Showing posts with label coronavirus. Show all posts
Showing posts with label coronavirus. Show all posts

Tuesday, February 28, 2023

The Many Excuses for Ignoring Science – Where Did SARS-CoV-2 Originate?

 


The COVID origins story started off with a bang last weekend.  Woody Harrelson gave the monologue on Saturday Night Live comparing pharmaceutical companies to drug cartels and COVID vaccinations to illicit drugs. He was conveniently able to ignore the fact that these vaccinations have saved an estimated 20 million lives and could have saved more if vaccination goals were met. By way of contrast there are about 30,000 drug related homicides in Mexico every year, several thousand per year in the US, and tens of thousands dead from overdosing on illicit drugs. A stark contrast to the way this monologue was presented. There was plenty of commentary on the monologue – mostly focused on Harrelson’s antivaxx stance in the past including a post that he had to remove at one point. Elon Musk enthusiastically supported the monologue – but didn’t say if it was for the comedic or scientific genius. Harvey Levin praised producer Lorne Michaels for not censoring Harrelson, but didn't comment on editing for comedic content. Nobody recited the simple facts listed above.

The monologue was followed Sunday by a more detailed story without much more scientific credibility in the Wall Street Journal (1).  The authors of that story discuss a 5-page report by the Department of Energy stating the opinion that a lab leak was the likely cause of the pandemic but that theory was given a ‘low confidence’ rating.  They describe the DOE as having many relevant scientists.  Other than controversial headings and fueling partisan debate – what good is a low confidence theory?  The FBI has the same theory with “moderate confidence.” They explain that the US has an 18 agency intelligence community implying that there is adequate expertise there for these low to moderate confidence lab-leak theories. Is this the same intelligence community that was confident that there were weapons of mass destruction in Iraq and who seemed vaguely aware of Chinese balloons invading US air space?  They might have better things to do than speculate about pandemic virus origins and rate those speculations.  Protecting US infrastructure against cyberattacks and criminal activity would seem to be at the top of that list.

I would like to see that 5 page report at this point – to see if there is any reference to a recent consensus statement from the virology community on the origins of SARS-CoV-2 (2).  The full text of that report is available online.  If you read that report a few points jump out at you.  First – these are the professionals with the most expertise in viral genetics and evolution. It is their full-time job and they do active research in the area.  Second – beyond claiming expertise virologists have been very successful at reducing the disease burden through their efforts.  They get results. Third – while emphasizing neutrality they point out that the zoonosis hypothesis (wild origin) has the most supporting data and that there is “no compelling data” to support either a lab leak or intentional contamination hypothesis. Fourth they point out that “gain-of-function” is an inexact term but within the field it also means modification for therapeutic purposes.  The term has been used by some politicians to suggest “nefarious” activity. Fifth – they review the extensive oversight of their research.  They conclude that millions of people are alive today because of their research and that there is adequate oversight. All of that clearly stated before the start of Congressional hearings on these issues.

 There is pre-existing research on viral origins from other groups and wild origin is the most likely scenario (3, 11, 12).

In an interesting twist of events the celebrity gossip show TMZ (10:34 to 18 minute mark) ran with the story.  They started out with the Harrelson monologue followed by Harvey Levin’s characterization that the lab leak theory “blossomed” with the Wall Street journal article.  To their credit they brought on Michael Worobey an evolutionary virologist with a previous description of the wild origins of SARS-CoV-2 in Science (4).  Dr. Worobey pointed out that he wrote a letter in 2021 that the ‘lab leak’ hypothesis had to be taken seriously, but since then then there has been “really strong scientific evidence” of a wild origin of the virus and no real scientific evidence of a lab leak.  Just from a probability standpoint he pointed out that all of the cases were in the area of the Wuhan market, there were animals present that carried coronaviruses, and there is really no other explanation for that degree of localization in a city of 12 million people. He also pointed out the severe social media backlash that he received as a result of following the evidence but encouraged a systematic approach to the research.  He suggested taking the DOE report with a “grain of salt”.

A final comment on the DOE report was made on the public radio show All Things Considered.  Michael Osterholm from CIDRAP was interviewed (5).  He describes himself as being agnostic towards the lab leak versus zoonoses but clearly sees the preponderance of data supporting the wild origin.  He goes on to suggest that people want certainty when a high degree of certainty is not possible and that has led to definitive headlines (about lab leak for example) when hard evidence is lacking. He adds the following characterization and challenges the DOE to present their data:

“…. again, there is a very different type of theater being played out here. It's not one that's based on science.”

He also describes a very plausible scenario of a new virus occurring in the Caribbean and how that could be spun into a ‘lab leak’ from the CDC in Atlanta.

Expect a lot of political demagoguery on the issue with Congressional hearings in the months to follow. Unless there is any data as good as the references I have posted - keep an open mind.  In a postmodern world – people with no or vague expertise make unfounded claims about scientific evidence.  The strongest evidence by far is with the experts and scientists listed in this essay. And that is a wild origin of the virus – just like previous coronaviruses. Anyone suggesting otherwise needs to show up with some data and not excuse making or political theater.

 

George Dawson, MD, DFAPA

 

References:

1:  Gordon MR, Strobel WP. DOE Says Lab Leak Is Likely Origin of Covid-19 ---New intelligence about China outbreak spurs assessment; finding is given 'low confidence'.  Wall Street Journal.  Wall Street Journal.  February 27, 2023.

2:  Goodrum F, Lowen AC, Lakdawala S, Alwine J, Casadevall A, Imperiale MJ, Atwood W, Avgousti D, Baines J, Banfield B, Banks L, Bhaduri-McIntosh S, Bhattacharya D, Blanco-Melo D, Bloom D, Boon A, Boulant S, Brandt C, Broadbent A, Brooke C, Cameron C, Campos S, Caposio P, Chan G, Cliffe A, Coffin J, Collins K, Damania B, Daugherty M, Debbink K, DeCaprio J, Dermody T, Dikeakos J, DiMaio D, Dinglasan R, Duprex WP, Dutch R, Elde N, Emerman M, Enquist L, Fane B, Fernandez-Sesma A, Flenniken M, Frappier L, Frieman M, Frueh K, Gack M, Gaglia M, Gallagher T, Galloway D, García-Sastre A, Geballe A, Glaunsinger B, Goff S, Greninger A, Hancock M, Harris E, Heaton N, Heise M, Heldwein E, Hogue B, Horner S, Hutchinson E, Hyser J, Jackson W, Kalejta R, Kamil J, Karst S, Kirchhoff F, Knipe D, Kowalik T, Lagunoff M, Laimins L, Langlois R, Lauring A, Lee B, Leib D, Liu SL, Longnecker R, Lopez C, Luftig M, Lund J, Manicassamy B, McFadden G, McIntosh M, Mehle A, Miller WA, Mohr I, Moody C, Moorman N, Moscona A, Mounce B, Munger J, Münger K, Murphy E, Naghavi M, Nelson J, Neufeldt C, Nikolich J, O'Connor C, Ono A, Orenstein W, Ornelles D, Ou JH, Parker J, Parrish C, Pekosz A, Pellett P, Pfeiffer J, Plemper R, Polyak S, Purdy J, Pyeon D, Quinones-Mateu M, Renne R, Rice C, Schoggins J, Roller R, Russell C, Sandri-Goldin R, Sapp M, Schang L, Schmid S, Schultz-Cherry S, Semler B, Shenk T, Silvestri G, Simon V, Smith G, Smith J, Spindler K, Stanifer M, Subbarao K, Sundquist W, Suthar M, Sutton T, Tai A, Tarakanova V, tenOever B, Tibbetts S, Tompkins S, Toth Z, van Doorslaer K, Vignuzzi M, Wallace N, Walsh D, Weekes M, Weinberg J, Weitzman M, Weller S, Whelan S, White E, Williams B, Wobus C, Wong S, Yurochko A. Virology under the Microscope-a Call for Rational Discourse. mSphere. 2023 Jan 26:e0003423. doi: 10.1128/msphere.00034-23. Epub ahead of print. PMID: 36700653.

3:  Garry RF. The evidence remains clear: SARS-CoV-2 emerged via the wildlife trade. Proc Natl Acad Sci U S A. 2022 Nov 22;119(47):e2214427119. doi: 10.1073/pnas.2214427119. Epub 2022 Nov 10. PMID: 36355862; PMCID: PMC9704731.

4:  Worobey M. Dissecting the early COVID-19 cases in Wuhan. Science. 2021 Dec 3;374(6572):1202-1204. doi: 10.1126/science.abm4454. Epub 2021 Nov 18. PMID: 34793199. (see also the map of SARS-CoV-2 origins)

5:  Contreras G, Brown A, Shapiro A, How an infectious disease expert interprets conflicting reports on COVID-19's origins.  All Things Considered.  February 27, 2023.

https://www.npr.org/2023/02/27/1159821909/how-an-infectious-disease-expert-assessed-how-covid-19-started

6:  Worobey M, Levy JI, Malpica Serrano L, Crits-Christoph A, Pekar JE, Goldstein SA, Rasmussen AL, Kraemer MUG, Newman C, Koopmans MPG, Suchard MA, Wertheim JO, Lemey P, Robertson DL, Garry RF, Holmes EC, Rambaut A, Andersen KG. The Huanan Seafood Wholesale Market in Wuhan was the early epicenter of the COVID-19 pandemic. Science. 2022 Aug 26;377(6609):951-959. doi: 10.1126/science.abp8715. Epub 2022 Jul 26. PMID: 35881010; PMCID: PMC9348750.

7:  Pekar JE, Magee A, Parker E, Moshiri N, Izhikevich K, Havens JL, Gangavarapu K, Malpica Serrano LM, Crits-Christoph A, Matteson NL, Zeller M, Levy JI, Wang JC, Hughes S, Lee J, Park H, Park MS, Ching Zi Yan K, Lin RTP, Mat Isa MN, Noor YM, Vasylyeva TI, Garry RF, Holmes EC, Rambaut A, Suchard MA, Andersen KG, Worobey M, Wertheim JO. The molecular epidemiology of multiple zoonotic origins of SARS-CoV-2. Science. 2022 Aug 26;377(6609):960-966. doi: 10.1126/science.abp8337. Epub 2022 Jul 26. PMID: 35881005; PMCID: PMC9348752.

8:  Bloom JD, Chan YA, Baric RS, Bjorkman PJ, Cobey S, Deverman BE, Fisman DN, Gupta R, Iwasaki A, Lipsitch M, Medzhitov R, Neher RA, Nielsen R, Patterson N, Stearns T, van Nimwegen E, Worobey M, Relman DA. Investigate the origins of COVID-19. Science. 2021 May 14;372(6543):694. doi: 10.1126/science.abj0016. PMID: 33986172; PMCID: PMC9520851.

This is an important reference form May of 2021 signed by Dr. Worobey suggesting that a more thorough investigation of the origins of the SARS-CoV-2 virus needs to be done.  Per the above assay and several references - he has concluded that the virus originated in the wild rather than lab leak since this letter. I think this letter also addresses the censorship comments.  Clearly the suggestion by this group that the lab leak had to be reinvestigated illustrates there was no censorship on the science side. 

9:  Chait J.  The Surprisingly Contrarian Case Against Lying About Science.  The Intelligencer.  February 28, 2023  https://nymag.com/intelligencer/2023/02/lab-leak-hypothesis-lying-about-science-is-bad-for-liberals.html 

10: Garry RF. SARS-CoV-2 furin cleavage site was not engineered. Proc Natl Acad Sci U S A. 2022 Oct 4;119(40):e2211107119. doi: 10.1073/pnas.2211107119. Epub 2022 Sep 29. PMID: 36173950; PMCID: PMC9546612. 

11:  Pekar JE, Magee A, Parker E, Moshiri N, Izhikevich K, Havens JL, Gangavarapu K, Malpica Serrano LM, Crits-Christoph A, Matteson NL, Zeller M, Levy JI, Wang JC, Hughes S, Lee J, Park H, Park MS, Ching Zi Yan K, Lin RTP, Mat Isa MN, Noor YM, Vasylyeva TI, Garry RF, Holmes EC, Rambaut A, Suchard MA, Andersen KG, Worobey M, Wertheim JO. The molecular epidemiology of multiple zoonotic origins of SARS-CoV-2. Science. 2022 Aug 26;377(6609):960-966. doi: 10.1126/science.abp8337. Epub 2022 Jul 26. PMID: 35881005; PMCID: PMC9348752.

12:  Worobey M, Levy JI, Malpica Serrano L, Crits-Christoph A, Pekar JE, Goldstein SA, Rasmussen AL, Kraemer MUG, Newman C, Koopmans MPG, Suchard MA, Wertheim JO, Lemey P, Robertson DL, Garry RF, Holmes EC, Rambaut A, Andersen KG. The Huanan Seafood Wholesale Market in Wuhan was the early epicenter of the COVID-19 pandemic. Science. 2022 Aug 26;377(6609):951-959. doi: 10.1126/science.abp8715. Epub 2022 Jul 26. PMID: 35881010; PMCID: PMC9348750.

13:  Wu Y, Zhao S. Furin cleavage sites naturally occur in coronaviruses. Stem Cell Res. 2020 Dec 9;50:102115. doi: 10.1016/j.scr.2020.102115. Epub ahead of print. PMID: 33340798; PMCID: PMC7836551.

14:  Xiao, X., Newman, C., Buesching, C.D. et al. Animal sales from Wuhan wet markets immediately prior to the COVID-19 pandemic. Sci Rep 11, 11898 (2021). https://doi.org/10.1038/s41598-021-91470-2

15:  Lenharo M, Wolf L. US COVID origins hearing renews debate over lab-leak hypothesis. Nature. 2023 Mar 9. doi: 10.1038/d41586-023-00701-1. Epub ahead of print. PMID: 36890328.

"Michael Worobey, an evolutionary biologist at the University of Arizona, Tucson, who has studied genetic evidence from the early days of the pandemic, told Nature that he found the proceedings “shockingly unscientific” and that they do not bode well for the overall investigation. “Not one of those witnesses had any scientific record of investigating and publishing peer-reviewed research on the origins of this virus in quality journals,” he said."

16:  Cohen J.  Science takes a backset to politics in first House hearing on origin of COVID-19 pandemic.  Science.  March 8, 2023.  doi: 10.1126/science.adh5155

Very useful essay that points out little science is occurring and the intelligence is very sketchy.

17:  Rutledge PE. Trump, COVID-19, and the War on Expertise. The American Review of Public Administration. 2020 Aug;50(6-7):505-11.

This is a good reference to keep in mind because it points out that President Trump and his administration actively promoted the lab leak theory of the pandemic dating back as far as May 2020.  All of the pundits decrying censorship of the lab leak hypothesis should ask themselves how censorship is possible when the theory is being actively promoted by the Executive Branch. 

18:  Maxmen A. Wuhan market was epicentre of pandemic's start, studies suggest. Nature. 2022 Mar;603(7899):15-16. doi: 10.1038/d41586-022-00584-8. PMID: 35228730.

This study links to three preprints describing the origin of the virus in the wild with spillover to humans.  As far as I can tell these preprints became the 2 papers listed below as well as reference 12 above:

19:  Pekar JE, Magee A, Parker E, Moshiri N, Izhikevich K, Havens JL, Gangavarapu K, Malpica Serrano LM, Crits-Christoph A, Matteson NL, Zeller M, Levy JI, Wang JC, Hughes S, Lee J, Park H, Park MS, Ching Zi Yan K, Lin RTP, Mat Isa MN, Noor YM, Vasylyeva TI, Garry RF, Holmes EC, Rambaut A, Suchard MA, Andersen KG, Worobey M, Wertheim JO. The molecular epidemiology of multiple zoonotic origins of SARS-CoV-2. Science. 2022 Aug 26;377(6609):960-966. doi: 10.1126/science.abp8337. Epub 2022 Jul 26. PMID: 35881005; PMCID: PMC9348752.

20:  Mueller B.  W.H.O. Accuses China of Withholding Data on Pandemic’s Origins.  New York Times March 17, 2023.

21:  Cohen J. Anywhere but here. Science. 2022 Aug 19;377(6608):805-809. doi: 10.1126/science.ade4235. Epub 2022 Aug 18. PMID: 35981032.

22:  Cohen J.  Chinese researchers release genomic data that could help clarify origin of COVID-19 pandemic.  Science 2023 March 29; doi:10.1126/science.adi0330.


Supplementary 1:

The director of the FBI came out in the media today (02/28/2023) and reiterated that the FBI has concluded the virus most likely originated as a lab leak but provided no additional data. As far as I know at this point the FBI and DOE data has not been released to the public.

Supplementary 2:

How is science ignored?  I realize after reading the post it contains historical information but nothing explicit about how science is ignored.  Here is the short list:

1:  Science is a process of serial approximations to reality or more to the point - an empirically acceptable model of reality.  Politics, journalism, and entertainment clearly are not. As a result the scientifically informed realize this is often series of hypothetical steps and missteps until a widely agreed upon model is accepted in the scientific community.  That contrasts sharply with a long series of provocative headlines and opinion pieces.  

2:  Science deals with probability statements - politics, journalism, and entertainment exists largely on the plane of dichotomous thinking.

3:  The probabilities on the probability statements can be adjusted in either direction.  As is the case in the Dr. Worobey references above - his probability of a "lab leak or nefarious activity" hypothesis was adjusted drastically downward over time as the probability of a wild origin was adjusted upward to the point where it became most likely.  This adjustment of probabilities is often seen as a "mistake" or "lie" by the nonscientific community. Within the scientific community it can be difficult to change your mind.  Neither of those considerations invalidates the process. 

4:  There are still scientific standards that acknowledge expertise and peer review. Although peer review is criticized by authors it has resulted in conventions that probably limit grand pronouncements like a newspaper headline.  The evidence should be in the 'limitations' section of any scientific paper.  In the postmodern world expertise is seen as relative by those in many nonscientific endeavors - to the point that anyone who can Google is considered an expert. This is also the predominate social media method of operation. 

5:  The legal/political model of ascertaining the truth or reality is highly flawed - and the evidence is obvious in studies of racial profiling, unjustified violent encounters with law enforcement, wrongful convictions, unequal treatment based on economic considerations, fallible eyewitness testimony, and highly flawed interrogations. Focusing only on coronavirus - the interrogations of Dr. Fauci by Sen. Paul is an additional example. And yet - this is the process that is going to be used by the government to decide on the origins of the virus.  Unless the DOE or the FBI have concrete scientific proof - it will be an exercise in rhetoric.

6:  If not science what? Typical analyses presented in the media can occur at several levels that cut science out of the mix. Anytime you hear an analysis by a group of journalists, politicians, regulators, administrators or consultants who lack the requisite expertise to analyze the problem take a close look at that final product. Ask yourself if there is anyone with scientific expertise who should have looked at it.  Be very skeptical of analyses that are not disclosed because they are proprietary or classified.


Supplementary 3 (Updates):

Update 03/02/2023:  As expected the COVID origins appearance of controversy was still whipping up the media today.  TMZ continued with their fractured analysis – continuing to focus on the FBI and DOE reports as a game changer and not mentioning at all what the evolutionary virologist Michael Worobey told them yesterday.  They played a brief John Stewart tape and suggest that he was now “vindicated” for suggesting early in the pandemic that this was probably a lab leak. Harvey Levin pointed out that Stewart was not crowing about being correct in the brief clip that they played and how could he? How can a guy who knows nothing about epidemiology or pandemic viruses and has no information about what transpired in Wuhan suggest there was a lab leak?  The excerpt that I saw had Stewart talking about the need to have both sides represented.  TMZ did touch on the most important aspect of this debate and that was rhetoric and how President Trump’s racist polarizing rhetoric led to conflation of the viral origin hypothesis with racism and that created significant backlash from the left. But we are still dealing with a non-scientific argument and ignoring Dr. Worobey. Harvey Levin seems stuck on these events as primarily a free speech issue.  To me that is obviously not a problem given the degree of bullshit and demagoguery that occurred around this issue.  There was probably no more “free speech” exercised at any other time in the history of the country. Watching TMZ the last two days just illustrates that they can avoid science as rigorously as anyone else – even after talking to a top scientist in the field. As some level the free speech argument just becomes a rationalization.

New York Times political columnist Jonathan Chait wrote a piece in the Intelligencer entitled “The Surprisingly Contrarian Case Against Lying About Science”.  He claims the DOE analysis has weight because there is a division there that is supposed to assess bioweapons threats. To me that just deepens the nonscience of it all. From a rhetorical standpoint we have gone from an appeal to emotion to an appeal to authority.  He goes on to analyze the rhetoric starting with the need to shift blame away from the Trump administration and their “mishandling of the epidemic.”  He is the first journalist I have seen who writes about how China unleashing the virus on their own people (one suggestion) is absurd.  I would add even considering the coronavirus as a bioweapon is equally absurd. In his analysis of Peter Hotez Tweets he gets it wrong.  Dr. Hotez characterizes the antiscience aggression of certain elements of the media and Congress as: “The best defense is a good offense”.  Chait’s response is:

 “I’m neither a professor, a doctor, nor a Ph.D., but I know enough to state confidently that the ethos of the scientific method is not “the best defense is a good offense.”

What about the ethos of journalism and politics? I am confident that is what Hotez is referring to.  He ultimately makes the argument that the left is not skilled enough to parse the anti-science rhetoric of the right and as a result lump legitimate scientific discussion with anti-science crankery and this is not a good thing. He concludes that ideology cannot be used to settle scientific debate. Some good points and some bad points. I will add it is pretty obvious to anyone who knows a thing about science that real scientific debates cannot be settled in the media and every scientist I know has had bad experiences with the media because they are trying to tell the story they want to tell.  My classic example was television interviews that I was asked to give around the Christmas holiday when I was a young psychiatrist. I knew the reporter was trying to sell the story that there were more suicides at Christmas and no matter what I said there would be that suggestion. I finally just told them – no more interviews. After all – in this case what is the more provocative headline ‘COVID is a bioweapon leaked or intentionally released’ or ‘COVID is a coronavirus that jumped from animal populations to humans like all human coronaviruses before it – including the 4 normally circulating coronaviruses that are considered common cold viruses.”  Rhetoric is a very strong component here and if the press wanted to really be useful, they might point out that on a timeline basis.  The arguments are largely rhetorical rather than scientific and factual.  All the press would have to say about the science is that it is not settled and digress a little into how scientific decisions are made. But I have never seen that happen.     

Update 03/03/2023:  The following document reviews some of the history of the controversy and points out that there really is no definitive proof of the viral origins at this point.  In the last few paragraphs the scientists who see zoonoses/spillover as the most plausible scenario are looking for falsifying data but have not found it.

Robertson L.  Still No Determination on COVID-19 Origin.  FactCheck.org 03/02/2023: https://www.factcheck.org/2023/03/scicheck-still-no-determination-on-covid-19-origin/

Update 03/06/2023:  TMZ was at it again today.  They put up a weekend poll on the origins of COVID and posted 2 possibilities -  wet market or lab leak.  The vote went like this:

wet market - 12%

lab leak - 88%

Harvey Levin's analysis was that this showed censoring the lab leak hypothesis at the outset was the problem.  This analysis is incorrect at two levels. First, there are endless headlines from 2021 where Republicans like Senator Rand Paul accused Dr. Fauci of lying about gain-of-function and labs leaks.  The demonized Dr. Fauci about this to the point that he started getting threats and needed protection for himself and his family. The same sequence of events happened to many public health officials who became objects of right wing scorn.  Secondly - I don't know what you expect when you are hyping unscientific proclamations about lab leak for the past week. Let's not pretend the media is a disinterested party here. TMZ chose the story about "censorship" when there was none and chose to suggest that was a better explanation for why two government agencies were suggesting a lab leak over the expert they interviewed last week. Just another clear example of the title of this post. 


Supplementary 4:

House Committee on Oversight - COVID origins:

Here is the web site - not the current references to Fox News and the New York Post - both obviously the farthest information from science:

https://oversight.house.gov/landing/covid-origins/


Graphics Credit:

Eduardo Colon, MD photo is much appreciated.

 

Monday, March 16, 2020

The First Case Report - Implications For Coronavirus Conspiracy Theories



At the time of this writing I have encountered at least three coronavirus conspiracy theories.  The American version goes something like this. The current pandemic resulted from a leak from a Chinese bioweapons laboratory. The supplementary information generally talks about how these particular bioweapons labs are not very secure and leaks are common. The Chinese version has a human twist and it involves a visit to China by 300 US military athletes. The suggestion is that these athletes intentionally introduced the virus or inadvertently passed the virus to the Chinese population. There is an Iranian version - suggesting that the virus is basically an American bioweapon.  There are various embellishments. Prominent politicians are involved in restating these conspiracy theories. I have been reading about bioterrorism for the past 20 years and would dismiss these theories as being implausible from a technical perspective. From a political perspective, it makes perfect sense to me that politicians will always try to look for a way to deflect any responsibility. One of the most common ways to do that is to blame an adversary - especially one that might be unpopular with the majority of citizens.

The report of the first case of coronavirus in the US is a rare opportunity to end all the conspiracy theories with real evidence. I do realize that conspiracy theories are not generally refutable by facts.  This post is directed at those who can incorporate factual information into their worldview. There has been a lot written lately about distinguishing opinion from fact, including the results of a standardized international test suggesting that American students may have some deficits in this area.

Detailed case report in the New England Journal of Medicine is interesting from a number of perspectives.  The patient is a 35-year-old man walked into an urgent care in Snohomish County, Washington on January 19, 2020 the four-day history of cough and “objective fever”. He had returned from visiting relatives in Wuhan, China. His health history was basically unremarkable. Initial vital signs showed a temp of 37.2°C, BP of 134/87, and pulse was 110 bpm. Restaurant rate was 16 breaths per minute and O2 sat was 96% on room air.  Initial viral screen for influenza a and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and for common coronaviruses was negative. The CDC was contacted and samples were collected for 2019-nCoV. The virus was confirmed one day later.

The patient had been discharged home but after 2019-nCoV was confirmed he was admitted to an airborne isolation unit for observation. The clinical course is described in the figure below that is taken from the original paper (with permission). The symptom course before the admission date of January 20 is estimated on the diagram. I think it is instructive to note that cough preceded the development of a low-grade fever on day five of 37.9°C or 100.2°F. The patient also had fatigue nausea and vomiting before the development of fever.



Laboratory findings over the course of the illness are presented in the original article and six blood samples did not show any marked abnormalities. He had mild elevations of alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase. Blood tests were done due to fevers and they showed no growth.  Chest x-ray on day 9 of the illness showed left lower lobe pneumonia that correlated with decreased O2 sat down to 90%. At that time he was put on supplemental oxygen. It is also treated with vancomycin and cefepime for presumed hospital acquired pneumonia. On day 10, based on his chest x-ray, the need for supplemental oxygen, and reports of the development of severe pneumonia is physicians decided to treat him with an investigational drug - remdesivir. By day 12 he was clinically improved and no longer needed supplemental oxygen. His oxygen saturations were normal on room air. As seen in the diagram, is always symptoms at the time were a cough and rhinorrhea.

Contrary to the conspiracy theories, this paper points out that the Chinese researchers shared the full genetic sequence of the 2019-nCoV in the National Institutes of Health GenBank Database and the Global Initiative on Sharing All Influenza Data (GISAID) database. 

The authors emphasize at the time of this writing that the full spectrum of clinical disease is undetermined. Transmission dynamics are also undetermined because the patient had not visited the seafood market in Wuhan or had any contacts with known cases in China. They list several complications noted in the Chinese population including acute respiratory distress syndrome, severe pneumonia, respiratory failure, and cardiac injury. There are several radiographs on Twitter suggestive of significant lung injury and at least one report of myocarditis in a significant subset of patients. The authors also point out that the patient had nonspecific symptoms prior to the onset of pneumonia that were consistent with a number of common respiratory viruses. In differentiating this illness travel history, the decision by the patient to seek treatment, and a coordinated effort among public health officials led to the timely identification of the virus. I would add that this case report also shows the clear need for clinical expertise as the illness transforms from what appears to be a typical respiratory virus to pneumonia. The question that needs to be asked is whether that level of expertise is available everywhere in the country.

Addressing the threat of emerging infectious diseases requires a public health infrastructure and cooperation across many countries with their own political interests. Many those countries may have public health officials that are cooperating with one another, but politicians who may decide to use a pandemic for their own interests. With most countries engaged in significant quarantine efforts at this time, clear cooperation among world leaders in stopping this pandemic is urgently needed.

George Dawson, MD, DFAPA



References:

1: Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, Spitters C, Ericson K, Wilkerson S, Tural A, Diaz G, Cohn A, Fox L, Patel A, Gerber SI, Kim L, Tong S, Lu X, Lindstrom S, Pallansch MA, Weldon WC, Biggs HM, Uyeki TM, Pillai SK; Washington State 2019-nCoV Case Investigation Team. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020 Mar 5;382(10):929-936. doi: 10.1056/NEJMoa2001191. Epub 2020 Jan 31. PubMed PMID: 32004427.



Permission:

Figure 2 above is from the original article in reference 1 - with permission from the Massachusetts Medical Society.  License date is March 16, 2020 - license number is 4791120888948 for 12 months from the date of the license. 


Saturday, March 14, 2020

The Pandemic Report From Beam Avenue





It was my day off yesterday but I have been looking at a “need maintenance” light for the past four days. I had to leave the house for car maintenance. Given the pandemic status this would be a whole new trip. Even though Minnesota does not have a lot of cases at this time, they are increasing and there is an identified COVID-19 case in a town 5 miles away and a neighbor four houses away with direct exposure to coronavirus in the workplace. My secondary goal during this trip was to take a look at social distancing and the other practical suggestions to contain the spread of this virus.

Beam Avenue is a busy thoroughfare that connects Highway 61 on the west and White Bear Avenue on the east. My Toyota dealer is on the west end of Beam Avenue and 1.5 miles away a popular shopping mall sits on the corner of Beam Avenue and White Bear Avenue. St. Johns Hospital is about half way down and the photo was shot from the sidewalk. Average vehicle traffic in this area is about 17 to 18,000 vehicles per day.

I don’t generally set up appointments for vehicle maintenance. I wait until the light goes off and then I typically drive in and wait. Even though the wait takes 1 to 2 hours, the accommodations for customers at this dealership are excellent. A comfortable waiting area, free cookies, and free coffee. This waiting area is generally very congested due to the high levels of work done at this dealership. It was going to be a challenge to see if social distancing was possible or not.

I pulled into the service area and was greeted by one of the service managers. He took me over to his desk and we started going through all the details. I told him I needed a new battery in my starter fob. He took it from me, pried open, installed the new battery, blew the dust out of both halves of the fob with his own breath, snapped it together, and handed it back to me. We talked about the purpose of this visit specifically oil change and tire rotation. He offered to sell me a new service plan but I told him I was thinking of trading in my current RAV4 for a new one. He asked me what my timeframe was and I told him:

“I want to see this coronavirus thing pans out.”  He smiled at that.

After deciding the course of action he told me it might take one to two hours and I headed into the customer waiting area. I have probably seen more customers there at other times but it was packed, everyone was eating cookies and drinking coffee, and there were few open seats. There are study carrels along one wall. That is where I typically sit and do computer work while I wait. I decided it was a bad idea because there is no expectation that these surfaces would be sanitized. The same would be true of the padded and more comfortable seating in the middle of the waiting area. Appropriate social distancing was not evident and in fact I counted 16 people in the service area that were probably within a 10 foot radius of me. I decided it was a good time for a walk.

Beam Avenue is not the ultimate walking course. There are numerous pedestrian crossings just to get to the main sidewalk on the north side. Several large businesses have entrances across that sidewalk. It was an opportunity to see how many motorists never stop or even slow down when making a right-hand turn at a red light or stop sign. Costco motorists seemed more prone to that maneuver. The problem with the walkway is the intensity of traffic and the associated noise and exhaust fumes. That might explain why during the entire 3 mile walk I did not encounter a single fellow pedestrian. The traffic at 3 o’clock on Friday afternoon was as intense as I have ever seen it.

I got to the mall and walked through the main entrance. All the entrances and exits to the mall had pneumatic sliding doors and that is clearly a plus in terms of virus transmission. As I walked further into the mall those benefits seem to diminish. I came across children who were swarming all over free plastic playground equipment. I also saw kids jammed into moving seats wearing some kind of virtual reality goggles that appeared to be simulating a Star Wars battle. I did not inspect all of this equipment but hand sanitizers were not apparent. The kids all looked like they were having fun - it is probably hard to think about social distancing when you are a parent of young children.

When I got to the food court I was surprised that the tables had been thinned out. It looked like there was about a 60% reduction in the total number. As a result there was roughly 10 to 12 feet between most of the tables-the suggested social distancing interval. The other notable change was that even with fewer tables, there was hardly anybody eating at the food court. There was one long line of what appeared to be high school students who had not been seated. There is also visible housekeeping staff with sanitation equipment and they appear to be interested primarily in the food court area.

The men’s room was disappointing. With all the emphasis on handwashing there should be an expectation that any facility will be adequate for that task. In the men’s room, 40% of the soap dispensers and 60% of the faucets were not working. One of the faucets was totally gone. There was a paper towel dispenser that was empty and two air hand dryers. I had time to discover that I needed to go from sink to sink but if there was any crowding - I am sure it would affect the number of people adequately washing their hands. I headed out the door and back to the Toyota dealer.

When I got back - social distancing remained a problem. The service manager met me in the cashier line and reviewed all of the billing. There are two cashiers with six people in two lines and we were all about 1 foot apart. Nobody was coughing or sneezing. I was able to pay and leave in about five minutes.

On the way home I had to pick up some milk and bread and stopped at one of the major grocery store chains in the Twin Cities. The parking lot was packed. I decided to shop without a cart and avoid any cart contamination. There were hundreds of people in the store many of them very old. The store was well-stocked and the only thing that was missing was the toilet paper and paper toweling. A woman in front of me laughed very loudly when she turned the corner and saw that there was about a 50-foot section of shelving completely empty where these paper items had been. I grabbed the milk and bread and headed to the self-checkout line. Six people in line again to get to the touchscreen checkout computer. I checked out got in my car and used a liberal amount of hand sanitizer. I had also used outdoor gloves to negotiate doorways at the car dealership.

On the final drive home, I was thinking about how social distancing was absent in most of the scenarios I encountered. Vehicle and foot traffic were heavy and there was plenty of congestion.  What will it take to get people to stay home and out of public spaces? Some commentators have said that inconsistent messaging is a big part of it. Declaring a pandemic a political hoax one day an actual public health emergency the next day doesn’t work. Today I read three different conspiracy theories on COVID-19 as a bio weapon that was either deliberately used by the United States or China or inadvertently escaped the Chinese bioweapons lab. None of those theories appears to be consistent with what really happened. I was watching a celebrity news program and saw a caller say that the only time he took the pandemic seriously was when he learned that Tom Hanks and Rita Wilson had contracted the virus.

I started to think about why I take it seriously. I worked on two different Avian Influenza Task Forces about 15 years ago. It was a significant effort. One of the main concerns was surge suppression or preventing emergency departments and other resources from being overwhelmed by people who thought they had the disease. There is actually a program called Psychological First Aid where mental health professionals train volunteers to counsel these people and direct them away from emergency departments. I was a trainer for this course. In our meetings there was always a vague discussion of what would actually happen in hospitals if they were overwhelmed by patients with avian influenza.  In some of those discussions we would see a PowerPoint slide of a pallet loaded with Tamiflu at some Air Force Base. We were reassured that in the event of a local epidemic- that medication would be made available. The specifics about negative pressure rooms, ventilators, workflow, and manpower requirements were never really discussed. The current strategy for coronavirus of slowing the infection rate by social distancing and quarantine was also not discussed. At some point it was apparent to me that if avian influenza pandemic occurred, we would be making it up as we went along. I had studied several of these epidemics and had concerns about surge suppression especially in a highly infectious situation.

There appear to be some common errors that are made along the way when considering that pandemics are not only possible but likely. The first one is analyzing the situation according to a particular political bias. This is a very common mistake these days even though it clearly doesn’t work. Contradictory information in addition to those political biases amplifies the problem. Independent of political bias, it takes the ability to imagine that a pandemic is possible. That approach can be historical, biological, medical or mathematical. Any one of those disciplines can provide the necessary knowledge base. There are concerns today that in the era of social media dynamics – every one is an expert at the rhetorical level. The signal of real expertise is lost in the noise of grabbing for celebrity and the associated benefits. Self-selection leads to all of the adherents of a common belief isolating themselves in one little area on the Internet. That leads to the expected cognitive biases but also the illusion that life can go on as a member of an isolated group with no role in greater society.  Pandemics directly confront that denial.

I did see some bright spots on Beam Avenue today, but not many.  Vehicle and foot traffic is heavy and social isolation is a problem in high congestion areas. If people are expected to wash their hands frequently – washrooms need frequent attention and repair. The focus on cancellation of mass sporting and entertainment events is useful, but day to day sources of possible contamination need attention – especially when there are clearly identified cases and exposures in the area.

People need to stay home unless travelling to congested areas is absolutely necessary.  It is the best way to prevent the severe measures being taken in some countries right now and get through this.


George Dawson, MD, DFAPA