The graph, by itself, tells much of the story. We are still in the first wave of COVID-19, but the US is seeing a second hump to that wave. We are having the highest number of new cases right now, five months into this pandemic. A few months ago we hoped that by July we would start to see the tail end of this first wave, while we anxiously await a possible second wave in the fall, but instead we are seeing a surge. What is happening?

It’s always challenging to clearly see what is going when we are still in the middle of this pandemic, and our information is always a couple of weeks behind reality. But infectious disease experts and epidemiologists are seeing some patterns and are all expressing the same concerns. First, part of what we are seeing is just the natural course of this pandemic. In the US it largely started in urban centers with airports. NY had multiple introductions of the virus from Europe, for example. For this reason they were hit early and hard, while rural America was largely unscathed.

But the wave has moved through those urban centers into the rest of the US. Part of the problem is that, if you look at pooled US data it looked in May and into June that the death toll was declining and new cases were also declining. This created the false impression that, as a country, we were seeing the end of the first wave and we could start opening up. Plus there were legitimate concerns about the effect on the economy of prolonged shutdown, and understandably people were getting lockdown fatigue. But the total US numbers did not tell the full story. In April, as total US numbers started to go down, if you just removed New York from the data the rest of the 49 states were still going up. New York City, which was hit very early, was distorting the data. In May and June all you had to do was remove NY, CT, NJ, and MA from the data, and the other 46 states were increasing. But the illusion that the first wave was winding down had its effect.

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A study by Russian researcher purports to find that a treatment, Impaza, increases penis length during copulation in rats, while the water placebo group and sildenafil (Viagra) did not. The authors conclude: “This effect, together with an absence of motivational actions, suggests that Impaza may be the most valuable treatment for erectile dysfunction.” The study was originally published in the International Journal of Impotence Research, but was later retracted by the editors. The primary reason for the retraction is that the editors discovered that Impaza is a homeopathic product, something that was apparently missed on initial peer review.

This is definitely an editorial fail, but at least it was quickly corrected. To put the failure in context, however, Impaza was not presented as homeopathic, but rather as a “release-active antibody-based” drug. This is code in Russia, apparently, to disguise the homeopathic nature of certain products. It is not uncommon in pseudoscience for proponents to come up with scientific sounding euphemisms for their nonsense in order to hide from the negative association with charlatans and quacks.

Editors and reviewers, however, need to dig deep enough to uncover such pseudoscience. At the very least there was a lack of curiosity on the part of the editors, and insufficient vigilance against the intrusion of pseudoscience.

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It often seems that for every modern advance that helps humanity live safer, more comfortable, and more productive lives there are those who claim that advance is a bane to be avoided, perhaps even the plot of a sinister conspiracy. One of the more perplexing examples is raw milk aficionados. These are people who claim, against all evidence, that raw milk is healthier. A new study adds to the pile of evidence that they are wrong.

Most milk consumed in the US and industrialized nations is pasteurized and homogenized. Pasteurization is the process of flash heating raw milk in order to kill bacteria, making the milk safer and extending its shelf life. The process involves heating milk in stainless steel containers to 161° F for 15 seconds then rapidly cooling down to 39° F.  Many European countries prefer ultra-pasteurized milk, which involves heating to 280-300 degrees F for 2-3 seconds. This produces so-called shelf stable milk that does not have to be refrigerated.

Pasteurization undeniably works as advertised. As Mark Crislip summarized over at SBM, the widespread use of pasteurization has reduced milk as a source of human bacterial infection outbreaks from 25% to 1%. Many studies have shown that consuming raw milk is a risk factor for bacterial infection. So why would raw milk proponents claim it is better? They believe that raw milk is more nutritious and tastes better, and contains healthy probiotics.

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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 »