they become ill at all.

The government alone cannot achieve control in a country like ours. We need to take personal responsibility to keep level-heads, to be informed, and to adjust behaviors until we get through this. And, hope for an early, warm Spring.

Ed Rensimer, MD

 

 

CORONAVIRUS UPDATE 2: SEEKING EVALUATION FOR CORONAVIRUS (COVID-19) 2/12/2020

You’ve recently traveled to a place where coronavirus cases have been diagnosed. Now, you have developed fever, cough, shortness of breath, and/or diarrhea. From your reading, you know coronavirus is a consideration.

What do you do?

1. Call your local hospital Emergency Department and ask if their lab is equipped to send specimens for COVID-19 testing.

The point of this is your doctor’s office cannot collect and process specimens since there are complex rules for safely packaging and shipping such infectious samples, and they must go at least to the state health dept. lab, or interstate to the Centers for Disease Control in Atlanta, GA. Individual practices are not set up to do this until local labs are able to do the testing; at which point specimens need not be shipped.

2. Tell the ER staff you need evaluation for COVID-19 and ask what is their procedure for seeing you while minimizing risk of exposing others (their staff and other patients) to you.
a. Likely, they will tell you to call on your mobile phone when you arrive outside their facility, so they can meet you with a respiratory mask before you enter.
b. Such a procedure is necessary to not expose unaware medical staff or other patients to COVID-19. And, a facility not handling this with a rigorous, clear procedure might find itself shut-down by public health officials, should a COVID-19 case be diagnosed after-the-fact. Your doctor does not want this, nor does a hospital Emergency Department.

3. Until you are seen by a physician, separate yourself from others-
a. Do not go to public gatherings: shopping areas, schools, church, etc.
b. If you can procure an N-95 respiratory mask (medical supply stores, Home Depot, etc… Google it), do so.
c. Wash your hands frequently, but optimally have no physical contact with anyone.
d. Cough into your bent arm if you haven’t a kerchief.
e. Drive yourself- no passangers.

4. Alternatively, you can call your county or state health department to get directions on where best to go for evaluation and testing. Your primary care doctor will not be able to handle this situation at this time, as testing is not available through his/her routine laboratories.

Finally, realize that influenza is much more likely to account for such illness in the U.S., at least until about the end of April.

Edward R. Rensimer, MD

Director, International Medicine Center

Houston, TX

Copyright, E. Rensimer, MD, 2020, All Rights Reserved

CORONAVIRUS UPDATED 1: 2019 NOVEL CORONAVIRUS (COVID-19)
China Origin 1/30/2020
FACTS TO KNOW/ PERSPECTIVE

COVID-19 is an apparently “novel” respiratory virus that emerged in Wuhan, China and spread from animals (?bats) recently to cross-over to cause disease in humans for the first time. That is what makes it “novel”, and so more dangerous as there is no broad-based immunity in the human herd from infection in prior years (such as exists with influenza viruses from past vaccines and infections). As such, the conditions exist for rapid spread widely, across large populations. How deadly it might be is not clear as of yet and relates to the COVID-19’s “virulence”, or ability to cause destruction in tissues and to invoke an immune response, which can destroy tissue (see the “Spanish Flu” of 1918). As the virus passes through humans, it can mutate such that virulence and transmissibility can increase or decrease, strengthening or weakening the ability to cause serious disease or death. It is a slot-machine model on which way that goes. If everything lines up, you have a worldwide pandemic. This is why you are seeing urgent public health bulletins from the CDC, the main goal containment to minimize passage through human bodies and so the risk of mutation and evolution to a more ominous disease agent. The news media, on the other hand, hype everything for market share. Realize that paying attention to this is being responsible, without assuming a position of emotional distress or outright panic. Maintain rational balance as information develops to inform your actions.
The other relevant facts are that there has been a COVID-19 case with dramatic inflammatory lung infiltrates in a person who was exposed (and so presumed contagious), but with no symptoms of disease or illness. Additionally, it appears that COVID-19 has an incubation period (virus acquired but the victim not yet showing signs of illness) of several to 14 days. Both situations mean you could be exposed and at risk for illness and not know it.
So, what are reasonable conclusions at this time?

1. Travel: If planning travel to or through areas where there has been widespread COVID-19 illness, it would be prudent to delay such travel.

Public health and political officials often craft propaganda during outbreaks to stabilize social and economic volatility over the specter of widespread, communicable illness. So, you must weigh the information at hand as possibly the tip of the iceberg. Officials tend to bleed bad information out gradually, in small doses, to calm the populace. As such, you could find yourself on a trip and,

2. Your itinerary is totally disrupted because of barriers to transportation and public health prohibitions.
3. Large public gatherings are prohibited (quarantined), such as at tourist spots, restaurants, retail centers, etc.
4. Healthcare resources are overwhelmed (just as you become ill).
5. Airports are shut down or travel directed to chosen airports (out of your way).
6. Quarantines are imposed on travelers attempting to return to the U.S. until a 14-day incubation period has expired without evidence of illness.
7. You become ill and must engage a foreign healthcare system, with all that that implies. Be aware, most people who can afford travel to exotic places are probably over 50, usually over 60. The majority of deaths from COVID-19 have been in those over 65. Not a good set of facts.

What to do if you must go?
1. Take an N-95 respiratory mask.
2. Take hand cleansers (60%, or more, alcohol concentration); soap and water.
3. Avoid close contact with anyone with respiratory symptoms or fever (6 feet or more distance).
4. Avoid spending prolonged periods of time in closed, shared air-spaces with others, especially groups.
5. Take a thermometer and medication for fever, body aches, nausea/vomiting, and diarrhea; possibly a respiratory tract infection antibiotic for bacterial infection secondary to the preceding viral infection.
6. Review your health insurance and obtain a temporary supplement for international travel. Medicare does not cover overseas medical care. Hate to say it, but if you are over 50, consider a medical air-evacuation policy and policy for repatriation of remains (death).

Finally, if you return from a country with COVID-19 activity and develop a fever-associated or respiratory system illness (fever, cough, sore throat, and/or shortness of breath), seek prompt medical evaluation, but wear an N-95 respiratory mask (can obtain at a pharmacy or medical supply store) and warn your doctor, the urgent care center, or emergency department staff that there may be a concern for COVID-19 so they can take measures to protect themselves and their facility (from Public Health closure). Also, put yourself on quarantine from family, friends, and co-workers.

Edward R. Rensimer, MD

Director, International Medicine Center

Houston, TX

Copyright, E. Rensimer, MD, 2020

COVID-19 Testing Center

Re: COVID-19 Testing Center

Colleagues/Patients,

Just to let you know, in case your patients are having difficulty accessing COVID testing, we have a fairly in-and-out process.

Direct them to traveldoc.com and the tab on COVID testing. If they scroll down to the sentence highlighted in red and click on it, they will find our office visit procedure and a brief form to fill-out.

We are located on I-10, just east of Blalock Road.

Stay Safe,

Ed Rensimer, MD
International Medicine Center
Houston, TX