Post #616: Aerosol spread, and taking stock of how vastly better the picture looks right now, than it did just one week ago.

Source: Science, 4/2/2020, brief piece authored by Robert F. Service.

Panic gets a bad rap these days. A lot of people push a meme of “Don’t Panic”. Keep calm and carry on, and all that.

But my motto is: Panic Early and Often. Panic can be a good thing when it gets you off your butt and doing something productive. There’s a reason we have a fight-or-flight reflex.

I didn’t really hit full panic mode until the morning of 4/2/2020. I explain below how I know the exact date and time. But, at that time, panic was an entirely reasonable reaction in response to facts as they then existed.

But I went through that panic. A panic based on my judgment of the facts. And I’m not panicked now. Again, for what I believe to be excellent reasons.

So I figured, all things considered, I might as well share those reasons. Because my assessment of how things look today is vastly more upbeat than it was when I hit flat-out panic on 4/2/2020. And it’s not that I’ve changed. It’s that the facts have changed.

My wife tells me that I’m about three days ahead of the newspapers on this pandemic. Sometimes more, sometimes less. So, as the death tolls mount, and the case counts continue to march upward, I figured I should take the time to point out how vastly better things look now than they did one week ago.

This, from a guy who’s been a few days ahead since the start of this. And one whom no one would call an optimist. Skip down to “What a difference a week makes” if you just want the bottom lines of these topics.

Sub-exponential case growth
Plausible, readily-available treatments
Public mask use
Other benefits of shutdown

Panic Early and Often

Some people might consider my showing the article at the top of the page to be the rankest sort of fear-mongering. A crass attempt to spread panic.

But it’s not. Instead, the contents of that article are exactly the sort of thing that separates simple Nervous-Nellie-ism from a proper strategy of Panic Early and Often.

It’s not fear-mongering. It’s science. Or, rather, it’s Science (arguably the most prestigious US peer-reviewed journal for general science, reporting the conclusions of the U.S. National Academy of Sciences, a body set up by President Lincoln to advise the Federal government on key matters of science and technology. This article is only now filtering into the popular press.

A virus will do what a virus will do. If it’s undergoing aerosol transmission (as opposed to droplet transmission), then it’s been doing that all along, and it will continue to do that. Talking about it doesn’t change what the virus does. But it can change what we do to protect ourselves. While aerosol transmission is incredibly dangerous, what’s vastly more dangerous is failing to realize that aerosol transmission may be a material factor in this epidemic. And then failing to change how we are protecting ourselves.

Scientific understanding changes in response to a change in the known facts. And so, once you absorb that, you realize that the presence of that article is good news. It doesn’t change what the virus is actually doing. It just means that we’re finally getting smarter about this. Despite the President. Despite, to some degree, the US FDA. Despite, to some degree — and it truly pains me to say this — the US CDC. As I explained in Post #601.

And, to a degree, despite the World Health Organization (WHO). Or, more plausibly, despite our not grasping why certain WHO conclusions about disease spread — based on China, where everybody wears masks during an epidemic — may not have applied directly to the U.S.A. — where, before now, almost nobody wore masks in public.

I’m going to expand on that, because, having just disparaged the POTUS, I need to point out one true fact he has managed to grasp. In general, the President has acted, and is continuing to act, in a remarkably ill-informed and unhelpful manner. I mean, just consider: We’re in the middle of what we hope will be a once-in-a-century pandemic. Arguably, it’s going to be followed by something resembling the next Great Depression. And the President’s latest Big Idea is to de-fund the World Health Organization (WHO). As a technique for blame-shifting, that’s a genius idea. As a technique for getting through this pandemic, that’s about as helpful as a plan to (e.g.) start locking up all the ER docs in the US.

In case you didn’t realize it, WHO staff volunteered to travel to China, to the heart of the epidemic, to the hospitals and clinics that were dealing with the COVID-19 case load, and live and work there for the late stages of the epidemic, in order to gather the information and make that report. And in case you don’t bother to look up the facts, our annual contribution to WHO amounts to 0.003% of the money we just spent in the $2T relief bill. I mean, the first relief bill. Normally, I would say “Penny wise, pound foolish”, but that would understate the rank stupidity of this by about three orders of magnitude. This one’s more like penny wise, C-note foolish.

But on one small point, the President is right: Some of what we have done wrong, to date, we did wrong because we were guided by all the conclusions of the WHO analysis of what went on in China (Post #551). The original CDC guidance on how we should deal with this was, I believe, largely derived from the evidence presented there, because that was the only systematic evidence available at the time.

It would be far too charitable to say here that even stopped clocks are right twice a day. That’s not really the aphorism that applies, because the President appears to have latched onto this fact not from any understanding of the science. It’s because the WHO is a useful target for blame shifting. The more apt aphorism would be “the buck stops anywhere but here”.

In hindsight, the WHO report is a mix of things that directly apply to the US epidemic, and things that may have been unique to China, and so not directly apply. And we weren’t fast enough on our feet to realize that. And, really, no human could possibly have been smart enough to realize that.

Certain conclusions from that report clearly and directly provided excellent and helpful information to the US. For example, COVID-19 largely spares children. It does, in fact, have a very high mortality rate (though much higher than the 4% rate reported in the WHO report, for the reasons I explained in Post #551.

But other things that probably were true of the Chinese experience — relating to how this disease is commonly spread — may or may not apply to the US experience. And, after some reflection, I’m willing to bet that’s not due to underlying genetic differences. Or to some mutation of the virus. Or to differences in medical treatment, or authoritarian government, or to any of that.

I think that’s due to behavior of the population. And in particular, my guess is that it’s due to the single largest and most obvious difference between Chinese and US citizens: The Chinese always wear masks, in public, in an epidemic (Post #610). They always have. Nobody needs to tell them to do it, and when times are tough, that is rigidly enforced, both by social norms and by the government. But in the US, we rarely do, and we are only now slowly and sporadically getting on board with that.

And so it’s now apparent that some parts of the WHO report on the (mask-wearing) Chinese experience may not apply to the (non-mask-wearing) US. And the important one is the conclusion by Chinese epidemiologists that the only transmission route that matters materially is droplet transmission from symptomatic individuals. I.e., being in range when people who are tangibly ill are coughing or sneezing, or touching surfaces that those droplets have fallen on or been spread to.

Surely droplet transmission is important in the US as well. But, increasingly, there have been aspects of the Western experience that can’t plausibly be explained by droplet transmission. The most startling of these is the Mount Vernon, Washington choir practice superspreader event (Post #585). And I would add events like the Prime Minister of Great Britain falling ill long after everyone knew enough to keep anyone who was even remotely ill out of any public spaces. And, finally, continued spread of disease in the post-lockdown US, despite the rigid social enforcement of a rule of staying out of public spaces if you have any sort of illness (Post #601).

So, blaming the WHO for what is, in essence, a byproduct of our current cultural bias against face masks in epidemics, that’s clearly stupid. But predictable, given the President we have. Nor can you really blame the CDC for failing to realize that the US experience might plausibly differ from the Chinese experience. We have little-to-no understanding of how population-level public mask use alters mechanisms of disease spread. So there’s no point in blaming them either. I’m all in favor of blame where blame is due. But none is due here, and focusing on blame-shifting is not helping the USA.

But here’s the good news: We’re smart enough to figure it out and change behavior accordingly. The CDC issued new guidance. Mask use has increased. And we’re aware of the potential for aerosol transmission, even if that’s not part of the CDC cannon on this disease yet. Particularly, people seem to be increasingly aware of the potential for short-range aerosol transmission, and the real need to be masked at all times when you are around other people in public spaces.

So, for sure, the CDC has figured this out. Let’s just hope that the American public can figure it out.

What a difference a week makes.

Now that I’ve come full circle, from calm to panic and back again, in a bit over one week, I realize just how vastly better the situation looks now than it did just one week ago. Better in Fairfax County. Better in the Commonwealth. And, plausibly, better for the U.S.A. as a whole.

This, despite the rising death tolls and case counts. Despite the mounting economic losses. And so on. As I said above, I’ve managed to be a few days ahead of the curve on this. So let me explain what I’m seeing.

So the situation does not look particularly good. But it looks a lot better than it did one week ago.

On the morning of 4/2/2020, that’s when I ventured into the insane Ebay market for sanitary (single-use) face masks, and purchased the masks that (I hope) will be arriving in the next few days. (And please read my other posts on masks before you flame me for buying these. These masks are not what hospitals use. The are not rated for filtration and it would be illegal for hospitals to use them. The are (e.g.) still available on Amazon after Amazon has pulled all supplies that could be used by front-line medical workers.)

That’s also when I started ordering various types of furnace filters, so that I could make a few hundred masks that would plausibly provide some protection against aerosol spread (the topic of the article featured at the top of this posting, and on the front page of this website.) And that moment of panic is why I’ll soon begin making and distributing those masks. Even if, at this point, people may or may not see a need for them.

But, to be clear, this is not time to relax. It is not time to start breaking the rules. Recall that Wuhan was on total lockdown for 11 straight weeks. In the Commonwealth, we’ve just now reaching the 4th week of far more moderate restrictions. It’s way to early to declare victory and go home. But it is time to summarize the bits of good news that have come out in the last week.

Then versus now 1: Exponential versus subexponential case growth.

Edit 4/11/2020: Nope, this was way too optimistic. We did slow it, and by eye, at that time, it looked like this. But if you do the numbers right, all we did is knock the exponent down a bit. Doubling time was three days, doubling time now looks like one week. And that isn’t going to cut it. See Post #621.

Original post follows:

Then: If you go back a week or so, the only thing the data showed you was that the Commonwealth still appeared to be on an exponential growth path. That is, case counts were rising at an ever-faster rate. The curve looked like the side of a bowl. This, despite more than two weeks of social distancing (which I mark as starting on the day the schools shut down, 3/13/2020). A week ago, there was little-to-no tangible evidence, from the case counts, that social distancing was working here in the Commonwealth. We looked like we were headed for the same fate as New York.

Then: Here’s the last chart I did before 4/2/2020. Blue is the Commonwealth.

Now you can start to make the good case that Fairfax has at least gone “sub-exponential”, meaning that while daily increases are not yet falling, the curve looks more like a straight line, or maybe the top of a hill. Not the side of a bowl. And while it’s too early to say that we’ve hit the inflection point yet (passed the top of the hill), that’s at least in the realm of the plausible, for Fairfax County.

And while the Commonwealth has not yet clearly gotten off the exponential growth path, Fairfax is the single largest source of cases. And our Governor had the good sense to shut things down sooner rather than later. At this point, all the scientific evidence says that a shutdown and sub-exponential growth are literally cause-and-effect. We didn’t get lucky. Our Governor, and our County, got smart.

Finally, there are hints that other critical regions are managing to achieve sub-exponential case growth as well. Again, from shutting down non-essential functions and enforcing social distancing. Including, critically, New York, which was, at that time, maybe two weeks away from mass deaths. Now, it looks like it’s going to be pretty awful, but not the once-in-a-century disaster that it might have been there.

A special prediction on what will happen next on social media. It was completely predictable that someone, sooner or later, would start pushing the approach of “just let them die” (Post #570, Post #571). I wrote that up as soon as I saw it, because I knew it was coming, and it’s just a twist on the old (and wrong) “high cost of dying” argument.

And of course, it was the usual suspects — the nutty right-wing Fox-friendly pundits, and the evangelicals. The folks who lack an understanding of even the most basic science or economics. And are unaware of their fundamental ignorance.

Here’s my prediction: Give it another two weeks, and if our containment strategies succeed in avoiding ventilator shortages, mass deaths, and so on, those same folks will be back. But this time they’ll be telling us that they were right all along, this was way overblown, it wasn’t that big a deal, we didn’t need to shut down the economy, we wasted a bunch of money, and so on. And, most fundamentally of course, that out response was all just some Deep State plot by Liberals to undermine the President.

So when you start hearing that — and it will be coming out of the woodwork in any number of varieties of argument — just take those arguments out into the light of day, walk them around, and given the a good look-see. Because they all boil down to:

“Our containment strategies worked, and we avoided mass deaths. And so the lack of mass deaths is evidence that our containment strategies were not needed.” (And then thrown in a dash of your favorite conspiracy theory on top of that.)

That’s like saying, e.g., whooping cough doesn’t kill many kids any more, so there’s no point to the DPT vaccine. People rarely get thrown through the windshield in car accidents any more, so seatbelts are clearly unnecessary. Nobody has invaded the US in centuries, so we clearly have no defensive need or a military. And so on.

Those are statements that only make sense to people who are literally too stupid to understand basic cause-and-effect. And you might be saying to yourself, nobody could be that dumb.

Hah. Just wait and see.

Then versus now 2: Folk medicine versus two promising treatments available right now

You can go back to my post on Folk Medicine (Post #552) to see what appeared to be state-of-the-art treatment as of just a short while ago. There was none. You had physicians in China frequent using anti-virals off-label, and that was about it. They weren’t very effective, and in particular, they had to be given early in the disease to have a significant effect. There were some new anti-viral drugs being developed, but a plentiful and tested supply of those would be months to years away. And they would be sold at horrifying prices, if the recent history of the pharmaceutical industry is any guide.

We were literally back to medicine as it was practiced prior to WWII. Wash your hands. Don’t go to public gatherings. Wash your hands. Quarantine the sick. The only thing we were missing was “wear a mask in public”. And now we have that recommendation in place.

And so I did the only rational thing I could do. I did my own bit of “scientific folk medicine” and came up with high consumption of flavonoids as the sole chemically-based preventative that made any sense to me, based on what I could glean from the scientific literature. To which I’ve now added zinc and two new flavonoids (green tea extract and quercitin) — with the zinc taken a few hours away from the flavonoids, so that they do not bind together in the digestive tract — on the “zinc ionophore” theory that maybe hydroxychloroquine’s effects appear greater in the presence of zinc supplements because if its role as an ionophore, transporting zinc through cell walls, where the presence of higher concentrations of zinc ions can suppress replication of this virus. I take the zinc separate from the compounds that are known to bind with zinc, because I want them to bind in my blood plasma, not in digestive tract, so that those compounds can act as ionophores and get the zinc through cell walls, which it normally cannot do. Got it? This is not medical advice, this is just my daily routine. No clue whether it has any effect or not.

Now, it looks like medicine is wising up.

First, hydroxychloroquine was shown to be extremely effective, in vitro (in a test tube), against the first SARS epidemic (SARS 2003). The only reason it wasn’t developed int a tested treatment at that time is that the first SARS epidemic fizzled.

Now, we know that hydroxychloroquine shows the same potent anti-viral effects against the current SARS epidemic (SARS-CoV-2, aka COVID-19). There are case reports of some effectiveness in humans. And there are now multiple physicians — seemingly responsible individuals — who say that the key is the addition of zinc supplements. Which, when I go looking for it, is something that was already in the process of being tried as a preventative, for health care workers, in a proper controlled clinical trial. See Post #607 for a writeup of all that.

This is far from settled science. But so far, all the surprises seem to have been on the happy side. Not only do we have this handful of spectacular case reports, and some trials indicating effectiveness, the American Thoracic Society has endorsed use of this drug. The Chinese put it on the list of drugs approved for treating COVID-19. And so on. The drug and the zinc supplements are both cheap, we have millions of dose on hand, and it’s fairly easy to produce.

It’s a dangerous drug, for sure. It’s predecessor (chloroquine) had a reputation for killing people on occasion. This one causes changes in heart function, among other things. But they’ve been using it for more than half a century, so it’s clearly something that physicians can use with some confidence.

So this is one where I agree with the President. But this is also one where I think the stopped clock metaphor is apt. If you throw enough (verbal) darts, one of them will hit something. It’s beyond implausible that POTUS understands the existing body of research regarding this drug and SARS. And, to be clear, it was being recommended by mainstream scientists for months now, has undergone clinical trials in both China and France, and so on. The story that Fearless Leader, alone, somehow identified this drug in a feat of sheer brilliance is …pure bullshit. This was well along in mainstream science channels before anyone in the White House knew how to pronounce it.

Next, convalescent plasma appears to work. Speaking of ancient medical practices, one way to treat an infectious disease is via blood transfusion from a person who has recovered, and so presumably has antibodies against the organism causing the disease. This is the notion of “convalescent plasma”. Another term is “passive immunity”, because you, in effect, borrow a survivor’s immunity rather than actively develop it yourself. Not only has it been around for at least a century, it was in fact used in modern times against viral disease that had no known effective treatment, such as Ebola.

And now, a clinical trial out of China says that it works for COVID-19. So, in the US, we’re fast-tracking that, lead by none other than the Mayo Clinic. If they can acquire sufficient phoresis (blood-separation) equipment, then the pool of recovered patients becomes a pool of plasma donors. My vague understanding is that an individual can safely give enough plasma to treat a small number of infected individuals — something like 10 or so.

So while that’s a risky approach — you want to avoid any blood or blood product transfusions if you possibly can — right now it looks like it probably ought to work. Particularly And while they would vastly prefer to extract plasma from individuals with known high concentrations (“titers”) of antibodies to coronavirus, they could, in a pinch, do any of a variety of whole-blood-type transfusions.

Anyway, the report of the Chinese experience is here, in this scholarly article. If I may translate it to something simpler. They had 10 patients who were probably on the path to dying from COVID-19. Out of desperation, they gave each of them 200 ML of plasma from someone who had recovered. (Which ain’t much — when you donate blood, you typically give a pint, which is about 450 ML). Ready:

Clinical symptoms were gone in three days.
Their blood was virus free in seven days.
Their lung lesions had healed in seven days.

Yeah, it’s only ten patients, and yada yada yada more clinical trials are needed and blah blah blah. But as case reports go, that’s pretty damned spectacular.

Then versus now 3: Change in the CDC guidance on public mask use.

Source: https://www.maskssavelives.org/

I’ve harped on this one enough that there’s no need for me to repeat myself. The only new news here is that enlightened business around town are figuring out that it’s far cheaper to provide quality masks to their employees than it is to have them sick, or have them quit.

So my evidence here is two anecdotes.

We know a young guy who works at Wegmans. He is in a public-facing position. He’s the source of my Wegman’s Wage post. He quit yesterday. Figured that, in essence, minimum wage plus two bucks was not enough for the risks involved. Wegmans was not, at that time, providing him with a mask.

I talked to an individual who runs a five-person construction crew in Vienna. They had masks sewn up for all their works — five cloth masks each, one a day. We had a conversation about whether or not to add some Filtrete (R) material to the filter pocket sewn into the mask. I was in favor of it.

I’ll also pass along a tip that had not yet dawned on me. Arguably, the largest piece of strong elastic you own is in your fitted sheets. If you are thinking of sewing masks, and can’t find elastic, and have some old sheets that you don’t mind cutting up, that’s a source of a large amount of elastic.

Then and now 4: Side benefits of the shutdown

I just thought I’d toss these out there. These are both things I’ve mentioned before.

Source: clipart-library.com

One is that, to my eye at least, the sky is and remains unnaturally blue. I’m betting that we’ve passed the point where the majority of otherwise-suspended fine particulates (PM2.5, the ones that cause haze) have been rained out of the lower atmosphere.

I can’t prove that, yet, but for sure, that bright blue sky is cheering.

Two is that social distancing continues to suppress the previous flu epidemic. Nationally, our rate of fevers is way below what was projected.