It’s always disappointing (not surprising, but disappointing) when a purely scientific question unnecessarily becomes a political or social one. Whether or not to wear a face mask during an historic pandemic should be purely a question of risk vs benefit – does it work, and is there any downside? The evidence is clear enough at this point that mask wearing helps reduce the spread of COVID-19. David Gorski recently reviewed the evidence, including a recent meta-analysis, and found:

When it came to masks, an analysis of 29 unadjusted and 10 adjusted studies demonstrated that the use of masks was also associated with a large decrease in transmission, both for N95 masks and for disposable surgical masks or similar reusable 12- to 16-layer cotton masks.

Since that review there have been further studies, such as this one, showing that countries who adopted mask wearing early had fewer cases of illness. The benefit, therefore, seems clear. What’s the downside? Pretty minimal. Sure, it may be a pain and a bit uncomfortable, but this is a minor nuisance at worst. People who are hard of hearing and rely on lip reading probably suffer the biggest downside. There are masks with transparent sections over the mouth to facilitate lip reading, however, for those who need to deal with the hearing impaired.

So wear a mask if you are sick, around other people who are sick, or just in public. In some countries it is considered hygiene etiquette, as it should be.

As a side note, there is some confusion because early on the WHO recommended not to wear a mask in public unless you or others were sick. This was not because the evidence did not support it, however, but because there was a shortage of PPE and people were hording. The idea was to make sure that essential workers had enough masks. This is no longer an issue, and the WHO has revised their recommendations, which are now in line with the CDC – wear a mask, even just to go in public.

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There is pretty clear evidence now that the lockdown worked in “flattening the curve” and reducing cases, hospitalizations, and deaths from COVID-19.  By one estimate the lockdown has already prevented about 60 million cases in the US alone, and about 250,000 additional deaths, perhaps more. This doesn’t even take into consideration what would have happened if the pandemic was allowed to overwhelm hospital systems around the country. In the Northeast, which was hit early and hard, hospital systems were overwhelmed in that they had to reconfigure their resources, and compromise on protocols in order to meet the demand. In some NY hospitals they had two patients on one ventilator. Imagine this, but far worse, and more widespread. How many deaths not directly related to COVID-19 would have resulted from this strain on the system?

So I think we can take fair comfort in the fact that the lockdown, as painful as it is, has at least worked as intended. Many people have raised the question – did the lockdown work also on the flu? If so, why don’t we do some version of the lockdown during the height of flu season? We now have data on the effect of the lockdown on this year’s flu season in the northern hemisphere – it stopped the flu season about 5 weeks earlier than is typical.  It’s possible some of this decrease in numbers is due to fewer people seeking treatment, but it’s likely that it is mostly due to reduced spreading of the flu virus.

This year in the US the flu season was toward the higher end in terms of cases and deaths – not out of the range of typical flu seasons, but at the bad end of the spectrum. In the US there were between 39 and 56 million cases of flu this year, with 24-62 thousand deaths. The upper limit of flu season deaths is around 65 thousand. The reason for the wide estimate range is because most people don’t get tested in order to confirm that their flu-like illness is indeed the flu. So confirmed cases are a small percentage of total cases, which are estimated by clinical presentation. Globally the estimated number of flu deaths each year is 290,000–650,000.  Right now the global number of deaths attributed to COVID-19 is 436,000, but the number of new cases is still on the upswing.

Before you fall prey to the “COVID-19 is just a bad flu season” fallacy, keep in mind that the pandemic is not over yet. And, as stated, this is with lockdown. But, what does this say about how we handle typical flu seasons, and how we will likely handle COVID-19 in the future? Here are some thoughts.

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Pangolin’s are adorable and weird animals. They are mammals, with eight (although some references say seven) species in their own order, the Pholidota (all eight species are also in the same family and genus). They have scales, no teeth, and a long tongue, and are native to Africa and Asia. They are also endangered for a very specific reason – their scales are valued as medicine in Traditional Chinese Medicine. They are endangered because of culturally and politically sanctioned pseudoscience.

This is why it has come as welcome news that China has finally removed pangolin scales from the list of official TCM treatments. They have also upgraded pangolins to the highest level of protection. I applaud this decision, which may be a “game changer” in terms of protecting pangolins, but I do have to point out that China is just mitigating a problem entirely of its own creation. It’s like announcing that you are going to stop beating your wife. Congratulations.

What remains to be seen is how strictly they are going to enforce their new protections. Striking pangolins from the list of official TCM products will not magically erase centuries of culture, or a very lucrative black market – just as banning ivory did not instantly disappear the ivory trade and save the elephant. Further, China needs to do the same thing for the entire list of TCM treatments based upon animals parts. No tiger bones, bear bile, or rhino horn.

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The safety and efficacy of hydroxychloroquine for the treatment of COVID-19 has quickly become an important medical question in managing this pandemic, although not by far the most important. There are many drugs under consideration, and some with promising early results. But hydroxychloroquine has garnered the majority of attention for purely political reasons. I most recently wrote about the scientific evidence for hydroxychloroquine on May 18th, referring to four studies all showing no benefit. Since then there have been more studies, including this one in NEJM showing no benefit from hydroxychloroquine in terms of preventing the contraction of COVID-19. Systematic reviews, which are being done in an ongoing manner, also conclude no benefit from this drug.

But at the end of my May 18th blog post, on May 22nd, I added a brief addendum because another study had just come out I thought was worth noting – a multinational study which compiled evidence from 120 different hospitals involving over 90,000 patients. This study found no benefit but significantly an increased risk of heart complications and death from hydroxychloroquine. If you follow this link now you will see a giant “retracted” posted over the study. The Lancet reports:

But in an open letter last week, a group of scientists raised “both methodological and data integrity concerns” about it.

These included a lack of information about the countries and hospitals that contributed to the data provided by Chicago-based healthcare data analytics firm Surgisphere.

One other hydroxychloroquine study used data from Surgisphere, this one published in the NEJM, and has also since been retracted. So what happened and what does all this mean?

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A new study published in Australia evaluates the accuracy of 27 online symptom checkers, or diagnostic advisers. The results are pretty disappointing. They found:

The 27 diagnostic SCs listed the correct diagnosis first in 421 of 1170 SC vignette tests (36%; 95% CI, 31–42%), among the top three results in 606 tests (52%; 95% CI, 47–59%), and among the top ten results in 681 tests (58%; 95% CI, 53–65%). SCs using artificial intelligence algorithms listed the correct diagnosis first in 46% of tests (95% CI, 40–57%), compared with 32% (95% CI, 26–38%) for other SCs. The mean rate of first correct results for individual SCs ranged between 12% and 61%. The 19 triage SCs provided correct advice for 338 of 688 vignette tests (49%; 95% CI, 44–54%). Appropriate triage advice was more frequent for emergency care (63%; 95% CI, 52–71%) and urgent care vignette tests (56%; 95% CI, 52–75%) than for non‐urgent care (30%; 95% CI, 11–39%) and self‐care tests (40%; 95% CI, 26–49%).

More distressing than the fact they the first choice was correct only 36% of the time, is that the correct diagnosis was only in the top 10 only 58% of the time. I would honestly not expect the correct diagnosis to be in the #1 slot most of the time. For any list of symptoms there are a number of possibilities. If there are 3-4 likely diagnoses, listing the correct one first about a third of the time is reasonable. You could argue that the problem there is simply not ordering the top choices optimally.

But not getting the correct diagnosis in the top 10 is a completely different problem. This implies that the correct diagnosis was entirely missed 42% of the time.

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In March Trump tweeted: “HYDROXYCHLOROQUINE & AZITHROMYCIN, taken together, have a real chance to be one of the biggest game changers in the history of medicine. The FDA has moved mountains – Thank You!” He has continued to support this untested drug since, turning what should have been a minor footnote in the COVID-19 pandemic into a political controversy.

As evidence of putting politics above science, Dr. Rick Bright claims he was removed from his post simply for questioning the promotion of hydroxychloroquine:

Dr. Rick Bright was abruptly dismissed this week as the director of the Department of Health and Human Services’ Biomedical Advanced Research and Development Authority, or BARDA, and removed as the deputy assistant secretary for preparedness and response. He was given a narrower job at the National Institutes of Health.

In a scorching statement, Dr. Bright assailed the leadership at the health department, saying he was pressured to direct money toward hydroxychloroquine, one of several “potentially dangerous drugs promoted by those with political connections” and repeatedly described by the president as a potential “game changer” in the fight against the virus.

The Plandemic conspiracy theorists promoted hydroxychloroquine as a cure for the pandemic, suggesting the government (yes, the same one headed by Trump) was withholding it to make money off an eventual vaccine.

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Perhaps one of the positive outcomes of the pandemic is an acceleration of acceptance of telehealth and telementalhealth – treating patients online instead of in person. For example, we have been trying to institute telehealth where I work for years, but have met with roadblocks. Then, all of a sudden, we were able to do it. Our clinic manager estimates that we accomplished in three weeks what would have otherwise taken three years. I have been doing mostly telehealth visits for the last two months now. It’s not perfect, but for many patients it is an ideal option.

The advantages are pretty obvious. A regular visit involves driving into a clinic (which may be in a city, and involves fighting traffic and finding parking), then checking in, and sitting in the waiting room until finally called. Then the meeting happens with the physician. Afterwards you go to check out, and then have to drive home. Depending on the length of the drive, you may spend 2 hours or more total time for 10 minutes of face time with the physician for an uncomplicated follow up visit. Compare this to signing onto an app from the comfort and convenience of your home, having the 10 minute visit over video, then you are done. This also means you are not sitting in a waiting room with potentially sick individuals. Many patients also have a difficult time getting to the clinic. They have physical limitations, and may even require special transportation to get there.

You can even do a limited physical exam over video. Anything that is purely visual and doesn’t require physical contact can be examined. But many patients do not require a physical exam as part of their follow up – their original exam was normal and there is nothing to follow. I see many patients with migraines, for example. Once it has been established that their headaches are indeed migraines (the workup, including exam, for other causes is negative) there is no need for any further physical exam unless something changes. Continue Reading »

The question of whether or not wearing a facemask “works” is incredibly complicated. It may not seem so at first, but let me list some of the specific questions contained in that broad question. We need to consider different kinds of masks – cloth, surgical, N95. We need to consider who is wearing the mask – someone known to be infected, someone who is well, and in what setting, out in public or in the presence of those known to be sick. We also need to operationally define “work.” We can measure reduction in the spread of the virus, in droplets, in aerosolized particles, and also in different conditions (breathing, coughing) and at different distances. We can measure deposition of virus on surfaces. We can also measure transmission of actual disease, both the chance of spreading and of catching specific illnesses. And of course, all of these questions need to be addressed with each specific infection, and so prior research may not apply perfectly to COVID-19. And further we need to compare the efficacy of wearing a mask to the real-work effectiveness of intending to use a mask.

It should not be surprising, therefore, that we do not have all the answers to these questions specifically for COVID-19. What we have are slices of research with different results and therefore you can look at the preliminary evidence we do have and come to different conclusions. The CDC and the WHO, in fact, have done this. Here is the CDC recommendation:

“CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies), especially in areas of significant community-based transmission.

CDC also advises the use of simple cloth face coverings to slow the spread of the virus and help people who may have the virus and do not know it from transmitting it to others.  Cloth face coverings fashioned from household items or made at home from common materials at low cost can be used as an additional, voluntary public health measure.

Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

The cloth face coverings recommended are not surgical masks or N-95 respirators.  Those are critical supplies that must continue to be reserved for healthcare workers and other medical first responders, as recommended by current CDC guidance.”

And here is the WHO:

If you are healthy, you only need to wear a mask if you are taking care of a person with COVID-19.

The WHO recommends masks for those who are symptomatic or known to have COVID-19, and those exposed to people who are sick, but not for the healthy out in public. The guidelines are actually not that far off from each other, but there is that one difference.

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As is often pointed out, the SARS-CoV2 virus is new, and therefore we have limited data on its characteristics, as well as the disease it causes, COVID-19. This complicates our modeling of what is likely to happen, and recommendations about best practices. But scientists around the world are busy studying this pandemic as it is occurring, and therefore our models and recommendations are evolving.

Already we know quite a bit. For example, one review of NYC patients found:

Among the 393 patients, the median age was 62.2 years, 60.6% were male, and 35.8% had obesity. The most common presenting symptoms were cough (79.4%), fever (77.1%), dyspnea (56.5%), myalgias (23.8%), diarrhea (23.7%), and nausea and vomiting (19.1%). Most of the patients (90.0%) had lymphopenia, 27% had thrombocytopenia, and many had elevated liver-function values and inflammatory markers. Between March 3 and April 10, respiratory failure leading to invasive mechanical ventilation developed in 130 patients (33.1%); to date, only 43 of these patients (33.1%) have been extubated. In total, 40 of the patients (10.2%) have died, and 260 (66.2%) have been discharged from the hospital; outcome data are incomplete for the remaining 93 patients (23.7%).

One question, which is especially important as the northern hemisphere approaches summer, is if SARS-CoV2 is less virulent in warmer temperatures. Coronaviruses in general tend to spread less in warmer months, so there is some reason to hope this will be the case. However, a new review of COVID-19 data pokes a hole in this hope. The authors looked at many countries around the world and correlated the number of new cases with various factors, including temperature and humidity.

To estimate epidemic growth, researchers compared the number of cases on March 27 with cases on March 20, 2020, and determined the influence of latitude, temperature, humidity, school closures, restrictions of mass gatherings and social distancing measured during the exposure period of March 7 to 13.

They found no correlation between the number of cases and temperature, and only a weak association of reduced spread with increased humidity. This is, perhaps, the most comprehensive study to date. There have been numerous previous studies, mostly regional, that do show a negative correlation with virus spread and temperature. The authors suggest this is due partly to lack of rigor in those studies. Also, an expert review of this data (prior to the most recent study) urged caution. They note that the studies showed inconsistent results, and it is difficult to generalize the data to what is likely to happen in the world with COVID-19.

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A promotional video on YouTube for a new documentary, Plandemic, is making the rounds and promoting quite a response. The video features Dr. Judy Mikovits, and is basically an interview with her. Unfortunately this is a slick piece of utter nonsense and conspiracy mongering. Mikovits has zero credibility in any of her claims, but they are combined with music and clips of videos to create the impression that there is some reality behind her outrageous claims. Let me focus on a few claims to show how low her and the filmmaker’s credibility are.

In her introduction the narrator states that she authors a study in Science that “sent shockwaves through the scientific community” because it showed that fetal and animal tissue in vaccines was causing an epidemic of chronic illness. This is straight up lie, but that is the narrative of this video – that she is a courageous fighter going against the establishment, which is killing people for profit and trying to destroy her for calling them out.

Here is the original Science paper. It alleges to have found the XMRV virus in patients with chronic fatigue syndrome. This did make a splash when it was published because it purported to find a possible cause of an otherwise mysterious illness. It has nothing to do with vaccines at all (although you could argue, falsely that the virus came from vaccines, but that is not what the research was on). But then, here is a retraction of the paper by Science. Was it retracted as part of some global conspiracy against Mikovits? No – it was retracted because:

“Multiple laboratories, including those of the original authors, have failed to reliably detect xenotropic murine leukemia virus-related virus (XMRV) or other murine leukemia virus (MLV)-related viruses in chronic fatigue syndrome (CFS) patients,” says the retraction notice. “In addition, there is evidence of poor quality control in a number of specific experiments in the Report.”

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