Warning from the Virologists



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This is a very interesting paper!  It is a detailed virological and immunological study of 9 patients with COVID-19, presenting from Jan 23 – 27, 2020, all with mild upper respiratory symptoms (not requiring ICU admission or ventilators) in Germany.

I will try to summarize it.

  1. Pharyngeal virus shedding (from the back of the throat) was very high during the 1st week of symptoms, peaking at day 4 although earlier time points were often not available.
  2. During the 1st week after onset of symptoms, infectious virus (able to infect cells in a test tube) was present in throat (swab) and lung (sputum) samples (16% of  swab samples; 83% of sputum samples), but not in stool samples.  There was no infectious virus after day 8 of symptoms. Viral RNA sometimes lingered in the stools for weeks but there was no infectious virus
  3. Active viral replication in the throat was confirmed by a nifty assay which detects RNA intermediates that are only present with active replication (subgenomic viral RNA transcripts).  By comparison SARS-CoV, the virus that causes SARS, does not replicate in the upper respiratory tract, but only in the lungs (lower respiratory tract).
  4. Shedding of viral RNA (RT-PCR tests detect this) in sputum outlasted the end of symptoms
  5. Seroconversion (the appearance of IgG and IgM antibodies to the virus) occurred after 7-14 days, but was not followed by a rapid decline in viral RNA
  6. there were no co-infections – they tested at least 16 other common viral respiratory infections
  7. the titers of viral RNA (swab tests) were highest on day one of symptoms and then gradually decreased.  This was when symptoms were still minimal and “prodromal”.  The peak viral loads were at least 1000 fold higher than in SARS.
  8. A rise in antibody titers was not closely correlated with clinical improvement
  9. antibodies showed cross-reactivity to 4 endemic human corona viruses (viruses that cause the common cold).

Bottom line:

  • The COVID-19 virus replicates big time in the nose/throat and very early on, often before  symptoms – it is probably VERY infectious
  • Because RT-PCR tests for viral RNA can persist for as long as 20+ days after initial symptoms appear, one must remain concerned about current recommendations for a 14-day quarantine.  Is it really long enough?
  • The antibody response was poorly correlated with getting better.  Since antibodies are but one of several arms of the immune response, I would guess that CD8 cells, subsets of CD4 cells and perhaps cells of the innate immune system all participate in overcoming the viral infection.  A prior paper documented the response of these cells in a single patient.
  • Should therapeutic interventions such as anti-viral drugs or even convalescent plasma transfer focus on the earliest stages of the infection when symptoms have just appeared? That is when the virus is replicating massively.  Currently, these therapeutic interventions are focused on the sickest patients in the ICU and on ventilators, at a much later stage of the disease.  Paradigm shift?
  • The utility of EARLY testing for viral RNA is obvious by either throat or nasal swab or expectorated sputum
  • It will be interesting to compare these results (from patients with a milder disease course) to those of patients with severe disease.


PS: 17.9% of persons with COVID-19 are asymptomatic (have no symptoms what so ever) and are still producing virus and infecting others.  That is 1 in 5 infected people  have no symptoms.  Think about it.


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The Case for Masks

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The headlines and what the reasoning is behind them:

Austria makes masks compulsory as protection debate shifts!

Four European countries make masks mandatory!

From Czech Doctors  & Citizens – The CRUCIAL MISSING Coronavirus Protection Guideline https://www.youtube.com/watch?v=hVEVve-3QeM

A University of San Fransisco research scientist shows how anyone can make a mask using a long sleeved T shirt, scissors and a paper towel as a filter.  He shows how to cut the t-shirt and it is utterly simple and easy to do. He tells us the scientific data on masks and what materials work.

How Czech Republic Maintains Low Contagion https://www.youtube.com/watch?v=T2dOs-LhJaQ

How to make your own mask  https://www.youtube.com/watch?v=4FB–BOyTiU

I would add that I use construction masks that I got at Home Depot: less than $10 for one box with 50 masks.  Not sure whether they are still available.


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I love it!

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Mike Francesa’s takedown of Donald Trump: ‘Treat this like the crisis it is’

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Mike Francesa has given Donald Trump the handwave.

The longtime New York-based sports radio gasbag took to the airwaves on Monday night, offering a takedown of Trump and his response to the coronavirus pandemic plaguing the nation, and specifically, New York.

“There’s a disconnect. We’re watching one thing happen in our city on the 11 o’clock news every night. We’re watching people die,” Francesa says. “And now we know people who died. And we’re not seeing one or two people die now in our neighborhood. We’re seeing them die by the 10s and 20s by the day. They’re bringing people out of the hospital in Queens in body bags. …

“Treat this like the crisis this is,” Francesa continued. “And how can you have a scoreboard that says 2,000 people have died, and tell us it’s OK if another 198,000 died, that’s a good job. How is that a good job in our country? It’s a good job if nobody else dies.”

Francesa, as you may know, is one of the kings of sports radio — but is also New York’s Numbah 1 in bad takes, inaccurate takes and “I nevah said that!”s in the history of broadcast radio.

But Francesa is also known for his political takes, as — for some reason — listeners across the tri-state area tuned in to Francesa in 2016 for his political opinions during the election year. While it’s largely speculated that Da Sports Pope cast his vote for Trump, he hadn’t publicly stated that he did. He was a big Trump supporter during his election run, however.

“I think it’s about doing a good job. His ego will not let him do anything but a good job,” Francesa said of Trump in 2016.

Francesa’s afternoon drive spot — originally from 1 p.m. to 6:30 p.m. ET — is now tucked into a nice, half-hour spot on WFAN 101.9 from 6-6:30 p.m. He was recently given another show on Sundays while the sports radio world struggles to find something to talk about.

Interesting to see if Trump will be back aftah this.

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Kinsa’s thermometers

This is probably the most exciting thing I have read related to COVID in some time.

This from the NYT

“Kinsa’s thermometers upload the user’s temperature readings to a centralized database; the data enable the company to track fevers across the United States.

Owners of Kinsa’s thermometers can type other symptoms into a cellphone app after taking their temperature. The app offers basic advice on whether they should seek medical attention.

Kinsa has more than one million thermometers in circulation and has been getting up to 162,000 daily temperature readings since Covid-19 began spreading in the country.”

The technology was first published in 2018 and used to track annual influenza outbreaks:

2018 Jul 18;67(3):388-397. doi: 10.1093/cid/ciy073.

A Smartphone-Driven Thermometer Application for Real-time Population– and Individual-Level Influenza Surveillance. Miller AC1, Singh I2, Koehler E2, Polgreen PM3.

Now Kinsa is tracking spikes of “atypical fever”, fever that does not follow the historical flu patterns and was not predicted:

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Note the red part of the curve (March 9-20) did not follow the predicted patterns, and was perhaps due to COVID-19 , designated “atypical”. Very interesting is the dip (orange) that follows after March 20 to levels below “2% ill”.  This dip in the curve is being attributed to effective social distancing measures.  It would be the first measure of the effectiveness of such regulations and it certainly would help guide public policy.

Especially interesting are the interactive maps on the Kinsa website:

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The above map shows the location of “atypical” illness (presumed COVID-19). It is the “amount of unexpected illness expressed as additional share of the population affected by influenza like illness above the expected values”

Note the concentration in Florida.  That is fascinating because the RT-PCR testing for the coronavirus has not yet really shown the expected rise in cases (Florida ranks #6):

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I presume the Kinsa technology is much faster at detecting trends, than counting positive cases and deaths.  I am thinking that most of those people that are having atypical fevers have not yet been tested for the virus of they are waiting for a result.  (Some people that I know well have been waiting for 9 days or more.)

This map is fascinating too:  it depicts trends. By placing the cursor over your county, you can get very local data:

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This is a 7 day rolling average of change in the illness level expressed as percent change up or down.

In Suffolk County, NY, the illness (atypical fevers) trend is decreasing by 4.3% and thankfully the decreasing trend is seen across the country. There is only one county in Texas (Hardeman Cty) where the trend is not decreasing.

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This map (above) shows you how much influenza-like illness is being detected throughout the country. It is a map of how severely the population is being affected by atypical influenza like disease.  I presume this data lags the data in the above graph on location of “atypical” illness where Florida was mostly in the red?

Here is what the company concludes:

(3/24/2020): Due to widespread social distancing, school closures, stay-at-home orders, etc. feverish illness levels are dropping in many regions. This does not mean that COVID-19 cases are declining. In fact, we expect to see reported cases continue to surge in the near term, but it may indicate these measures are starting to slow the spread. See CDC COVID-19 Cases in U.S. for details.



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“She didn’t deserve to die this way”

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Dated March 30, 2020

Dear Colleagues and Friends:

Three days ago I had no Covid-19 patients in the hospital. Two days ago there were two in critical care. One of the two, a patient for more than 20 years, died Sunday (March 29) at 3pm. Her daughter cried to me “She didn’t deserve to die this way, all alone.” She’s right. My first, not my last, patient to die of Covid-19. When the daughter gave me details of who else was exposed to her mother, those that need for testing, I said ashamedly that I have no access to testing or tracking of exposed individuals. Another patient of mine is intubated. I am hoping he will survive.

Before Trump’s inauguration, there was a warning from the Obama administration: ‘The worst influenza pandemic since 1918’ would be coming and Obama officials briefed the incoming administration on this exact scenario.

What’s Trump’s planning approach: “Trump ties coronavirus decisions to personal grievances”. Trump took to Twitter Sunday afternoon to tout the ratings of his news conferences, claiming without evidence that mainstream media are going “CRAZY” because of his popularity on television”.

In the absence of both medical equipment and testing in the world’s richest country, many are debating how to allocate scarce medical resources.  Patient-level decisions are being made with this perspective.

Others are thinking about estimating the cost of this pandemic. Academics are calculating how we can decrease social distancing after implementing contact tracing and adequate testing

Still, others are trying to put pen to paper imagining a better health system that includes planning for the next pandemic. Meanwhile, Scott Gottlieb and Mark McClellan (excellent Repub policymakers) have detailed options for the current pandemic.

To put any long term health reform ideas into place, we need members of Congress and an executive branch interested in long term health reform not just tearing down health systems.

Via Ask Nurses and Doctors, I am in the process of organizing round tables for incumbent members of Congress and encouraging people to write letters to the editor such as these. The picture in the excellent LTE by Barbara Floyd is worth a thousand words.  Happy to help anyone who is interested in putting “pen to paper”.

In the meantime, my physician colleague has been extubated and continues to improve but is still in the hospital.

Norbert Goldfield MD

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From London: If you are over 65 with COVID-19, good luck

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The numbers are normalized per 100,000 population.  Since the US is a far larger country the number of deaths will be far larger. Daily deaths are predicted to peak after around three months if people don’t change their behaviour. Image: Imperial College COVID-19 Response Team




From a medical consultant in London. This was sent initially to his family on Sat March 28th, 2020.  It is a frank assessment.  Expect the same situation here in New York and elsewhere in the USA.  (NB: this was sent to me via my British family)

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