COVID-19 Update No. 20: COVID and Travel

 6/17/2022

It has been a bit more than two pandemic years and you are restless. Time to get out and see things, be among people. The COVID variants are taking over and, though spreading much more easily than the alpha or delta strains, hospitalizations with serious illness and death from COVID have decreased dramatically- more like typical seasonal flu. The illness is much more like a head cold, but with fatigue and bodyaches and often fever. And it tends to be relatively short duration- – 5-7 days. Why? Well, the variant viruses are less virulent. They target the upper respiratory passages, not the lungs so much. And, they do not cause the blood-clotting problems the original strains did. And, we’ve gotten smarter. We know who we need to socially distance and isolate because their medical infirmity puts them at high-risk for serious illness. Moreover, many of those people did die early in the pandemic and now the large majority of people have had COVID and/or the vaccine and so there is at least a good deal of herd immunity. Finally, we have very effective medications that diminish the chance of serious illness by over 90%.

                So, we can travel. Even the U.S. government is promoting it by removing the mandate for testing for COVID as a condition to enter the country from abroad.

                Of course, this is a fluid situation and as people come out of hiding and co-mingle, we may see reports of localized outbreaks, but it is likely these will just be fairly benign events as the virus mutates to co-exist better with its human host, as I have stated in previous updates.

                What about air travel? Planes are probably some of the safest, close-ventilated spaces within which you can be regarding airborne diseases. Jetliners process the entire cabin air volume every 2-3 minutes, running the air through Millipore filters that catch viruses and bacteria nearly 100%. That is why you just don’t hear of disease outbreaks, including COVID, in groups of airline passengers. That, along with herd immunity and awareness (such that many of those with respiratory infection symptoms act to delay flying) has made flying about as safe as it gets, probably more so than many places you go in your daily life.       

                So, it is time to travel, and without irrational fear. However, there is still some thinking to do, especially if you are elderly, have serious medical problems, and are in a travel group. This document resulted from a colleague’s wife traveling with him overseas becoming ill with COVID and having their long-awaited trip disrupted. Now that I’ve given context, some bullet points, particularly about international travel,

1. If you develop symptoms consistent with COVID and test positive (remember, the at-home tests are a reliable positive, but somewhat unreliable negative; the latter means re-testing several times if symptoms continue), you must go public with the information and notify your trip officials. Why?
   • Ethical Behavior: It is the right thing to do. You would want this if someone traveling in your group became ill with COVID.
   • Medical Aspect: A greater proportion of group travelers (tour groups) are elderly and may have serious medical conditions, including weakened immune systems.
   • Liability Aspect: You could be financially liable for others in a tight group becoming ill from exposure to you and your failing to timely disclose your illness to them. They could have medical bills, trip disruption losses, etc.

The trip organizer/manager likely has a policy and procedure on COVID illness cases developing en route for liability protection. It would be advisable to ask about this before proceeding with a trip. Could it require quarantine? Early trip termination? Do they carry insurance for this? Are you credited for losses on a disrupted trip?

• Trip Medical Supplies
  • N-95 masks
  • Fever meds- Tylenol, ibuprofen, aspirin
  • Cough med
  • Paxlovid (COVID antiviral)- It is free, but requires a prescription. And, you must check potential adverse interactions with other medications you take in order to stop or dose-adjust them should you need to use Paxlovid- check lists on the Internet: www.covid19treatmentguidelines.nih.gov
  • The travel mate of the COVID positive traveler might reasonably consider taking the 5-day Paxlovid medication course to avoid illness on the record.
  • Rapid COVID Tests- How many to take along depends on the length of the trip, but probably a few is enough; and you can get them abroad, but prices may be high.
• Medical Consultation: Consider pre-arranging a way to communicate with a reliable expert back home should you develop COVID illness abroad, so you can craft an action plan fit to the circumstances.
• Medical Insurance: Be sure to check on whether your U.S.-based coverage can be adjusted to cover medical expenses abroad. Medicare does not, but may be able to be modified. By the way, all elderly people should look into a repatriation of remains coverage for international travel, always.
• Check on current airline policies (continually evolving) on criteria for boarding post-COVID illness. Their rules may differ from the government.
• If you arrange trip cancellation insurance, determine whether the coverage is just for pre-travel travel disruption events, or also while traveling- should you need to terminate your trip or substantially modify it (such as quarantine). Also, be sure there are no exclusions or disclaimers regarding COVID-19 positive tests or illness impact on the travel. You might see if there is coverage specifically for COVID-related events.
• Post-COVID Testing (for clearance): To date, the guidelines are that re-testing for COVID can be done 24-hours after fever has gone (with no fever reducing medication) and other symptoms improving. Since rapid tests are less reliable negatives, it would make sense to do two tests, 24-hours apart, before concluding you are no longer shedding virus.

Obviously, for the next year or so this will be a somewhat fluid environment, but I want to emphasize that I would consider travel as medically very safe. However, should you acquire COVID and become ill, be aware of the hype and paranoia that has been messaged by the media and government/public health authorities such that you will not want to be the object of anger and rage in your travel group. Note how many people are still walking about with masks, convinced of an ongoing serious danger that is just not backed up by the facts. If you follow my recommendations, you will have responsibly addressed the issue in your own interests and the interests of others.

                Perhaps a year from now this will all be behind us. But, as always, perception is as much the issue as the reality. And you must account for this misinformed perception and hysteria when traveling in a group.

Ed Rensimer, MD

Director, International Medicine Center

COVID Update No.19: Where Are We? – Somewhere Between Hysteria and ENDemic

1/8/2022

On December 16, 2021, President Joe Biden, attempting to goad Americans into COVID vaccination, said, “For the unvaccinated, we are looking at a winter of severe illness and death, for themselves, their family, and the hospital they’ll soon overwhelm.” This guilt-trip message was inflicted on the citizenry one month after the COVID-19 Omicron variant emerged in South Africa, with many, many infected, but not one death. History will see this as one of the most astonishingly shameless misinformational and disinformational messages on public policy ever rendered by a Chief Executive. Why get political? Because this pandemic has been exploited and manipulated by agenda-driven propaganda such that no ordinary person can possibly make sound, personal medical decisions. What is the truth? What is the science? Who can be trusted? When a “crisis” is manufactured and sustained at stake are jobs, careers, educations, financial health, and personal relationships. Even our communities, our economy, ultimately our national security. Lives are put at risk.

                I will not dig deeply into statistics and numbers. You can retrieve that from numerous reliable, unconflicted sources on the Internet. Instead, I consider these “Updates” as “Op-Ed” – type essays, offering analysis of biomedical and political (which I did not create) context, hoping the reader can be brought to rationally start thinking beyond the “messaging” of media and “leaders” to calm down and to make reasonable personal medical decisions. To date, the messaging to the American public has been misinformed, hysterical, virtue-signal bullying, and fear-mongering. It has led to autocratic tyranny (lockdowns, mask-mandates, school shutdowns, possible required vaccine passports) and societal dissension and disunity. Any wonder why there is confusion and anger? That, by the way was the point, along with a new norm for Americans’ relinquishment of constitutional rights. Let’s get to the medical.

                This pandemic is going exactly according to Nature’s plan (see COVID Update No. 17). This virus is evolving according to precedent of other pandemics. They are all the same- except this one has the compression of time and mega-amplification of messaging and information (as well as its corruption) by the Internet. And the speed of mutant virus emergence and spread across societies is magnified and time compressed with global travel now normative.

                Pandemics always wind down after the emergence of the “novel” origin virus in 3 or 4 resurgent infection waves by variants/mutants of the novel virus (see 1918 Spanish Flu). Gradually herd immunity is established to flatten the incidence curves of new cases and the spin-off virus variants become more adapted to the human host (to not kill it, and so not be a suicide virus… life is “pro-life”, by nature). Variants are Nature in action- Darwinian evolution.

                So, is there a reason for panic or fear when we have understanding? Maybe, for those who misinform us for a purpose.

                What is the truth about Omicron at this point in time?

1. Omicron is everywhere. It cannot be stopped; none of the viruses could. It will spread until the herd is immunized by vaccine, or by infection (virus as vaccine) and/or a more favorable to humans virus variant emerges from it. Eventually, it will compatibly become part of the human condition, like seasonal flu.
2. Omicron is not nearly as dangerous as novel SARs-CoV-2 virus (COVID-19) or Delta variant,
   • 7 x less hospitalizations
   • Has not overwhelmed UK or S. African healthcare systems
   • 75% less admissions to ICU of hospitalized patients
   • 5X fewer patients have ended up on ventilators
   • Deaths only 25% of totals of prior COVID pandemic viruses
   • Hospital admission in S. Africa peaked and rapidly declined in 33 days.
   • Omicron virulence (abilty to cause serious physical damage and life-threathening illness) is likely much less than the prior viruses- so far, most illnesses are like a moderately severe “head cold”. Omicron does not attack lung tissue like the prior COVID viruses.
   • High degree of transmissability does not translate into serious illness risk or death- only faster timeline to herd immunity, and so likely end of the pandemic. A good thing.
   • Only 1/3 of hospitalizations with Omicron in S. Africa were due to Omicron. 2/3 were people with a positive test for the virus (a carrier), but admitted for another unrelated medical problem.
   • Omicron hospitalized patients: 18% on oxygen compared to 74%, prior; median stay = 3 days compared to 8 days, prior; death rate 2.7% compared to 29%, prior.
   • N-95 masks are the only type of benefit; surgical cloth masks are worthless.
3. Omicron’s exponential transmissibility and dramatic decrease in virulence should lead to rapid herd immunity and be the soft-landing end of the pandemic in the next 2 months. This variant should be the solution.

So, are people dying? Of course, every minute, every day- from car wrecks, eating out (foodborne illnesses), in-the-home accidents, alcohol/drugs, suicides. Dying is part of living. And, living in a community or society puts you at risk for violent crime death, vehicular death, and communicable disease death. There is no risk-free environment (no deaths is a goal, but not an achievable standard). Those who assert any COVID deaths are unacceptable tragedies should be in favor of no social schooling, no motor vehicles, no alcohol, no eating out. An irrational position. If 10 people are infected with a COVID virus, there will probably be no deaths. If 10 million people are infected, thousands will die. Just as we have 25,000-65,000 deaths every year from regular, seasonal influenza. Nevertheless, regarding flu, we do not close schools. We do not close businesses or mandate vaccination of employees. We do not mandate masks. With the Omicron reading more like flu, why the hysteria over testing, mask mandates, and mandatory vaccination? You must ask yourself. To be sure, the “COVID deaths” totals are high- over 800,000. But, it is a certainty these numbers are inflated, probably significantly,

1. The nasal PCR test is not a culture. It detects only viral RNA (chromosomal material)- which may only be remnants of prior infectious whole virus. So, a person could be hospitalized in respiratory failure due to their heart or lung condition and have a positive COVID swab (done on all admitted to the hospital so as to isolate from other patients if positive, as appropriate), then die. They very well be termed a COVID death by the hospital- employed hospitalist physician. Hospitals have been incentivized by the government to handle COVID cases- pay 120% of the Medicare rates at a rapid rate (30 days). Not a bad business.

Additionally, many of the death totals occurred with the novel, original COVID-19 in the first 8-12 months of the pandemic when we were ignorant on high-risk groups and containment measures, had shortages of personal protective equipment (recall Dr. Anthony Fauci early on telling us masks were not helpful), and no proven treatment weapons or case management expertise. Furthermore, over 800,000 is a big number. But, we are about 330 million. The Spanish Flu killed about 675,000 out of about 108 million Americans, at a time when viral testing technology did not exist- so probably a substantial under-count. The point is not to demean or diminish the loss of over 800,000 Americans, rather to emphasize the questionable or shaky foundation of such statistics, clearly the basis for public panic and hysteria, and submission. The media makes its money by hype.

Can we come to some conclusions on current pandemic reality?

• Vaccines: The vaccines have proven safe, at least in the near-term. Several years more are needed to appreciate any longterm ill-effects, which are unlikely.

Early in the pandemic, with a deadlier virus, few or no reliable treatments for illness, and ignorance on high-risk (for death) patient groups, and transmissibility, vaccination and short-term lockdowns made sense to slow virus spread and so to match the volume of illness to existing medical professional staffing and hospital beds/ventilators. The idea was to avoid tragic rationing of care and resources as occurred in Italy and other places, condemning some to death.

Does that make as much sense now as so many have been vaccinated (by the vaccine or the virus as vaccine) and Omicron appears to be mostly more like historical natural coronavirus infections (not a bioengineered novel bioterrorist weapon)- a head cold? It is really hard to assert medical necessity (the standard of care) for vaccination now with available COVID illness treatments over 90% effective and so few hospitalizations, except for those with serious immune deficiency or pre-existing medical conditions- certainly not for healthy young people under 20 yrs.-old. I see no justification for vaccination of any healthy young person. The same goes for vaccine boosters. Taking the vaccine is NOT an action to guarantee not acquiring or spreading the virus, both of which can occur in the vaccinated. So, not being vaccinated is not a contemptable negligence toward the community, as some have vehemently charged.

• Mask Mandates: Again, given the context of where we are in the pandemic, the nature of Omicron (now 65-75% of U.S. COVID viruses), the almost certainty of over 85% herd immunity, the availability of very effective treatments to prevent progression to serious illness, routine mask wearing seems to be an exercise in public health threater. Certainly, masks would be appropriate in closed ventilated spaces on anyone with respiratory symptoms or when in sustained, close contact with others at risk for serious illness. There may be other circumstances where masks make sense, but, in general, they do not.
• Testing: This should be reserved for,
  • those with COVID-type symptoms.
  • those with close contact with the public, such as first-responders, medical professionals, and caregivers of the elderly.

The virus is everywhere, and almost certainly everyone will get it. It cannot be stopped, or its further variants. It will be minimalized when most of humanity has some immunity.

                Currently, anyone with a positive test is being called a “COVID case,” dramatically inflating pandemic numbers and alarm. This is wrong. Asymptomatic test positives should be called that and not tallied in the numbers of COVID toll on society. It only adds to hysteria, as seen by the long lines of people lining up for tests they have come to believe they need. They can be negative that moment, and have the virus 2 hours later. Futile!

• Lockdowns: There is no justification for this, especially regarding schools. However, it appears that teachers’ union officials are now interpreting “the science” and crafting public health policy, with no expertise or authority to do so.

Children have not been a significant source of adult infections in schools, even with the original COVID virus. Teachers have mostly acquired COVID infection outside the classroom. Certainly, high-risk, older teachers can be vaccinated and excused from in-school work if COVID incidence rises. But, the harm done to children from prolonged school shut-downs makes it medically imperative the schools remain open in their best interests.

Lockdowns have not prevented (perhaps slowed) virus spread anywhere in the world.

                If you’ve gotten this far in this essay, there are compelling questions that arise from the facts as stated here and the picture painted by the media and political leadership. These questions (and the logical answers, which I will leave to you) are inescapable and are at the heart of the confusion, anger, disunity, and mistrust we are all experiencing.

1. Why, from the beginning of this pandemic, has there been a disinclination, a virtual black-out, to discuss the possibility the Chinese were doing bioterrorism work on coronaviruses and, once escaped from the lab, China failed to disclose all its information on its “gained function” novel virus to help minimize illness, death, and societal disruption worldwide? Total obstruction.
2. Does political leadership believe what it says, its “messaging”? How, when they shut down religious services, hospital visitation to the dying, small businesses, sports events, etc., yet excuse and support mass super-spreader events events such as the George Floyd demonstrations, allow open-border invasion by COVID infected illegal immigrants (and disseminating them around the U.S.), and are themselves caught without masks at restaurants, weddings, private parties, etc?
3. Why is there anything “political” at all in what should be entirely a public health crisis and event, with public health officials giving the straight science to the public and unequivocal policies, uninfluenced by their paid government positions and elected politicians who have no expertise in this?
4. Why has all the emphasis been on vaccines and boosters, and authoritarian controls like lockdowns and mask mandates? All this when we now close in on to two years experience at failure to stop viral spread. Why has there not been a priority to reassure the American public with information on very effective treatments for the viruses, such as monoclonal antibody infusions, fluvoxamine, Paxlovid? At the very least, the hysteria and fear would be dampened- a great public service to the people. Yet, virtual silence by the media and political leadership.
5. Why has there been next to no explanation to the public that natural immunity in a large segment of the population is the best possible protection, far better than a vaccine?
6. How much has the government paid the vaccine producers? The corollary to this question is how much lobbying and other politically-directed dollars are going to Washington from Pfizer, Moderna, and other vaccine producers? A study of this is top priority.
7. For the vast majority of Americans under 65 yrs-old who are in good health, Omicron poses near no risk of death or serious illness. And, we, again do have effective treatments.

So,

• Why is this still being treated as a public health crisis?
• Why are people with no symptoms being tested?
• Why are healthy children being vaccinated (with virtually no risk of serious illness)?
• Why is not the solid protective effect of natural immunity after earlier COVID infection not being reasonably emphasized?

ANSWERS:

• Continuing the “crisis” continues conditioning the public to a new norm of elected leaders controlling their behavior and restricting constitutional rights.
• The crisis continues battering the middle-class and pushing them to financial desperation, inclined toward socialism.
• This crisis will justify continued laxity in election voting rules and so opportunities for cheating (voting by mail-in ballots) heading into 2022 elections.
• The crisis sustains the money laundering from the U.S. Treasury’s tax payer dollars to Big Pharma companies and hospital corporations and to teachers’ unions and back to Washington politicians. Pandemic is Big Business. Free vaccines. Free monoclonal antibody. Free boosters. Free COVID tests. Free from the U.S. Treasury. Redistribution of wealth… mainly from the working U.S. middle-class.
• Authoritarianism: People love to exert power over other people. Certainly, when we live communally, we have an obligation to agree to and abide by rules (laws), such as responding to traffic lights and stop signs. But, at what point are policies and regulations not based on sound information and the best interests of the community, as well as the rights of the individual, the basis of the American model? This question should be weighed by every official creating a policy and by the community upon which it is imposed. Does it make sense? Is it in the best interests of the community and its individuals? Does it infringe on rights and is that justifiable? Is that infringement temporary or permanent and, if the latter, is it a dangerous, unacceptable change in what we choose America to be? At what point is a policy an abuse of power and authority and a greater peril than the problem the policy addresses? We do not expect our leaders to be perfect, but we do expect two thing of them. That they work in our best interests, even at their own expense (rather than holding onto their office and power). And we expect them to exercise wisdom. Wisdom resides in decisions and actions that are PROPROTIONATE to the risk of the problem being considered. Whether the decision-making is political, social, economic, military, medical or even personal, wisdom is the best action based on risk/benefit. Considering the current facts of the pandemic and all that led up to this point, no one could rightfully assert that the call to vaccinate healthy children or to keep them out of school is wise. This is just one of many examples of how our leaders (including teachers) have failed at their jobs and their duty, in fact undermined our best interests.

These questions are sublimely and overtly working in all of us as we see inconsistencies in word and action from authorities, many of whom have no credible expertise in what they are doing.

Let me give an example from my world. As you enter a hospital or medical facility the past months, you are asked questions and often had your temperature taken. So, a great number of COVID infected have minimal or no symptoms and only a brief temperature eleveation that does not even bring them to use a thermometer. Additionally, COVID infected are shedding high amounts of virus up to 24H before symptom onset and can be shedding virus out to 3 weeks or more after illness onset. Does stopping people at the hospital entry achieve anything other than “medical theater”? I have asked the staff doing the screening how many fevers they detected that day? None. How about that week? None. How about at all? None. Why? Well, who goes to a hospital to visit the ill if they feel ill? And, even the most serious, life-threatening infections only cause intermittent, not sustained, fevers several times a day.

So, the chances a screener will catch a COVID infected person and stop them from entering is virtually zero. Yet, the virtue- signaling hospital administration is doing something– a show for the public. Is every hospital worker in close contact with seriously ill patients screened with a COVID test as a requirement to enter the workplace every shift? Hospitals could. But the rapid tests (which would be the only way to do it) have a high rate of false negatives (especially with no symptoms). The nurse with two young kids at home with runny noses (which they often have) picks up the virus and brings it in-house, at the hospital. Yet, the public is stopped at the doorway as though that achieves anything, biologically.

What is the extreme result of authoritarian action? Recall all those who were not allowed, by policy, to be by the bedside of and hold the hand of a loved one dying on a ventilator– saying goodbye by iPad or Facetime. Why not give them a medical legal waiver to release the hospital from liability and then allow them to be there, gowned and shielded, at a life critical moment for them and their loved one, rather than passing away among strangers?

This is when authority and policy is at its worst. Irrational. Thoughtless. Ill considered. Ineffective. Dangerous.

Yes, authorities are in difficult positions. But, they are supposed to be leaders. They are supposed to balance the interests of the community and the individual. Sometimes there are no good answers. But, people will respond to truth, candor, credible facts, communication, and explanation of a suboptimal situation. This has not been happening. Our Leaders have not acted as leaders. They have resorted to authoritarian imposition, choosing to rule rather than fulfilling their obligation to serve. Choosing, rather than to rule. They have spoken down to the people, rather than working with them and the medical profession. Our leaders have been long on “theater” and short on wisdom and service. The bureaucracies of government, public health officials, and corporate medicine, and somewhat corporate big businesses have run the show. And, the people are either enraged or beat-down and submissive. Hopefully, we have all learned from this and will call leadership on it– hold them accountable and take our lives and country back.

• Since pandemics have always behaved as this one has, why has the current Administration not anticipated the current variant virus and been prepared with adequate testing and monoclonal antibody treatments, arguably the most effective treatments?

Everything is about state control of behavior: imposing vaccines, masks, and lockdowns through coercion and fear-mongering, rather than a balanced approach concentrating public health policy and medical efforts on those only at high-risk, with equal focus on safe-guarding individual rights and the viability of the economy and American society. The country is more important than any individual or group of individuals.

• Why did the President insist everyone should get a vaccine booster in August, 2021, saying it would be available in late September? He was not pushing this medical recommendation based on science, since his own FDA leadership contradicted him 2 weeks later saying that boosters for everyone was not a policy based on scientific evidence. Why, then, would the President assert this? Who was he serving with this inexpert, incorrect proclamation? Think about it. Vaccines and boosters are his mission, regardless of scientific evidence, not treatments. It is important to recall that Pfizer refused to announce the availability of its COVID vaccine (produced at unprecedented speed through President Trump’s Operation Warp Speed Project) until 1 week after the presidential election. Payback time. President Trump had stated the summer before the election that a priority in his second term would be reforms on pricing of drugs by Big Pharma and what Medicare would pay for them.
• Are public health institutions and their leaders unconflicted, trustworthy, and credible? Do they speak for the medical profession? No and no. As a clear example, a few days ago the CDC issued a policy on quarantine and post-illness testing for an Omicron illness. 10 days. That’s it. Then, within a couple days, the CDC revised its position to 5 days. Its director, Dr. Rochelle Walensky, stated that revision after an apparent outcry from the U.S. business community. Further, others outside the CDC (our highest medical authority) raised alarm that retesting for Omicron toward the end of quarantine to decrease the chance that the victim was still a contagion risk to others was needed. So, CDC then said you could get a test after 5 days… or not… up to the patient. Further, CDC admitted some people might have positive tests substantially past 5 days… but that might not indicate whole, infectious virus. And, CDC recommended rapid (home) antigen tests — known to have a high false negative rate. In other words, unreliable to establish infection-free.  Are you now reassured that you have been given solid, evidence-based, reliable advice from the experts supported by your taxes? Note, there had been no new scientific information that triggered these rapidly changing recommendations with serious flaws in assuring people are not infection risks. This was a transparently pressured political response… typical over the entire pandemic.

The medical profession that actually practices medicine has long distanced itself from these doctor bureaucrats who are on government payroll and so under enormous pressure from political leadership. They are not physicians. They are politicians. Furthermore, realize that editors of prominent medical journals, leadership of academic medical institutions, and leaders of organized medicine (the American Medical Association) have strong ties to federal political leaders and are clearly taking their political agendas into account in their positions on the pandemic. Many of them direct training programs and research activities that are heavily dependent on federal grants and subsidies to stay in business. A title is no guarantee of credible information or advice. This is the where and why of constantly changing positions, contradictions, and hypocrisy. Be alert.

The American public needs to think about these questions and to pay attention to what is science and what is propaganda (messaging for a political agenda) – always consider any financial conflicts of interest of the messenger. Otherwise, there is no way to make sound, personal decisions on testing, vaccination, or boosters. You have been told to talk with your personal physician. He or she will not know because they cannot be expert on all these issues of an unfamiliar, rare medical phenomenon; evolving, complex science; and corrupt political manipulation of everything. Re-read President Biden’s quote that opened this essay and juxtapose that to the facts that followed.

Consider reading some of the my prior “Updates” to round out your intellectual approach to sorting out your proper understanding and stance.

Take Aways

1. Healthy individuals under 20 yrs-old should not be vaccinated.
2. Consider getting a blood test for SARs-CoV-2 IgG antibody to see if you have been infected (even if never ill) to decide if you are immune, even without vaccine. A significant percentage of SARs-CoV-2 and variant virus cases have had minimal to no symptoms and many never reported to a physician or were tested; more so with the young and with Omicron. Natural immunity is rock solid and probably durable for years, if not for life–with no need for a vaccine or booster. The only exception will be if a virus which is highly divergent structurally (from the original, novel virus) emerges, which has not yet happened and is unlikely.
3. Do not get tested for the virus unless you have COVID-type symptoms or have been in close contact recently with a confirmed COVID illness. Tests should be rationed and saved for those who truly need them.
4. Do not fear airline travel. Airline cabin air is entirely filtered every 2-3 minutes for infectious agents–among the safest places to be vis-a’-vis respiratory infection. And, masks are mandated.
5. Whether vaccination is medically necessary with a very diminished danger from Omicron variant is highly debatable and should be a decision made after discussion with a medical expert. Vaccinations are only clearly medically necessary for those at high-risk for serious illness. A blood test for SARs-CoV-2 antibody may help with the decision to take the vaccine or not, especially as the pandemic winds down.
6. Schools should stay open.
7. If you have COVID positive illness, discuss treatment (or none) options with an expert,
   • Monoclonal antibody
   • Fluvoxamine
   • Paxlovid
   • Remdesivir
   • Steroids
8. With Omicron illness, you can retest for the 5 days after symptoms onset if no fever x 24H and other symptoms improving. A nasal PCR test is the most reliable. Rapid home tests give reliable (true) positives, but are not reliable when negative. The PCR test (done twice in 24H) should be used to consider yourself not a contagion risk.
9. Individuals are most infectious 24H prior to and 36H post symptom onset.
10. There are no containment measures that will stop spread of these viruses on a large scale. Preventive measures should be directed at high-risk groups, and the broader public informed on effective treatment options and the need to start them early on in illness.
11. Masks are for those ill with respiratory symptoms and those at high-risk for serious disease and for their care-givers.
12. Most children have no or minimal symptoms with COVID infection, likely more so with Omicron. Before subjecting a child to vaccination (which is not medically justifiable unless the child is at high-risk for serious illness due to pre-existing conditions), it would be advisable to do a blood test for SARs-CoV-2 IgG antibody to see if they already have natural immunity from prior, unrecognized infection.
13. Vaccine does NOT prevent acquiring, carrying, and spreading the virus, more so with variants like Omicron.
14. Mission Objective: Minimal medical losses while preserving the economic and societal health and spirit of the nation by,
    • Vaccination only of those at high-risk (for serious illness) and essential workers/medical professionals (with their approval) and caregivers of the elderly.
    • No lockdowns, including schools.
    • Focus on COVID TREATMENT supplies, and access and aggressive application.
    • Testing only of those with COVID-like symptoms and those with high-risk exposures.
    • Direct resources like testing and vaccines away from those under 20 yrs-old and toward those at COVID high-risk.
    • Teachers who refuse to attend work without a specific COVID medical waiver by a physician should not be paid, and likely terminated.
    • Unrestricted return to normal life across the society for low-risk individuals.
15. Omicron will spread universally and give humanity the most effective immunity.

These are personal, professional perspectives and opinions of an Infectious Diseases Specialist of 40 years practice experience with special expertise in pandemics. However, none of this should be construed as specific medical advice or recommendations for any individual. Review this information, as appropriate, with your personal, treating physician in arriving in what is right for you and your family.

Edward R. Rensimer, MD

Infectious Diseases

Director, International Medicine Center

Houston, TX

COVID-19 Update No. 18: Delta Variant- The Truth, The Whole Truth, and Nothing But…

7/22/2021

So, now we are being told by Administration political leadership as well as the mainstream media there is a “surge” afoot of the Delta-variant COVID-19. The number of infections are rising, and there are hospitalizations and deaths. The COVID-19 vaccine is considered the answer and the president proclaimed that any anyone who did not submit to the vaccine is “killing people”. Pretty presidential, huh? Is he going to say that about influenza vaccine since it decreases flu infections and 20,000- 65,000 die yearly from flu, including children?

Yes, the Administration, its Surgeon General, and media commentators are accusing those who are not whole-hearted vaccine advocates of “misinformation”. How dare they! I will refrain from a political essay on their numerous and regular “misinformation” on just about every topic of the day, but instead speak within my expertise.

As you know by now (from prior COVID-19 Updates), I am a specialist in Infectious Diseases, with a particularly developed aptitude in pandemics. If you re-read some of those earlier updates, I think you will see I was very much on target about how this might and did play out, as far back as March, 2019.

The other comment to set up the context of this essay is that I am a committed Darwinist. The Theory of Evolution has no serious arguments against it. In a sentence, it holds that life is about more life, and the fittest survive. Those simple ideas tell you all you need to know about infectious agents, pandemics in general, and the truth of where we are (not what we are being told).

I wrote extensively about mutants and variant viruses on 2/5/2021 in “COVID-19 Update 17: Mutants! A Problem? No… The Solution”. Life forms replicate imperfectly, throwing off variants of the original version (in humans, we call them birth defects). Over incomprehensible periods of time (many thousands of years), such variants allow a species better chance of survival in case the environment into which it is born is changing in a direction that will not allow the original live form to thrive. “Variants” provide species variety so they are not at an evolutionary dead end, rigidly fit only for the current environment. So, the variant then becomes the new “original”, or dominant strain, best suited to the evolving environment. In the case of COVID-19, “the environment” is its human host.

So, with millions and millions of passages through human hosts, each individual infection accounts for millions of viral replications in each human host. Many variants result, many or most of which are too defective for continued survival; and so the variant is a dead-end and dies off. However, if  a variant has advantageous  characteristics for enhanced survival, compared to the parental strain, it will replicate with vigor to become the new, fittest strain. What would that look like? Exactly what we are seeing all around us and which I predicted months ago in “COVID-19 Update No.17”. The Delta strain is much more transmissible, human-to-human, than parent COVID-19 (SARS-CoV-2 virus). That’s good for the virus, right? Mother Nature at work. And, though it is not yet concluded by studies, the Delta variant is likely less virulent (ability to cause serious illness or death) than the parent. That’s good for the virus and for us. After all, a virus that kill its host is a kamikaze virus, a suicide virus… does not live to see another day. Charles Darwin would say that’s against Nature, unnatural. Remember, life is about more life… or over these past billions of years there would be no life on earth. Remember the 1918 Spanish Flu virus that killed 675,000 Americans and 20-100 million worldwide? Did it keep on going as a scourge of humanity… to end the human race? No. Thankfully, Darwin was right and it mutated to evolve to coexist with its human hosts, and to become just another seasonal flu virus.

Finally, the more variant infections, the more herd immunity– the virus becomes a vaccine.

Good news, wouldn’t you think? We’re out of the woods. Bring on the messages of optimism! The vast majority of COVID-19 deaths having occurred in the first months of the pandemic when we had little reliable information on the Wuhan virus (thank you, China) and had not yet learned who were at most risk for death (to quarantine), had not developed methods and medications for managing the seriously ill, and did not have the Trump vaccine. The virus was novel to humans, and that cost lives. It always will. Now, the virus is no longer novel. But, you wouldn’t think so to hear the alarm, hyperbole, and dire comments on the news and from the Administration. There are increasing numbers of cases– of course there are, as this Delta strain is a somewhat, but not completely, new virus. There are some deaths from the virus. Of course there are, there always will be. With our next flu season will we have such alarmist alerts because people are dying from flu? If there were not one more COVID-19 variant infection, there would not be one more death. Living in fear of COVID because of increased transmission of Delta Strain (with herd immunity now 72-94%; see below) is like deciding not to drive because there is traffic on the highways. When did you do that?

Oh, I forgot. Our standard now is, “One more death is one death too many.” So, guess none of us are driving tomorrow, since 9 people are killed every day in vehicles around Texas, and similarly around the U.S. about 4,000 children die annually in motor vehicle accidents. No more alcohol. No more eating out. Cannot have one more death. Mask everybody and do the lockdowns again– wreck the country and countless lives so we have not one more COVID death. I suppose our leaders require a risk-free life, or everyone stay at home. Irrational and ridiculous.

You know, we heard from “leaders” over and over that we must “follow the science”. That is, until the science and the facts got in the way of political agendas and their exercise of power and so our public health expert officials on the government payroll had to give their adjusted “expert” opinions; more opinions than science. Have you noticed the continual moving of the goal posts during the Pandemic Game?

Oh, but they’re experts and the public are illiterate sheep that will just follow anything they say.

Well, at the risk of losing some of you, we need to do some math, to get to the truth, but first a couple factual premises.

1. COVID-19 deaths in those under 20 yrs-old are virtually non-existent; in all Western countries, such deaths have been rare. 93% of the deaths are in those 55yrs or older. In the U.S., so far, deaths in those 25 yrs or younger = 0.001% of COVID deaths.
2. Most children with COVID-19 have little or no symptoms.
3. Children barely transmit SARS-CoV-2 to adults; they have mild if any symptoms; so, meager tissue inflammation and viral particle shedding.
4. Most of those who are unvaccinated are people at low-risk for serious disease or death, as the limited supplies of vaccine in its first months were given to “essential” workers and high-risk, mostly very elderly people. And, early in the pandemic, the virus claimed the lives of the weakest of the human herd.
5. There are 400 deaths in U.S. children under 19 yrs-old from COVID-19 over a 17-month pandemic period. 188 children died from flu during the 2019-2020 season (only 7 months), and that is probably an under-count, per the CDC.
6. COVID—19 Death Statistics and Reality: It has been a point of professional discussion that having a positive SARS-CoV-2 test and then dying are not necessarily cause-and-effect linkages. With such a high proportion of COVID-19 cases being asymptomatic, many “COVID deaths” may have been deaths from other causes with coincidental colonization with the virus. It is a fact that early on in the pandemic the federal government was expediting payments and at significantly higher dollar amounts than usual for hospital-based services for pneumonia and respiratory failure to incentivize taking on the risk of COVID-19 cases. COVID-19 was a cash-cow for hospitals and, with many physicians now hospital-employed and subject to employer pressure, it has been documented that cases were termed COVID-19 deaths when that was not the case. Many hospitals likely gamed this. Why mention it? Did 400 children die from COVID, or just some? Time for the well-known quote “There are three kinds of lies: lies, damned lies, and statistics”. Finally, a positive COVID test does not necessarily even indicate viable (infectious) virus- the test may be positive with just remnants of viral RNA from the prior complete virus; and such positive tests can persist weeks after infection has resolved. So, you have a heart attack and die in the hospital ER, but have a positive COVID test (as all patients presenting to a hospital are now screened with these tests)… just a sleep-walk for the paperwork to conclude “COVID  death”.

If all of the above are true (and they are), why are we vaccinating normal kids and adamant that no one can remain unvaccinated? I am a big proponent of the vaccine for those at high-risk for serious illness and death, and any other adult who elects to take it, especially when the original strain was surging (most of 2020). There have been only 5,200 “breakthrough” infections in the U.S. who required hospitalization in those who had been vaccinated, with over 181 million vaccinees. So, efficacy is not in question. But, this is an FDA Emergency Use Authorization (“EUA”) vaccine, meaning it is still “experimental”. Should we be advocating it in people fitting the above premises when there has not been time to evaluate effects on those still growing and who will be childbearing in the future? Does the risk of the virus to children and the minimal risk of children as vectors of disease to adults justify exposing them to an EUA treatment? Seems all risk and questionable benefit. Shouldn’t we give more time to quantify vaccine-related myocarditis (heart inflammation), possible tendency to blood-clotting problems, and possible vaccine-associated autoimmune trigger reactions before promoting vaccination of children? The exceptions? Children with serious, underlying medical conditions putting them at COVID-19 high-risk for serious illness or death, and kids obligatorily living with adults who are in high-risk groups and unvaccinated.

All of this, of course, is contrary to the school teachers’ unions using COVID-19 as leverage for more full-pay time-off and “working” from home. This despite solid studies showing hardly any transmission of SARS-CoV-2 from students to teachers. Only 25% of teachers qualify as COVID-19 high-risk, for whom special accommodations might be justifiable. However, data show teachers get SARS-CoV-2 from other teachers. The hot bed for virus infection is in their homes! The safest place for them, based on the science, is in the classroom. Why this seeming digression? It is not. It is a black and white example of how this pandemic was used by manipulative operatives to pervert a public health crisis into personal power and financial gain by a messages of disinformation and misinformation, not the science. Propaganda, pure and simple. This is all perfectly relevant to what we are being told by media and Administration operatives about Delta variant. They want this to keep going as their grip on power tightens and permanent societal changes loom. I know many teachers who are professionals and appalled at not being able to practice their profession in the best interests of their students—held captive by their union and some opportunists in their ranks.

Now, to the math.  The statistics are about up-to-date and, though changing daily, the trends are valid.

COVID-19 (U.S.)

1. 33 Million Confirmed Cases (positive tests)
2. 607,000 Deaths (243/100,000)
3. 40% (conservative estimate) of COVID-19 Infections= No symptoms
4. Take #1 and #3= 55 Million Total Infections
5. 181 Million= Vaccinated (by 7/4/21, 55% over 12 yrs-old had been vaccinated).

So, we can conclude,

1. With a U.S. Population of 332 Million, If those vaccinated + infected (naturally immune) = 238 Million, then we have 72% “Herd Immunity”.
2. If you subtract those under 20 yrs-old (80 million) out of the above numbers (since near no risk of death or serious infection and extremely low risk to pass SARS-CoV-2 virus to adults), then Herd Immunity= 94%.

As we were told we must “follow the science” (to not listen to President Trump, who was characterized as “anti-science”), Dr. Anthony Fauci, National Institutes of Health Director, said our goal was 70-80% herd immunity to indicate we had turned the pandemic corner, and then masks and other restrictions would largely no longer be needed. Did you notice they are no longer talking about herd immunity now that we’ve achieved it… moving the target and the goal posts, to keep “the crisis” ongoing and the public subjugated? Of course, anyone watching has seen that Dr. Fauci’s flip-flops are a pattern of behavior. He has the highest paycheck in the federal government to protect. Now, although our above figures and facts, which are “the science”, say we are well past Dr. Fauci’s originally stated goal, Governor Gavin Newsome (D), California, is re-imposing indoor mask mandates regardless of vaccination status with no substantial surge in COVID-19 deaths or ICU admissions, the key indicators of concern. Did anyone tell this guy the CDC said 2 months ago that masks are not needed once vaccinated? So, even the great protection of the vaccine does not alleviate their wanton exercise of power. Never ends, does it? Not if they can help it. They will have their way. COVID has been just too good an opportunity to change election rules, crush the middle-class, payback the teachers’ unions and other supporters, and accustom the American people to ceding their constitutional rights and power to politicians… all the while seeding the conditions for socialism. And, stay tuned to this channel regarding whether booster vaccinations will be needed. Remember, Pfizer withheld information that President Trump had succeeded at driving what was a miraculous, unprecedented delivery of a safe, effective vaccine to the American people in historically record time, by several hundred percent; withheld that information in the last week of the presidential campaign until after the vote. They did not need him getting credit for the single thing that can be said to have saved tens to hundreds of thousands of American lives and the American economy. Sweep him aside and have Biden try to make it his vaccine. Pfizer and Moderna are making many billions on this, so I am counting on the “need” for a booster, as payback to Big Pharma for helping deliver the White House. You ask yourself, “At this point, given all the facts, what is pushing this insistence on universal vaccination?” And, in the near future, booster recommendations? Big Pharma payback? Admittedly, I am a bit cynical.

By the way, where is President Trump’s Nobel Prize in medicine? Yes, a bit of political commentary here, but excuse my outrage at the perversion of science and human misery for political gains, since our profession has been entirely mute on these matters.

So, how bad has COVID been, comparatively?

If you take the 55 million U.S. infections with 608,000 deaths (243/100,000 population), the death rate= 0.24%, or 2.4/ 1,000. And, it is probably lower since population-wide testing has not been done to see if tens of thousands more were infected as symptom-free COVID-19 carriers, without disease (which some have estimated as possibly 6-8 per each test- confirmed case). If that is so, the number on true death rate and peril from the virus drops dramatically. For reference, seasonal flu has about 0.15% death rate. So, they may be about equal. Well, then why 608,000 deaths? That’s serious, right? Way past 20,000-65,000 annual flu deaths. Explanation is these pandemic numbers stretch over 17 months, versus the usual 7-month flu season. Secondly, this was a novel virus with likely many millions more infections than actual illness; and so, many more total COVID-19 cases than seasonal flu since many people have some immunity from prior flu season infections and vaccinations aborting many flu infections, while there is no historical immunity with the novel SARS-CoV-2 virus. In other words, total numbers of COVID-19 infections is probably much higher than our statistics and it is much less dangerous than being hyped.

Finally, compare COVID-19 to 1918 Spanish Flu. There is no way to achieve a completely reliable death rate for the 1918 virus since testing and epidemiological expertise was not set up adequately in the early 20^th century.

However,

U.S. Deaths

COVID-19 608,000

1918 Spanish Flu 675,000

Total U.S. Population

During COVID-19: 332 Million

During 1918 Spanish Flu: 104 Million

        No comparison. Yes, 608,000 deaths is 608,000 deaths, plus many thousands with serious complications and damage who survived. But, with most of those COVID deaths occurring in those over 55 yrs-old (93%), and the very most in those near or beyond their natural life expectancy of about 80 yrs. (60% of total COVID deaths), the draconian state-level lockdowns can never be justified beyond 1-2 months, March-April, 2019. Many thousands of lives were saved by the prior Administration fast-tracking of vaccines, medications, and monoclonal antibody treatments, in addition to creation of hospital beds, exponential manufacture of ventilators (previously unthinkable), and extraordinary increase in personal protective equipment (PPE) under Operation Warp Speed. However, countless businesses, careers, marriages, and lives were seriously damaged or ruined by the prolonged lockdowns. Looking at the science and the objective medical facts, public health officials and political leaders behind the long lockdowns should be fired or impeached.

If you haven’t figured it out by now, the strident demands that all remaining unvaccinated adults, regardless of age or medical conditions, be immunized (or be “killers”), masking be resumed, and other isolation measures be reconsidered are not congruent with the science. Then there are the door-to-door Gestapo visits by government operatives to query citizens on vaccine status and intent. Add this to the fact that a number of “medical authorities” and public officials deemed the George Floyd mass population demonstrations during the height of novel COVID-19 activity and hospitalization and deaths of more priority than COVID-19 containment, and you get the politicization of the Pandemic Game… and now the public’s distrust and disgust of “authorities”.

The American people see the hypocrisy of allowing illegal immigrants to invade our Southern Border without COVID screens, and then transporting the people across the country, exposing America’s citizens to COVID, while stringently screening U.S. citizen travelers to assure they are COVID negative before permitting air travel in and out of the U.S. This dramatically shows the Administration’s political interests supersede the welfare of our citizens. It is all about power, not principle or jeopardy to the populace.

What is this? Irresponsible demagoguery and manipulation at best. This started as 2021, but is fast becoming “1984”. At worst, a new norm… a dangerous attempt for a new norm, a reset of our American Constitutional Model.

Know these facts, then make a personal medical decision, possibly after consulting an experienced, knowledgeable physician– your decision, not the government’s. I took the vaccine. I am 71 and in excellent health. But, as an Infectious Diseases specialist I had a duty to stand “a-post” to serve our community and to do my job. My decision was fast and intuitively obvious.

But, now with the “novel virus” pandemic waning, deliberation is the operative word, as the risk-benefit calculus of remaining unvaccinated versus getting immunized is changing by the week.

Re-read this. Contrary to the drastic mis-messaging by politicians and media, there is a lot about which to be optimistic. This is not a time for acting on impulse. Sit on these facts, after you have carefully considered your social and medical situation. Yes, Delta is on the move, but most of those still unvaccinated are not at risk for serious illness or death–those groups have largely been covered with vaccine or have passed away, unfortunately.

My take-aways,

1. Control measures, like vaccination, should be age (and so risk of serious illness) specific.
2. Kids are near no-risk for anything serious from SARS-CoV-2, and so should not be vaccinated unless with serious, relevant, pre-existing medical problems or living with others who are at high-risk and unvaccinated, until the vaccine is FDA-approved.
3. All adults should consider being vaccinated to increase herd immunity and so decrease further medical system costs, get the society up and running, and get the pandemic behind us.
4. The Delta strain, with every new infection, is vaccinating the remainder of the herd.

My guess, given that virtually all those at high-risk or COVID-19 serious illness/death have been vaccinated or infected, is that, were we to clear the board of all the statistics due to the original, novel COVID-19 virus, the Delta virus sub-epidemic would be essentially like a seasonal influenza event, except with many more mild-moderate illness cases. The need for vaccination is no more or less than for flu. Masks only make sense for those who refuse vaccination and are at high-risk.

At this phase of the winding down pandemic there is no justification for any infringement on any individual constitutional rights. We are entitled to our own medical decisions and certainly our rights. The politicians are our servants and entitled to nothing but a clear message from an informed electorate. Mandates of any kind by government for universal vaccination have no place, by the science and The Constitution. Since the virus immunizes those it infects and is so highly transmissible, the emergence of the Delta variant was the signal of the beginning of the end of the COVID-19 Pandemic.

Edward R. Rensimer, MD

Infectious Diseases

Director, International Medicine Center

Houston, TX

Traveldoc.com

Copyright, E. Rensimer, MD, 2021, All Rights Reserved

COVID-19 Update No. 17: Mutants! A Problem? No…The Solution.

2/5/2021

Just banner “Virus Mutation” on your “Breaking News Alert,” and people will stop in their tracks, sit down, and get serious. The Hollywood version of that idea is zombies roaming widely and feasting on us. “Mutation” is a harrowing word. Indeed, charged with fright.

Maybe it’s time for a biologist, particularly a medical professional biologist, to explain why mutations are ordinary, good things…yes, good; in fact, necessary for sustaining life.

Viruses are living creatures, just as birds, fish plants, humans. They have DNA or RNA genetic material in the viral package. But, as opposed to other life forms, they are obligate passengers on other life-forms—virtual parasites. They need another living thing to “host” them since they cannot live on their own—do not have the equipment to replicate.

The next point should be self-evident, but all such things get lost in the blizzard of information that comes our way and, even though once upon a time realized, it gets sublimated as we go about our lives. What is that? Life begets life as its purpose. All else is biologically superfluous, off-point. If that were not so, there would be no living thing. It would come to an end. But, it hasn’t. To the contrary, the varied life forms everywhere we go, everywhere we look, are testament to the perfecting process of the machinery of life.

Ironically, it is the imperfection of living things and their progeny that is the essence of evolution that has sustained life, starting as a single cell, then colonies of cells, then organs and tissues, then highly complex interactive systems forming a bacterium, an ant, a fish, a frog, a snake, a sparrow, a dog, a human.

Each life form replicates—makes copies of itself. That’s reproduction. But, in countless cycles and generations of reproduction, every so often an offspring results a bit different from the parent, the rate depending on the specific life form—perhaps the order of amino acids in a blood protein, biochemical pathways, the shape of brain cells, hair distribution, heart size…changes in cells, tissues, anatomy. Most immediately, we are aware of a “birth defect” rate of 3.0% in humans. They are “defects” because we desire a perfect replicant of ourselves. But, more appropriately they are birth “variants”…or mutations. Certainly, such variants may not be as biologically “fit” as would have been a perfect copy…unless such changes in the offspring adapted the newborn to that environment better than the parent. We all know environments, usually over incomprehensible time, change. More hair for cold environments, hands and feet for land instead of fins and flippers, water-sparing physiology for arid climates.

Of course, I am vastly condensing the process for the purpose of simple explanation and comprehension. But think of such mutations occurring literally on a molecular level affecting body chemistry and structure (anatomy) over millions and millions of years, and billions of such changes in a single lifeform or species.

Let’s say there were no mutations. With time we would be highly limited as life-forms to extremely narrow environments and should a random ecological cataclysm occur, such as the meteor or asteroid that struck earth and wiped out all the cold-blooded dinosaurs with the sun blocked from atmospheric debris for thousands of years, we too would perish in the new conditions. The lesson? Variety and biological diversity is the insurance policy against the end of all life, extinction. Dinosaurs, highly specialized, were an evolutionary dead-end. They were “fit” (to survive) only in the narrowest ecological circumstances. Warm-blooded mammals fortunately had appeared over millions of years preceding the dinosaurs’ exit…through mutations! Mammals were mutants on an entirely different evolutionary limb, fortunately. All of this is basic evolutionary Darwinian theory. Environment perfects living things, but imperfection saves them. Nature’s elegant design—the balance of perfection and imperfection.

What has this to do with SARs-CoV-2 virus (COVID-19 agent)? Viruses mutate. That is, sudden changes in their DNA or RNA genetic code (the sequence of nucleic acids) occur, which are then inherited by the next generation if the mutant is fit to reproduce. These are random changes. And, they, like us, can mutate or change in any number of characteristics—surface spike (attachment) proteins, transmissibility, virulence (ability to provoke immune response, and so illness, from the host). And, any given offspring may mutate in more than one characteristic at any time. In this regard, mutations are Nature’s and Evolution’s slot machine.

What are we to make of this? Concern? Fear? Panic? I choose to understand.

I started out stipulating that, though philosophers may argue that life purpose and values as much define life as just living, the point of life is…more life—clearly a biologist’s perspective. Beyond that is metaphysics. What comfort is there in that regarding this virus and this pandemic? Well, if SARs-CoV-2 needs a host to live, killing its host is against its best interests. A virus that kills its host is a suicide virus. So, even if a random mutation or set of mutations can produce an highly virulent, killer variant, it cannot be around for long. Ever hear of Ebola virus? Ever hear of a worldwide Ebola pandemic? Why? It has a kill rate of at least 50% (overall, comparatively, 1.3% for the U.S. COVID-19 virus). It gets buried with its host, which relatively quickly ends any new outbreak. Ebola continues in monkey primates where it is adapted to reside, collaboratively, not in humans.

So, this novel (to humans) SARs-CoV-2 crossed over from the animal kingdom to humans in 2019 and now, as it passages and replicates in trillions of cycles through human hosts, it will spin off mutants. Those fatal for humans will die off with those unfortunate human victims.

Eventually, the virus will arrive at a model or variety that will co-exist with the human race synergistically. Just as seasonal influenza does which, because of its high mutation rate, assumes different forms virtually every year, such that new vaccines must be configured for each winter’s new strains. Actually, Flu mutates at a rate of 4X that of SARs-CoV-2. Some victims will die from these newer versions, usually those who are existing on the medical margins with advanced age and pre-existing conditions—a “natural” death. But, humanity will not be wiped out. The encouraging point is that SARs-CoV-2 appears to be more stable (slower mutation rate), and so may allow vaccines with enduring value. And, as a matter of natural law, viruses, if they are to keep humans as hosts, will gradually diminish as a threat to life.

And, finally, yes, certain, but not all, mutations can diminish the protective effectiveness of vaccines, which are static products directed at the virus variant available at the time of vaccine production.

In sum, mutations are desirable, no, essential, phenomena of all life forms. Without them, this earth would be rock, wind, and sea, and otherwise barren. Mutations are not to be feared. Rather, understood and monitored to adjust public health policies and medical weaponry to minimize jeopardy from a rogue mutant viral strain until it passes on to oblivion. For this reason, novel virus pandemics tend to play out over 1-2 years in several waves or surges as the virus adjusts and adapts to its new hosts. Proof of this is the exit of the 1918 Spanish Influenza virus that killed 675,000 in the U.S. when the U.S. population was only about 104 million.

Mutation is a life-critical feature of Nature—for all us living things. It is life-sustaining Evolution. Be not afraid. Rather, be amazed.

Ed Rensimer, MD

Director, International Medicine Center

Traveldoc.com

Copyright, 2021, E. Rensimer, MD, All Rights Reserved

COVID-19 Update, No. 16: The Playing of the American People and The Science

12/22/2020

Yes, America is starting to get it. COVID-19 is not a hoax. Over 300,000 dead say it is not (though more discussion on that number later under “SARs-CoV-2 Virus”). The dead are not to be dismissed or dishonored. But, COVID-19 is not the bubonic plague or the 1918 Pandemic Spanish Flu. In fact, the Spanish Flu killed about 675,000 in the U.S. in 1918-1919, when our population was about 103 million. With current population of about 328 million, were SARs-CoV-2 virus as virulent as Spanish Flu, we would have 2,150,000 dead. The recent overall U.S. mortality rate is estimated at about 1.8%, but that’s calculated on cases confirmed by a positive test. What about the CDC estimate that there may be 8-10x more people infected who have not been tested since up to 80% of COVID-19 infections have no or few symptoms? That brings down the fatality rate to around that of annual, seasonal influenza. Why so many total deaths, then? Because it is everywhere. It is extraordinarily transmissible and hides in the majority of people carrying it. It is largely a stealth agent of infection.

Yet, the American public has been fed and now is increasingly angered by persistent and recurrent authoritarian (probably illegal) public health mandates by political leaders, keeping kids out of school, small businesses closed, prohibitions imposed on gatherings on private property (parties, weddings, funerals). Their decrees proclaim, “The sky is falling!” while they are caught hypocritically dining in close groups, unmasked; having hair styled, unmasked; and engaging in leisure air travel—while their rules demand the general public can do no such things. And, it becomes real personal when it’s not just recreational or leisure activity—strictures on funerals, weddings, visiting a dying loved one in their last days and hours in an ICU. This is where the hypocrisy is chilling, in fact infuriating. Important personal freedoms are torched in the name of the public good, “supported by science.” But, the average American doesn’t need to be a physician or epidemiologist to smell something bad—that inconsistent positions on masking, business lockdowns, school attendance, dining out, and travel juxtaposed to the emerging information on COVID illness and the SARs-CoV-2 virus cannot be only based on hard science. If anything, established science, if nothing else, is consistent—unless it has been perverted by propaganda, misinformation, and political agendas. Just days after the Presidential election vote, Dr. Anthony Fauci then agreed (contrary to the prior position) that children could and should attend school. The science had changed, just after Joe Biden appeared to win.

So, before proceeding further, should a physician comment on political matters? Don’t we want our doctors and other medical professionals to be unbiased and non-partisan so they can provide our care dispassionately with respect to age, sex, religion, race, personal behaviors, and political affiliation? We want them neutral. The problem is political operatives have used a public health crisis to support their political agenda, and an authority grab, co-opting a society-wide medical crisis and the “facts” around it manipulated to impose their will and ideology on the American People. Only a knowledgeable expert can weigh in on what is true and what is not. To remain silent (to maintain the “neutrality” front) would be ethically irresponsible, especially when the patient at risk is America. Physicians must offer their opinions. What? Dr. Fauci has given opinions on COVID-19 policies. The New England Journal of Medicine (arguably the most esteemed medical journal in the world) has offered editorial essays on COVID-19 pandemic and the Trump Administration’s “mishandling” of it. Likewise, the American Medical Association. So, “the profession” has commented. Surely, the American public can rely on their pronouncements and opinions. However, most of the establishment of the profession leans “Left.” Many, if not most, who work and publish in academic medicine feed off government research grants and federal revenues and tax breaks as non-profit institutions. These medical leaders live off this. Dr. Fauci is a government bureaucrat, now over 35 years. The AMA fully supported the Affordable Care Act (Obamacare) and for decades has not represented the views of most practicing physicians (the people who take care of you), such that only about 17% of U.S. physicians are members. Are these examples of the political bias of the medical establishment? Just after the George Floyd death in late May, 2020 in Minneapolis, over a thousand medical profession “leaders” signed a letter proclaiming that the mass demonstrations, though potentially SARs-CoV-2 “supers-preader” events, were justifiable since they were being conducted in the name of social injustice. The imperative to protect lives from the virus just took second-seat to a liberal priority—unproven to actually exist systemically—yet, enough of a priority (to theur political ideology and agenda) to violate the Hippocratic Oath to first do no harm and to safeguard life. Apparently, the science had changed; or, the profession chose politics over medicine.

Another example of the politicization of these medical issues for political purpose (that demands physicians speak up) was when President Trump announced his belief that under his Vaccine Warp Speed Project there would be an effective vaccine available before the end of 2020, 100% of mainstream media and their “medical experts” decried this as fantasy and lies.

The narrative they had promoted and intended to make stick was that President Trump was a congenital, science-ignorant liar, buffoon, and illegitimate president. Another outrage by him. Do not listen to his false hope and irresponsible pronouncements. Well, now that the vaccines are being administered midway through December, not one media host or expert commentator has recanted and apologized for the insults leveled at the president last May. This was a political hit-job to undermine President Trump during an election year by a partisan press. So, politicizing this pandemic has been “the game.” It is time for physicians to step forward and speak up as the most credible advocates and protectors of the public good. We have taken a solemn oath to act in the best interests of our patients, who collectively are the community and the society. Arguably, physicians are among those most trusted by the public. And, the public must hear the truth. Remember, Benjamin Rush, Lyman Hall, Josiah Bartlett, and Matthew Thornton, all physicians, were 4 of 56 signers of the Declaration of Independence.

Let’s be honest. Virtually all of the most draconian authoritarian COVID-19 policies have been in Left Wing/Progressive leadership states and cities. That’s not an ideological position. It’s a fact. And, the underlying premise is that life is precious and the American People must be protected from themselves and from each other. But, these same leaders sat idle as U.S. citizens (and police) were threatened with violence by anarchists and looters. They would not intervene in the devastating social insurrection in Minneapolis, MN; Portland, OR; New York City, NY; Chicago, IL; Washington, DC; Seattle, WA; or Kenosha, WI, over the months leading up to the election. Many of them do not stand against late-term abortion. Yet, their justification for violating and removing constitutional rights is the risk of loss of life from a public health crisis. If these “leaders” believe in what they say regarding controlling the pandemic and protecting the public, why are they not closing our borders? Hypocrisy, inconsistency and lies.

Well, it’s time to reset on the apolitical science and what that means about the reality of COVID-19 and America—not the para-reality created by political despots.

1. SARs-CoV-2 Virus:

This virus, in the first months of the outbreak, demanded serious attention because of the mounting deaths worldwide and no science to understand the nature of its threat. It is now clear that from a virulence perspective (ability to cause tissue damage, and so disease), it is closer to seasonal influenza than to more deadly agents, like Spanish Flu, especially since it is a “novel” virus (never before experienced by humankind—which explains the total deaths being a multiple of the 25,000-60,000 from flu each year). Let’s look at the most important aspects of this agent and outrbreak.

a. COVID-19 Case Labels–

You need to have a test positive for the virus; you are then a case. However, the U.S. “case totals” are near meaningless since we are not testing the hundreds of thousands out there walking around with the virus and no symptoms. How can you have an accurate death rate (percent people who are infected that die) when “you don’t know what you don’t know.” Yet, the media daily report alerts of “record” numbers of cases and deaths. Well, the first case of COVID-19 was a “record,” since there were no prior cases. But, the “new record” hype serves to fear-monger and to panic people into submission to government “emergency” policies. This is conditioning the American People to a new reality regarding the state and its authority over their lives and rights.

What are the important numbers then to appreciate the gravity (or lack of it) of an outbreak? When so many cases are undiagnosed, you must go by numbers of patients hospitalized and rates of death (as a percentage) of those, as well as duration of hospitalizations as an indicator of case severity (3 days or 3 weeks?). Since the first months, these numbers had been going down, until the surge of “new cases” (positive tests, not illness) in the last month or so.

Further, be aware that there is concern that the SARs-CoV-2 nasal swab PCR (polymerase chain reaction) amplifies simple molecules of genetic material to the millions and, as such, may be very prone to false positives since the test is exponentially amplifying the most meager biological material—and so, may cause inflated case numbers. PCR is not a culture—a test where the virus itself is grown. Even remnants of dead virus that can no longer infect can convert to a positive test. How might this affect COVID case stats?

However, though there are varying figures on hospital lengths of stay and ICU death rates, both have gone dramatically down as we have successfully quarantined nursing home residents and other high-risk individuals and we have developed effective treatments (Decadron, Regeneron, remdesivir, bamlanivimab, convalescent plasma) and expertise. Recent estimates were a reduction of ICU case fatality of 30% last Spring to around 3%. Overall mortality has also been estimated to have fallen by up to 20% in the U.S. This is a much less fatal disease than when it emerged.

b. Prevalence-

Recent serum COVID-19 antibody data suggest that the virus may have been circulating for months in the U.S. before the first cases of illness appeared in January, 2020. This affirms the idea that the test-confirmed diagnoses are the tip of the iceberg, once again diluting and diminishing the “ominous” COVID-19 numbers being cited by media, to fear-monger and to justify restrictive public health policies in many places around the country. Positive tests (with no illness) are being called “cases” and added to COVID-19 case totals to emphasize an exponential pandemic explosion. Epidemiological statistics are extraordinarily subject to manipulation and misunderstanding. But, we are daily fed only the mounting totals on the nightly news—keep it simple, stupid, and just listen to the “breaking news alert” and obey the mandates.

Furthermore, the public is not aware that corporate consolidation in the business of medicine has forced many physicians to become employed by hospitals; private practice is now a medical profession dinosaur. Join that with the fact that hospitals are receiving extraordinarily high reimbursement rates and rapid turnaround times for COVID-19 case claims submissions to the federal government, and it is easy to imagine that there is an opportunity to increase profit-taking by having hospital-employed “diagnosis coders” working along hospital-employed physicians straining to call a hospitalized illness a COVID-19 case. This is all happening as hospitals are in serious financial distress because of postponed “elective” medical business (surgeries, diagnostic testing) with decreased patient traffic and COVID-19 shutdown of services. Every person admitted to a hospital is screened for COVID-19, for good reason regarding staff and other patients. But, if you were admitted with a stroke and no fever, so no illness reasonably attributable to SARs-CoV-2 virus, it would be simple to label it a COVID-19 case and put in a claim for reimbursement for this mislabel. Physicians have reported this as reality. What’s it mean? This is inflation of the extent of the epidemic as well as the death rate and risk.

c. Survivability/Mortality Figures

Survivability:             

Age        Survival %

0-19         99.997

20-49       99.98

 50-69       99.5

  ≥ 70          94.6

Mortality:    

Age             Death %

  < 1              0.006

   1-4             0.006

   5-14           0.2

   25-34         0.07

    35-44         2.0

     45-54         5.0

     55-64         21.0

     75-84         22.0

    ≥ 85           31.0

*Almost all deaths in all age groups had significant pre-existing medical problems (avg=2.8 problems/patient) under 40 yrs-old. For a huge part of our workforce, survival rate is about that of seasonal flu; actually true for most up to about 65 y.o. if otherwise no medical problems.

Does it occur to you the significance that politicians and the media obsess over COVID-19 death totals, but do not emphasize how many have survived?   

d. Children:   

They have a low number of ACE receptors (where SARs-CoV-2 attaches) in the nasal passages relative to adults. So, even when kids acquire the virus, they tend to shed only low amounts and so are not substantial sources of adult infections.

e. Mutations/Mutants:

In just the past few days it was announced, in a rather alarmist tone, that the United Kingdom had detected a new, more highly transmissible SARs-CoV-2 virus subtype that was making its way through the population. No one has stated that this new variant virus was more virulent, that is more able to invoke tissue destruction or bring about death.

I had written about this months ago, that viruses, as with all life forms, including humans, inherently mutate. It is part of the evolutionary process that millions of replication events (reproduction) will every so often result in a defective product (birth defects). But, most of these “errors” do not result in a life form variant superior to the parent. However, over time, some variants (mutants) will have a characteristic that makes them more fit to survive longterm in the life form’s environment, which is always changing. Maybe tolerate heat or cold or desiccation better. But, a mutant (as opposed to that concept used in Hollywood stories) is not always, actually not usually, biologically malevolent or ominous. In fact, as I explained before, as SARs-CoV-2 mutates, it should eventually spin-off forms that make it less of a killer for humans. Any change to increased virulence will be short-lived in that it will not benefit sustaining the virus species—it will die off. Reproducing in humans without killing them gives it a host, or home. Otherwise, it is a suicide virus. If it kills its host in a high percentage (like Ebola virus), it is a suicide machine. That is not productive, evolutionarily. But, let’s see how the media and power-hungry politicians package mutation as a worrisome problem; that justifies more strictures on our behaviors and rights. Mutations are an expected part of biology and have been and will be occurring as SARs-CoV-2 settles into its biological symbiosis with humankind.

2. Lockdowns:

The country is the patient. America is on life-support. Small businesses are failing (over 100,000 to never return). Mortgages are being defaulted at a rate of 60X baseline. Suicide, opioid use and overdose (up from 2,000/week a year before COVID-19 to 5,000/week), household violence, psychiatric illness (depression up 300%) are all on a sharp rise parallel with the pandemic. Kids are losing a year of education and social development. Marriages are breaking up. Life savings are being exhausted. As this proceeds, unemployment claims go up and those ex-workers are not paying taxes or healthcare premiums—putting at risk public services funding, Social Security, military defense funds, insurance company viability, and so medical practices and hospitals.

But, what about that science? Kids do not spread the virus to adults and they don’t die from it. Only teachers’ unions want the kids out of school as the teachers sit at home on paid vacation (of note, their unions are one of the biggest supporters of the Democrat Party). Yet, with kids at home, how does a family return to work? We are called “heroes” because those of taking care of the sick patients put ourselves at risk, yet traditionally teaching has been called a noble profession and the teachers are angels and heroes. Is that what we are seeing? Do they really care for the kids when they and their students are at minimal risk for serious illness and the kids are near no risk to transmit the virus to adults. We need to change the labels…it is an insult to those in our profession who have become ill and/or died from COVID-19 after putting themselves in harm’s way, to group teachers with medical professionals. Where have schools locked down the longest? Democrat strongholds (because teachers’ unions have the strongest quid pro quo relationship with the Democrat Party).

It has been clearly shown that the main source of COVID-19 infections is in the home—where co-habitors share closed ventilation airspace for hours a day. Not restaurants. Not bars. Not supermarkets. In New York City, studies show 70% of infections are acquired in homes, 2% in restaurants. Outside the home, most people wear masks when strangers are nearby and their “contact” is only glancing, not the at least 15 minutes CDC considers a significant exposure. And, it’s fair to assume that ill people are not out and about, mixing with others as they shed high amounts of the virus. The risk of infection from any infectious agent increases with “inoculum size”—the dose or concentration of infectious particles imparted with a sneeze or a cough.

If there are 8-10X the number of COVID-19 carriers as there are “diagnosed” cases (positive tests), then SARs-CoV-2 is everywhere and everyone will get it. Hopefully, those at high-risk for severe disease are vaccinated or improved treatments are available when that happens.  But, we cannot otherwise escape this inevitability unless each and all of us get on individual rafts and launch out to sea for at least 2 weeks, all at the same time. Once a virus this transmissible was out of the bottle, we were never going to stop it. Lockdowns, by the science, cannot work to eliminate the outbreak, only to slow it. Lockdowns won’t save us. They kill the country in a way that will remain long after this virus is gone or has become a usual virus. Lastly, the longterm, inevitable effect of a lockdown is to hide people from the virus such that, as the lockdown is removed, those bodies return to exposure and a possible tsunami of cases (which is what we are probably seeing now from the Spring Lockdown-the virus has not changed). Severe lockdowns will lead to severe pandemic relapses, potentially overwhelming the healthcare system’s resources and staff.

Finally, this lockdown scheme was started by a public health official (not a physician) in Santa Clara Country, CA as a model for response to grave bioterrorism infectious agents, not for a virus of the nature of SARs-CoV-2. It is way overkill and is effectively killing the country. Lockdowns are a luxury of the rich—they keep getting paid, have assets to live on, hire tutors for their kids. The poor and financially marginal are most impacted—lost jobs, savings, homes. Drug overdoses, alcoholism, domestic abuse. And, pay attention. Despite all this financial and social devastation, Nancy Pelosi , Democrat Speaker of the House in Congress, would not pass a COVID-19 stimulus bill to get relief money to small businesses and families in distress last August because she feared it would help President Trump get re-elected in November. She said this. She was willing to see middle-class lives permanently ruined to gain power by sustaining misery that would be seen as “Trump’s America.” Also, be clear that during this time many died alone with strangers holding their hands in hospitals, funeral attendance was restricted, and weddings also were constrained because of the lockdown. A lucid, appropriate and rational statement on lockdown policy, The Great Barrington Declaration, is displayed at GBDeclaration.org.

3. Schools:

For all the reasons stated, the children must be 100% in school immediately. If a child is found positive, immediate contact tracing with respect to their families is in order.

Teachers at high-risk for serious disease can be offered temporary disability until vaccinated. However, recent data suggest it is rare for teachers to acquire SARs-CoV-2 while teaching.

4. Vaccine:

The first vaccines available in the U.S. (Pfizer and Moderna) are both based on messenger-RNA (mRNA) technology. This is a nucleic acid strand that directs the recipient’s cells to form anti-spike antibody protein to block SARs-CoV-2 virus from attaching to mammalian cells at the ACE-receptors in respiratory passage and eye lining tissues.

The mRNA is not a life-form. This is not a live vaccine. Yes, this vaccine has been created in unheard of record time. Though no serious reactions have been seen in significant numbers, it will take 6 months to a couple years to have a reliable safety profile on the vaccines. However, the effectiveness of these vaccines are unquestioned—94-95% antibody production, even in the very elderly, which is not usually the case. The best flu vaccines are about 60-70% effective, much less so in the aged.

Be clear. Anything we put into our bodies has risk. Alcohol, medications, vaccines. The decision to take them is a personal risk-benefit decision. In Texas, every day that you get into your car you wager you will not be one the 9 people a day who die in accidents. If we require no risks (such as with lockdowns and the vaccine), then we need to stop alcohol sales, lower the speed limit to 5 mph (about 40,000 deaths per year), and have a complete society-wide lockdown every flu season from September-April (25,000-60,000 annual deaths).

There is a point where, if we are rational and intelligent and choose to live our lives, we calculate and accept risk and do not obsess over it; or, we have an emotional disorder.

It would seem sensible that with an infection that is worldwide and affecting literally every human being, their families, and their lives and livelihoods, a pharmaceutical company would be at great risk for exposing a huge number of people to an ineffective or dangerous product.

CONCLUSIONS

1. Masks:

It is inconclusive whether they protect us from getting the virus. It appears they mostly help in decreasing someone shedding SARs-CoV-2 from giving it to others. Cloth masks are probably worthless, and the small surgical masks not much better. Otherwise, it is a positive civic and ethical behavior to wear an effective mask when close-by the public.

2. Distancing:

This is the most useful preventive for COVID-19. But, 6-feet is a minimum. 20-feet is more advisable in closed ventilation with someone with respiratory symptoms. And any airspace where someone who may have been COVID-19 positive should be unpopulated for at least an hour.

3. Quarantine:

Anyone 65 or older is best advised to tightly control their exposure to others. Assisted living facilities and nursing homes should regularly screen their staff several times a week for SARs-CoV-2 as a condition of employment.

4. Lockdown:

Should not be done unless hospital bed capacity is approaching full and then where lockdowns should occur should not be unilaterally mandated by governing or public health officials. Instead, such measures should be done in collaboration with medical and public health professionals, government authorities, business owners and leaders, the general public, and any other stakeholders in such policies. Decisions can then be made by consensus on what businesses, services, and workers are “essential” and whether the onus of a lockdown can be rotated such that it is not imposed across an entire industry, sector, or service center. Again, the “patient” is the entire community and the country, not just those individuals with COVID-19 illness. Lockdowns and other very restrictive policies must be PROPORTIONATE to COVID-19 scientific data and other societal, collateral risks, or people will not comply. The public and leadership must work together, in trust. Right now, the trust is gone. The bottom line is that general, severe lockdowns have not worked. Case surges have occurred anyway, and will as this extremely transmissible virus steadily makes its way through humankind, only possibly short-circuited by vaccination and herd immunity of 60-70% from prior infections.

5. Schools:

Open (see above).

6. COVID-19 Illness:

We are quickly moving toward focus on the moderately ill cases to now prevent hospitalizations (previously treatment was centered on inpatient cases). We will see more and more of this going forward with treatments given earlier and outpatient.

7. Vaccination:

Obviously, healthcare professionals and first-responders must receive vaccine first, as most exposed to those who are shedding the highest amounts of virus in the acute onset of serious illness.

Current policy intention is to next vaccinate the very elderly as most at risk for death. I disagree with this. Most of the very elderly are fairly sequestered and relatively immobile socially and so not really practically exposed if focus is put upon keeping them relatively quarantined (and screening their caregivers) until the COVID-19 surge relents. It makes more sense to get herd immunity up (and so safety and confidence) in workers who we need to return to work. Once done, the elderly can be vaccinated. Lastly, the kids (at least down to 16 yrs-old for Pfizer and 18 yrs-old for Moderna, by current vaccines’ criteria).

8. Travel:

Again, this is a personal decision. But, airlines are equipped with high-efficiency particle filters (HEPA) in their ventilation systems and exchange the entire cabin air about every 2-3 minutes. If the flights are screening passengers for recent COVID-19 symptoms or known exposures/positive tests, if you wear a mask, if you are not seated next to someone with respiratory symptoms, and if you clean your hands before and after the flight, air travel should be very safe. So far, there has been no report of a super-spreader event related to an airflight.

I hope this has been of value. But, unfortunately, the medical profession has not voiced objections enough over the politicization of this pandemic, at times complicit (saying public demonstrations for social justice were more important than COVID-19 “super-spreading” concerns), and otherwise mute on the perversion of public health policy for a political/social agenda. It has been a disgraceful year for the profession, other than the COVID-19 caregivers and the vaccine.

We cannot afford medical and public health myopia, ignoring managing our “ill” American society, lest we sacrifice our country and our way of life.

I think I have made the case that our current dilemma is political and medical, inextricably bound. I personally have no question that the handling of this pandemic in the U.S., at odds with data, can only be ascribed to an exercise in political power and an agenda to re-order the society. All this in the context of Leftist leaders’ failure to enforce law and order over violent anarchists and property destruction from May through September, joined with their tone deafness for their constituents’ protests and desperation over lives falling apart from decreed public health policies, can only lead to a conclusion that all this mayhem has been an opportunity to subdue the middle class and create an environment where socialist, statist America is an achievable reality out of economic devastation—something the Left knew could never be achieved by vote. There really is no other rational explanation for the incongruity between “the science” and the extreme actions of progressive leaders on the pandemic “to protect lives,” yet their inaction to govern as anarchy raged. Of course, during an election year, creating a terrible vision of “Trump’s America” was the immediate goal, but the longterm aim has been an undoing of the American model and a “re-imagining of America” and a new order. At least, that’s one doctor’s take.

“The worship of the state is the worship of force. There is no more dangerous menace to civilization than a government of incompetent, corrupt, or vile men. The worst evils which mankind ever had to endure were inflicted by bad governments. The state can be and has often been in the course of history the main source of mischief and disaster.”

-Ludwig von Mises

Bolshevik Russia/Soviet Union, The Third Reich, Communist China, Venezuela…America, on the brink.

Finally, as always, these are my personal, professional opinions.

Edward R. Rensimer, MD

Infectious Diseases

Director, International Medicine Center

traveldoc.com

COVID-19 Update No. 15: Vaccine-Take It Or Not?

12/4/20

Let me start out by clearly stating I am obviously a science-based guy, entirely. Vaccines are one of the great miracles of modern medicine, saving millions from damage and death from communicable diseases. However, they can and do cause harm. That is not the rational argument (against them). If a vaccine kills one person but saves 1,000, what is the issue for anti-vaccers? U.S. cars kill 40,000 annually. You going to start walking everywhere? But, motor vehicles take people to hospital emergency rooms, transport food and medicines, make travel possible. As a society, we agree that it is OK if 40,000 people die each year, many of them young, because we want the benefits of rapid, economical, and individual transportation.

Vaccines need to be considered the same way. Risk v. benefit. Of course, in the middle of a pandemic with over 250,000 deaths and uncertainty on the future course and stability of the SARS-CoV-2 virus, that balance is disturbed. How do we decide whether and when to take a new vaccine? It needs to be given some thought, especially by those at low-risk for death from the infection. Unless you don’t know much, it is not a straightforward decision. Remember, all vaccines are relative not absolute protection.

So, here are some facts,

• m-RNA Vaccines: The Pfizer and Moderna vaccines, those most likely to get EUA (Emergency Use Authorization) approval from the FDA, are vaccines using this first-time technology. This method uses a SARS-CoV-2 gene to provoke specific antibody formation against the virus’s spike protein. This gene is not able to replicate itself and so constitute a risk of infection. It is not a “live virus” vaccine- not even a virus.There is nothing to suggest the m-RNA aspect conveys any particular biological risk for recipients, although, since this is novel technology, it remains an open question.

• Efficacy: Defined as “the ability to produce the desired effect”, this is a tricky issue, yet. These two vaccines have shown clear ability (over 90%) to produce high levels of virus spike-protein (attachment protein) antibody levels. Is that the same as preventing disease? That has not been resolved. The numbers of study recipients so far are low and the claimed efficacy of over 90% may not hold up as the number of recipients grow. Vaccine manufacturers typically turn out the most optimistic numbers when launching a new product, later to be revised.  This is often so with any vaccine (as well as the safety profile). Even if the rate of antibody production turns out to be 60-70% (that of the best flu vaccines), it still is worth it–that effect spread across the entire society would profoundly down-regulate the pandemic, if the antibody is the key aspect of immunity to the virus.

Furthermore, the human immune response needed to stop or minimize the bad effects of infection may be far more complex than a single antibody type, and these vaccines are developed to generate an antibody. It may be helpful, but not enough to impact infection, and so illness. Other parts of the immune system may be as or more important than any single antibody.

Another aspect is duration of immunity. The SARS-CoV-2 virus infection may only generate effective antibody levels lasting months to a couple years. Vaccines may not be as effective at doing this as the virus itself. Remember, these vaccines have been so fast-tracked in development (record time) that it is unknown how long their antibody production will endure. There just has not been enough time to study it.

Furthermore, vaccines may be less effective across different patient groups, especially the elderly. Although there is obvious intention to protect those at most risk for death, those over 65 yrs-old, it is usual that advancing age weakens everything, including our response to vaccines, such that antibody production from these COVID-19 vaccines may be much less than in younger subjects, importantly those who most need the immune protection. Again, not enough time yet to know what is the truth for these vaccines.

Lastly, these vaccines are very targeted at a specific, narrow function- to produce antibody that will bind the “spike proteins” on the surface of the SARS-CoV-2 virus (which make it look like a submarine mine), to interfere with its ability to attach to human cells. What if the virus, as all viruses do, mutates to devise other ways to attach to our cells? Possibly, a geometrically altered spike protein. Viruses, by Darwinian principles, through millions of reproductive cycles passaging through human host cells will generate mutant or altered forms that may be “defective” compared to the origin virus, but actually adjusted to the current environmental threat (antibodies from the current vaccines) to the virus’ ability to replicate and so to survive, so that the mutant becomes the dominant new, more fit (survivable) strain, and so another surge of cases. We are familiar with this phenomenon with annual, seasonal influenza, which requires a new vaccine formulation every year. So, a narrowly targeted vaccine could become obsolete or much diminished in its protection fairly quickly, depending on the virus’ ability to mutate. This also is an open issue.

So, what are the latest results from trials involving about 40,000 people.

Pfizer: The study group developed 170 COVID-19 infections.

Infections: 170              Placebo: 162 (9=Severe)            Vaccine: 8 (1=Severe)

Pfizer claims its vaccine is as effective in over 64yr-old recipients as in younger subjects. 95% effective.

Moderna: The study group developed 196 COVID-19 infections, (30 severe),

Infections: 196                  Placebo: 185                       Vaccine: 11

Moderna states the vaccine has been effective across all ages, races, ethnicities, and sexes. 94% effective.  Both vaccines caused these side-effects: fever, headache, bodyaches, fatigue, injection site reactions, but more severe. But, follow-up for adverse effects after the 2^nd dose (both vaccines are 2-dose) has only been 2 months.

• Safety: As stated above, in general, the risk/benefit for vaccines approved for use generally has favored the vaccine. These vaccines have been developed in about 10 months, versus the usual 2-20 years. Also, the m-RNA technology basis is cutting-edge and new invention. All of this is commendable as a miraculous achievement in a crisis.

However, substantial safety data will take at least 6-12 months more, with much larger numbers of recipients, to accurately assess this issue. Again, this is usual with new vaccines. It takes millions of recipients to get a complete picture, although the FDA would not issue a EUA unless fairly confident about relative safety. However, the urgency to do something to impact the pandemic’s effects on the American people and on our society and economy is pressuring granting of a EUA.

Safety and efficacy appraisals will be moving targets, evolving over time to a more reliable position.

So, what are the specific factors to consider in making a personal decision to take the vaccine?

COVID-19 High-Risk

• Exposure: “essentials workers” such as healthcare professionals, first-responders, food-handlers, etc.

• Over 64 yrs-old

• Pre-Existing Conditions: Obesity, diabetes mellitus, hypertension, asthma, immune deficient, etc.

COVID-19 Disease Incidence: If the virus activity (new cases) is leveling off in the months ahead because of increasing herd immunity (from those previously infected or vaccinated), it may be reasonable to not take a vaccine, especially if serious vaccine-associated ill-effects are being reported in substantial numbers. Of course, as with annual flu shots, there is the consideration of taking a vaccine as “civic duty”, as part of a collective community’s effort to minimize extent of a casually communicable disease. The answer to all this, on a personal level, is nuanced by what is going on at the moment and by one’s principles. It also must take into account all that has been so far stated about the specific vaccines’ risks and benefits, and how those are changing (again, a moving target during an epidemic outbreak).

Safety: This must be considered and re-considered as vaccine experience and data develop and then factored into disease incidence at the very time the vaccine is available to you.

COVID-19 Illness Treatment Efficacy: We have seen substantial decline in the hospitalizations, ICU admissions, and deaths as a percentage of all positive tests. That is, the rate or percentage of bad outcomes. The total number of cases (defined as positive tests) has been reported in panic tone by the media, but they have not emphasized the success the medical profession has had in understanding the virus, the nature of disease at a cellular and tissue level, and the timing of medical interventions that have dramatically improved the outcome of any individual COVID-19 case. For example, it was recently reported that U.S. ICU case mortality was about 30% in March-April, 2020, and now is about 3%–the worst of the worst cases.

Along with this is the fact that about 90% of COVID-19 positive individuals are without symptoms or only moderately ill—not requiring hospitalization or specific treatments. Yes, there are increasing death totals because there are many, many more positive cases, but for fewer deaths per thousand than early in the pandemic.

All of this colors the decision on taking vaccine or not, as well as when to do it.

COVID-19 Disease Risks: I will not restate the mortality rates for various age-groups, readily available at cdc.gov. Obviously, the high-risk groups have been well-established and those individuals almost certainly should be vaccinated (unless they can indefinitely avoid substantial exposure to the virus), if incidence of new cases substantially continues (large surges). But, the improving death rate should be factored into the decision, particularly until the relative safely of these novel vaccines becomes established. That may well be the case by the time the vaccines are available to the general public, likely in the 2^nd quarter, 2021. It is a more problematic for someone like me, 71 yrs-old and with front-line exposure as an Infectious Diseases physician.

Vaccinating people under 19yrs-old, given the near absence of deaths from the virus, is not about protecting them. It’s about decreasing the total protoplasm in the community available to grow and spread the virus to high-risk groups.

Finally, we still do not fully know the long-term effects of SARS-CoV-2 virus on some people. It will take another year to evaluate those who have had the illness to assess what damage has been suffered, and to what degree recoverable or permanent. Heart damage, lung damage, kidney damage, cognitive impairment (dementia), peripheral nerve damage, are all on the table, having been seen in patients some months after illness (but not asymptomatic patients). All of these problems are likely to be found, but, given the huge numbers of infections worldwide, the very high majority of COVID-19 patients will have complete recovery. And, any long-term damage will most likely occur in those with the most severe (hospitalized) illness and with underlying pre-conditions for higher death rates.

Conclusion

You can factor all this into your decision on whether to accept vaccine or not, according to your personal circumstances. I started out saying this is not straightforward, but now you are at least informed.

The data from Pfizer and Moderna are encouraging and, at least in terms of efficacy, should incline high-risk individuals toward taking the vaccine if SARS-CoV-2 virus activity is substantial when the vaccine is available. For most Americans, by that time, more data on safety and efficacy should be available. It is fair to be concerned about the unparalleled speed at which these vaccines have been brought to application. So, we all must pay close attention in deciding what to do.

But, what about personal principles around the idea of vaccination for communicable diseases? Should it be mandated that we receive it? Don’t we have individual rights and isn’t mandatory vaccination an infringement of such rights? I mean, we are Americans and live by a Constitution and Bill of Rights, right?

Well, first, just because we can cite our basic rights as statute protecting some of our behaviors does not make it right, ethically, to decline immunization. I am now articulating a personal, professional point of view of immunizations and the decision to receive them. This is within the context of there being no such thing as a no-risk position, vaccinated or un-vaccinated. We all live in a community, governed by laws. We are part of something bigger than ourselves, for our benefit, those we care about, and for all others. So, we agree to not drive intoxicated, not run red lights, not discharge firearms in public, etc. We give up some personal freedoms and, though given broad rights under our Constitution, with such freedom comes responsibility to act properly, to do no harm to others. So, we concede to laws and to abide by them. In addition to these communal rules, properly The Golden Rule is foundational to ethical behavior toward others. In medicine, a corollary of this is, “Primum non nocere”: First do no harm. The core of the Hippocratic Oath physicians swear upon receiving their medical degrees.

Putting all this together, the case is made that receiving immunizations for communicable diseases is truly a civic duty… exercised beyond your concerns for yourself as an expression of duty and caring for others in your family and, more broadly, your community. When I have encountered people who obstinately refuse the flu vaccine saying they are willing to risk getting the flu, and it’s their right, my response is that that’s fine, but what about getting it to decrease risk of flu illness and death to their friends, grandchildren, co-workers? As part of a community, we are compelled to be selfless. Certainly, we have a personal obligation to not harm ourselves. But, our lives are replete with risks: driving, eating out, drinking alcohol, and on and on. There is no absolute safety. I would challenge any one to show statistics wherein any FDA-approved vaccine may be rationally declined, though medically indicated, based on the risk/benefit calculation.

What it comes down to is our decisions on vaccination have potential serious negative impact on others, not just ourselves, and vice versa. We do not live in isolation. There should never be a need to mandate a vaccine in a responsible, functional, civilized society. The right thing to do is intuitive.

Whether by SARS-CoV-2 virus infections or vaccination, once we reach 60-70% herd immunity of the population, the epidemic will cease. There may be sporadic cases, even reverbatory smaller waves of infection, but hospitalizations and deaths will decline (as with seasonal flu). And, our society will be able to reclaim its life and vitality. And that is something of which we should all want to be a part. So ends my lecture on medical ethics.

Of course, the longer you wait to move forward with the vaccine, the more accurate information you will have on safety, efficacy, and relevancy to the COVID-19 virus community-wide activity at the time. Please notice in the Pfizer and Moderna preliminary trial numbers there were 170 and 196 infections, respectively, despite vaccination. So, as with all vaccines, the protection is relative and imperfect. Holding any vaccine to a standard of perfection has always been medically ridiculous. Even after vaccination you will need act responsibly until the epidemic is gone. Lastly, the further along all this goes, the more weapons and expertise we will have to apply to any case and to turn the situation around. On the other hand, there will never be a guarantee that any individual case will not proceed to physical damage, death, and collateral non-medical losses, like lengthy time off-work.

If these vaccine statistics and facts hold up after the FDA’s Advisory Committee reviews them in mid-December, and COVID-19 community-wide activity is still vigorous (likely, I will almost certainly take the vaccine as soon as it is offered, and advise my family and patients to do so; first those at high-risk for severe disease and death. Remember, I am 71 yrs-old and an highly exposed physician specialist– that’s my risk/benefit calculation.

I hope this information will be of value in your consideration of COVID-19 vaccinations. These perspectives will be true for any future COVID-19 vaccine products.

Edward Rensimer, MD

Infectious Diseases

Director, International Medicine Center

Houston, TX, USA

COVID-19 Update No. 14: “Trump’s Pandemic Performance”/Politics

10/26/2020

Just weeks away from Election Day and, if the polls are to be believed (not a given), President Donald Trump is behind. Since he fares better than his opponent on the economy, now and into the future, it must be that personal dislike of him and the public’s inclination to blame him for the state of the COVID-19 Pandemic account for the poll deficit. Of course, all this occurred on his watch, but a review of the facts will clarify what is and is not reasonable about all this. In order to arrive at proper conclusions, we must revisit the beginning of COVID-19 in the U.S. Starting there, the questions to answer are,

1. How might all this have gone, at best?
2. What was done?
3. How has it gone?

                Recall that the first U.S. COVID-19 case was Jan. 21, 2020. It had clearly come from China. Despite a widespread outbreak with many deaths in China at least the prior 2-3 months (very possibly longer), with the arrival of a novel virus on our shores, the first priority was to get information from the Chinese experience with haste. China would not cooperate. They would not allow our CDC experts access to their high security biological lab (much of which was funded by U.S. taxpayers) in Wuhan where SARS-CoV-2 (COVID-19 virus) had been under study, virtually the epicenter of the Chinese epidemic. So, from the outset we had no helpful information. We were starting at zero (and we now know the virus was spreading here exponentially, but silently). We were already behind. In addition, the Chinese misinformed us, suggesting human-to-human transmission was not a serious issue. By that time, SARS-CoV-2 was already showing up outside China, in other parts of Asia, India, and Western Europe.

Further, the nature of novel, pandemic viruses is to spread quickly and in rolling waves over 1-2 years after their first appearance. So, the cat was out of the bag with the first U.S. case and no one could have stopped it. No one. We now know that up to 20% of infections have no symptoms, and 60% are mildly ill. And, we had no test yet to detect the virus. So, we would spend a couple months just to collect actionable information allowing policies and protocols to contain spread. And we had no idea who was at most risk for serious disease and death. We were entirely in the dark for the first couple months on what we faced.

The President did what leaders do. While trying to develop information, he announced the problem to the country with a calm, optimistic tone. Should he have then been grim and worried, leading the country to panic- a rush on supermarkets, home supplies, banks? No. That is not leading. But, on Jan. 31, 2020 (10 days after our first identified case), he made a bold decision to stop travel from China, anticipating the worst. He was immediately criticized by Joe Biden as being “xenophobic” (racist) against the Chinese. Nancy Pelosi, Democratic Speaker of the House, smilingly told the country to go to Chinatown to eat Chinese food, as she did so on camera. This was the “anti-Trump” strategy. Whatever he does, do or say the opposite and find a way to label him. So, from the start, some Democrats worked this pandemic for political advantage. As Jane Fonda, a lifelong Democratic Party darling, recently said, “COVID-19 was God’s gift to the Left.” … but not to the over 215,000 COVID-19 U.S. dead.

He then shut down travel to and from Europe on March 12, 2020. Leadership.

1. How might this have gone? What was done?

With what we know about pandemic viruses’ behavior and the SARS-CoV-2 virus specifically, no one could have contained this. Infectious Diseases specialists and public health experts know this. President Trump’s COVID-19 Task Force, which he formed immediately, came out with the most reasonable approach. The goal was not to stop the virus. It was to “mitigate” it. The idea was to break an expected tsunami of cases into many smaller “surge” waves, so that the healthcare system had sufficient workers, facilities, and equipment to optimally treat the afflicted. Italy failed at this and so choices were made by its physicians of who would get the ventilator and who would be made comfortable to die… rationing care. This never happened once here, despite a horrific hotspot outbreak in New York City. Why? Because the President and his Task Force mobilized the military and private sector business to go into wartime mode to outfit two U.S. Navy hospital ships for expanded bed and intensive care unit capacity in a matter of weeks… record time. The ships were deployed to New York City and Los Angeles. Both the Democrat Governor of California, Gavin Newsome, and New York’s Democrat Governor, Andrew Cuomo, were effusively grateful and complimentary of the president’s time-critical effectiveness and speed in getting the job done for these governors and their constituents.

In parallel, the president had the biotechnology companies develop an accurate diagnostic test for SARS-CoV-2 within the first month, and then ramp up production and distribution of test kits as soon as possible over the next couple months. This was essential to success, to have a tool to detect the enemy and to track its behavior and extent. Only with this could we develop a containment strategy while working on the currently ill. Likewise, personal protection equipment (PPE) of facial visors, masks, gloves, gowns, and cleansers were urgently needed, especially for frontline medical workers, and the president pushed manufacturers to retool their factories for massive production of all this and ventilators that were sorely needed for survival. All of this activity was initiated and coordinated by the president’s Task Force. But, its work also included mobilization of the U.S. basic and medical science communities to study the virus in detail and to start clinical studies on patients and patient groups to start to define methods and standards of care for the clinicians charged with care for these patients—an ongoing process to continually re-evaluate new data and to optimize care, the goal being to minimize the death rate. So, the death rate and intensive care occupancy by COVID-19 patients has dropped radically.

Finally, the CDC also daily and weekly produced guidelines and protocols as new information was collected real-time for the medical profession, first-responders, and hospitals and the general public (schools, restaurants, bars, sports venues, etc). There was a necessity to address virus exposure across the society with the goal of mitigation to limit further spread. And so, to bend the building huge wave of new case numbers downward, all of this had to happen at virtually the same time. President Trump’s Task Force, under his leadership, got this done.

Sure, there were some shortfalls in production and distribution of supplies in the early months, but this was unavoidable with an unprecedented biological catastrophe (at least since the 1918 Spanish Flu Pandemic). And, President Obama and Vice-President Biden had exhausted the supplies of PPE with the 2009 H1N1 Influenza Pandemic from the national stockpiles and never replaced them. Nevertheless, everyone received the best care available in the moment.

To diminish the first, huge wave of cases, a “lockdown” of the country was done under the advice of public health experts, such as Dr. Fauci and Dr. Birx—to be managed by each state’s governor according to their state’s density of population, total population, rate of new cases, and many other factors. And, now that more was known about those most at-risk for serious COVID-19 disease and death, strict quarantine of the most vulnerable was effected. It was clear that any lockdown was a double-edged sword. The more severe and longstanding any lockdown, the more societal paralysis and collateral COVID-19 damage: ruined businesses, defaulted mortgages, exhausted savings, mental illness exacerbation, alcohol/substance abuse incidence rising, broken marriages, physical violence, diminishing tax bases threatening government and public services breakdowns, closed medical practices, and financially tenuous hospitals, and on and on. Knowing the peril to his white-hot economy and the potential political fall-out in an election year, President Trump called for sweeping lockdowns in outbreak hot-spot areas in the best medical interests of the American People, per the discretion of governors and local leaders.

One important point about lockdown that has not been discussed. The longer and more severe they are, the more people are not exposed to the virus and so not developing immunity. So, when strict, long lockdowns are terminated, it is a set-up for massive resurgence of infections—creating the tsunami that mitigation was designed to avoid. That is what is happening in Europe now. Lockdowns were over-done there. Lockdowns are supposed to be managed to slow down and, so to spread out, new cases. President Trump did that.

Finally, President Trump had the Food and Drug Administration (FDA) streamline its ponderous, inefficient approval process so that promising medications and other therapeutics could be fast-tracked in what was a public health cataclysm. This innovation also is relevant to what appears to be a record-breaking development of a COVID-19 vaccine, expected to be available by the end of 2020, an unheard of 8-9 month timeline, compared to the usual 3-5 years.  This could only occur with the lightning fast mobilization of U.S. basic science companies and academic institutions by an expert leader and manager to develop the science on the nature of SARS-CoV-2 as well as its interplay with human immune systems (immunology). This had to start up back in March in order to meet a vaccine target arrival date in late 2020, or early 2021. Fantastically ambitious and unprecedented.

Finally, it appears likely we will have a vaccine that will enable us to return to our usual lives understanding that a new vaccine is never a given possibility. Do we have a vaccine for HIV/AIDS, Herpes simplex, Zika virus? No.

How has it gone?

Well, cases continue to appear and deaths continue to occur. But, again, that was always expected. It could not be otherwise. We had to open, or sacrifice the country’s economy, and so America. With that, more people would be moving about, and so, with increased testing as well, there would be mounting case numbers. Many of these are positive COVID-19 tests without illness, though the media does not explain this critical detail when announcing panic “alerts” on “surges” of new cases, which fits their aim to exaggerate and to sensationalize. But, the focus should not be on the media’s alarmist “alerts” on new case totals as people re-engage in their lives. The focus should be on several facts,

1. The public is, by far, more used to the need to “social distance” and to wear masks, where appropriate. It is not the “new norm”; rather, a new norm for a while…probably another year (depending upon the effectiveness of the anticipated vaccines).
2. The medical profession now has methods and tools to deal with the worst cases. So, COVID-19 hospital admissions, ICU cases, and deaths are all way down the past 3-4 months. Most of the deaths occurred when we were COVID-19 ignorant and inexpert. This will only continue to improve as more medications and other therapeutics (monoclonal antibody and convalescent plasma infusions) become available. Many are in the pipeline and will be available in just months because of the mobilization of private enterprise, the healthcare system business and scientific communities, and military and public health sectors—all done immediately and in parallel by President Trump’s Task Force from the outset. An apt analogy would be America’s all-out, full-societal response to entering World War II after December 7^th, 1941, Pearl Harbor.
3. Children are increasingly back at school. That is necessary as they have been hit hard in their development in crucial years of their lives. Long-term life success is highly correlated with the elementary school years’ experience. There are next to no deaths in people under 19 yrs-old who are otherwise healthy. Recent studies show in 1 in 1,000 school children acquire SARS-CoV-2 at school; 1 in 2,000 teachers. And, children are now known to not likely spread SARS-CoV-2 to adults. Adults get COVID-19 from other adults.
4. With easing or cessation of lockdowns, we will see more cases. But, the great majority of those new cases are in people in their 20’s, not a risk for serious disease or death more than seasonal influenza. The more of this that happens, the more “herd immunity,” until finally, between those previously infected and immune and those who have been vaccinated, we will see this all in our rear-view mirror, much as any virus that is part of the human condition, such as influenza. The president is correct when he says we have “turned the corner.” Case counts will continue to register, but death rates and hospitalizations will go down and the virus will gradually mutate to a weaker form. Anything that suggests otherwise is misrepresentation to create panic. Walk away from that.

MASKS

One other topic should be discussed…masks. Politically, the failure to religiously wear a mask or to insist on it has been used as a “virtue signal” for social irresponsibility, and wanton disregard for others, in fact, gross negligence. This has been a drum loudly beat by President Trump’s adversaries. And, they have used mask wearing, virtually every time in front of a camera, to create political theater over the issue as a negative signal on President Trump’s alleged personally unethical behavior and incompetency, as well as an ever-present reminder that we have a pandemic and it is on Trump’s watch; so, he owns all its negatives (or so they assert).

No one can argue against wearing a mask. If it allays anxiety in an individual because they are “doing something,” then, so be it. But, it is clear that the data on efficacy of masks having a reliable impact on the risk of acquiring COVID-19 are conflicting. Likewise, the opinions of experts on the matter. The CDC just turned out data on patients who were so COVID-19 sick that they were admitted to the hospital. Of those, 71% had worn a mask all the time; 14%, most of the time. Seems like the mask did not provide much value. The U.S. Surgeon General, some months ago, doubted their value. On March 8^th, Dr. Anthony Fauci (NIH) said masks were not needed. He since then has seemed to advocate them, but he has vacillated on his position, like on other pandemic issues, many times during this pandemic. But, before we take a political party’s condemnation carte blanche, we should examine an issue, the facts of which are still evolving, ourselves. The Democratic Party and Joe Biden’s opinions on this are just perhaps not entirely motivated by established science. The bottom-line on masks from the CDC is that masks may decrease the risk that someone ill with SARS-CoV-2 will spread it to others, but it is less clear whether masks protect the wearer.

Note, just last week, the World Health Organization pronounced COVID-19 quarantine lockdowns no longer advisable because any value with respect to COVID-19 prevention were negated or even outdistanced by the severe collateral damage of societal isolation, economic damage, and non-COVID-19 medical morbidities and deaths from the lockdown as people delayed or avoided medical attention for serious problems out of fear (from the media) of acquiring SARS-CoV-2 while seeing a physician or going to a hospital. And, until this, lockdowns were written in stone, COVID-19 dogma, as necessary, even to the point of many Democratic Party governors over-reaching their legitimate legal authority to bring to bear almost COVID-19 martial law on their constituents as they restricted their constitutional rights. Yet, the lockdown issue is still open to debate by qualified experts.

You want to end COVID-19? Put every person on a private raft at sea for 3 weeks. Done, virus gone. The only fool-proof anti-SARS-CoV-2 intervention is strict social distancing. And now, knowing it hangs in the air in minute, aerosol particles, everyone must be at least 20-feet apart. As for masks, jury’s out.

The Election/Trump/Biden/Pandemic: Conclusions

Lexicon: Propaganda, misinformation, disinformation, political theater, exploitation, manipulation, mistruths

All of the above.

Well, if you’ve gotten here, you have the picture of all that went into, over a very short time, orchestrating a comprehensive public health, medical, and societal response to this unprecedented crisis, without the benefit of any collaboration with those who originated the outbreak. Really astonishing by anyone’s measure. I won’t say unprecedented. FDR, likewise, mobilized all needed expertise and resources with our sudden entry to WWII.

Nevertheless, Joe Biden, Kamala Harris, and the Democratic Party leadership seem to have gotten away, in this age of sound bites and partisan social media edits, to misconstruing President Trump’s leadership and effectiveness in confronting the pandemic for the American People. They claim President Trump has been asleep at the switch, fiddling away while Rome burned.

Joe says he would have done (in fact, will do) it differently. He’ll let us know (just like with Supreme Court “packing”) what groundbreaking solutions of his would have turned all this around, after the election. Funny. What happened to the telephone? To email? I am sure the Administration would have welcomed a message from him with his prescient wisdom to impart on ending the COVID-19 Pandemic from a former vice-president. Certainly, no one committed to the welfare of the American People (and the country) would withhold information that would save lives until after an election. That would be a pre-requisite for a would-be president.

Had Biden been president in January, he would not have stopped travel from China. Remember, China had a wobbly economy and would not take well to such a lockdown of travel between the U.S. and China. Besides, they needed the SARS-CoV-2 to spread broadly across the world—a receding tide to lower all ships. They needed the U.S. hurt, badly, without firing a shot so that their timeline for becoming the Number One Super Power of the 21^st Century was not derailed. And, the Bidens are tightly entangled with them through under-the-table business schemes when Joe was VP, more evident every day.

According to Joe Biden, President Trump is personally accountable for all the COVID deaths. Any competent president would have prevented all of them, according to Biden. Well, the pandemic modeling in February suggested about 2 ½ million U.S. deaths with what was known. That’s 6X more than so far. Had Biden been president and not stopped China travel, there would be tens of thousands more deaths. Parenthetically, tens of thousands of these deaths were mass-murder actions by several Democrat governors defying (New York, New Jersey, Pennsylvania, Michigan) CDC guidelines and sending recently infected elderly patients back to their nursing homes to pollinate thousands of doomed residents (about 11,000 estimated deaths by Gov. Andrew Cuomo, alone, who still does not take responsibility and still holds office; says a lot about their real concern for all those deaths about which they decry President Trump).

When Biden does offer up a sampling of what he would do, it is everything President Donald Trump already has done. But that’s just like Ole Joe. Once a plagiarizer, always a plagiarizer (the reason for his two prior failed runs for the presidency).

But, we don’t need to speculate. Joe Biden was charged by President Obama with managing the 2009 H1N1 Influenza Pandemic. In the U.S., 61 million were infected (compared with 5 million with SARS CoV-2).  There were about 12,500 deaths with H1N1 compared to over 215,000 so far with COVID-19. However, the SARS-CoV-2 virus is 6X more lethal than seasonal flu and 30X more lethal than the 2009 H1N1 flu strain. If SARS-CoV-2 had been the virus in 2009 with 60 million infected, Biden would have presided over 360,000 deaths. Joe Biden is in no position to criticize President Trump. Yet he does. Politics. Trump has been a master, given the unprecedented circumstances. His virus is a killer, more like the 1918 Spanish Flu with a death rate of 2%.

His chief of staff, Ron Klain, said, “It is purely fortuity that this isn’t one of the great mass casualty events in American History,” in commenting on Biden’s management of that pandemic. The fortuity was that, though the virus spread prodigiously, it was much less lethal than SARS-CoV-2. Joe lucked out. However, not so for the 12,500 who died, who were mostly between 15-40 years old. SARS-CoV-2 deaths are about 50% in nursing home patients, well past their life expectancy. 80% are over 65 yrs-old. So, Joe Biden was tested on a pandemic and did not fare so well, relatively.

So, in closing, just to get this right, first, Trump did too much, too fast, because he’s a racist. Then, he did next to nothing (and he doesn’t wear a mask in the shower!) and so mass-murdered over 215,000 people, which would not have happened with a President Biden. Guess we can all relax because all this will be over and we can return to our lives when he’s sworn in. At least that’s the Trojan Horse they’re selling to the American People. Maybe the Democrats will be charitable and at least take 25,000 off the death totals due to Democrat governors’ gross negligence, so as to not hold them against the president. Nah!

It is also essential to understand that from the outset the president was clear that COVID-19 was a pandemic, which is defined as a number of individual, contemporaneous epidemics, each one with its own particular expression according to the geography of each state as well as other characteristics particular to each locale: number of large cities, total population and population density, use of public transportation, number of medically vulnerable individuals, etc. In other words, the pace and extent and severity of the pandemic would be highly variable, state-by-state. Some needing total lockdown, others gradual or partial shut-downs. For example, at the start of the pandemic, the states and cities on the coasts were hit hardest because of their extraordinary exposure to international travelers. With all this in mind, the president plainly stated that each state governor should determine what measures were needed and when, to match their healthcare system resources to the nature of their specific COVID-19 epidemic that they were experiencing. President Trump said the federal government stood ready to provide whatever was needed by each state, upon request. He did so. Most notably, Governor Newsome of California and Governor Cuomo of New York, both Democrats, praised him unequivocally for his immediate and exuberant response to all their needs. President Trump overwhelmed them and anywhere else requested with sufficient supplies, equipment, and hospital bed capacity. So, this always was a multi-centric management strategy to be overseen at the state level by governors with the full support of the federal government. Nothing else would make sense or would be effective. To now try to lay all blame entirely at the feet of the president is preposterous.

If you say President Trump failed, you need to say what he did not do that should have been done and when, with the information available at the time, it should have been done. And, if so, where were you with these ideas when all this was playing out? You don’t get to be Monday Morning Quarterback with no facts, only criticisms, to claim you would have done better.

The best benchmark of success is a decrease in death rate (deaths per total cases), decrease in hospitalizations, and opening up of the economy. All of that has been happened about 6 months after the inception of this nightmare. The media panic us with “surging” new case numbers which mostly reflect more and more availability of tests…the vast majority are minimally ill, or not at all. Beware of this messaging. It is cynically perverse politicking the pandemic in an election year.

As for President Trump, as a specialist in these matters, I cannot see how anyone could have done better. Thankfully, we have had an expert business manager/developer executive as the Chief Executive when COVID-19 arrived. Biden, who has never created a job or a service, never been an executive manager, and never started and run a business would have been a tragic failure, with unimaginable losses for our country. If elected, he’ll get the benefit of all Donald Trump has done and President Trump will get no credit from the partisan media.

Edward R. Rensimer, MD

Infectious Diseases

COVID-19 Update No.13: Being A Low-Risk Patient

6/29/2020

How long will this go on? Well, we had the worldwide 1918 Spanish Flu Pandemic, which cycled continuously, with about three major surges of disease and death more than two years. It is a fair guess that 1-2 years of COVID-19 will be prominently in our lives. However, we are physically interconnected across the globe in a matter of hours with air travel. And, this is a below-the-radar SARS-CoV-2 virus that is spreading most vehemently in the 48 hours prior to the onset of illness symptoms, when the unsuspecting host is shedding virus profligately and that person is going about their life with abandon, unaware of the danger they pose to family, friends, co-workers. So, the features of modern civilized society make predictive models of COVID-19 behavior and pandemic timelines tenuous at best.

The best thing has always been to avoid doctors and hospitals by maintaining your health and physical conditioning. More so now, with the extraordinary communicability of this virus as every place in the healthcare system is a trafficking funnel that concentrates the sick, medically infirm, and elderly… those at most risk for COVID-19 fatality. The healthcare system is the worst place to be, the frontlines.

What are you to do? You are not a habitual medical care seeker (there are those). But, you have blood in your urine, unexplained weight loss, fever, extreme new-onset fatigue, or cryptic chest pain. Problems that cannot wait-out COVID-19. And, the collateral damage of COVID-19 contagion is yet to be tabulated- people delaying seeing a physician or going to the Emergency Department because of COVID-19 fear- and die of a stroke, heart attack, septic shock, ruptured appendix, etc.

How do you balance the risk-benefit of being evaluated timely in the context of COVID-19 exposure risk? Below, I will give you practical ideas and actionable points that should provide a template for your medical care until all this is way in our rear-view mirror.

Telemedicine Appointments: Many medical offices are offering at-a-distance visits that may be effective for the problem (we do). Most certainly, the physician should lean strongly toward this type service for those over 65yrs and/or with underling medical conditions. Whether an in-person visit is in the patient’s best interests, and so necessary, is a medical decision by the physician. Ask your physician if they are set-up for this.

Minimize Time in Medical Facilities: This is intuitive on its surface. There are creative ways to do this aimed at infection control. It is all about pre-emptive communications, personal preparations for the appointment, and operational flexibility of your medical professionals. To limit your exposure time to other patients and the medical staff,

• Complete all forms and provide all documents (updated insurance, prior medical records) prior to arrival.
• Inform the office staff you will wait in your car until they call you to enter the facility so that you can be showed directly into an exam room, with no time among others in the waiting room.
• Wear a mask (consider a double-mask, like I wear) and rubber gloves.
• Have your story (onset, timeline, encounters with other physicians, medications and their impact on the problem or lack of it, prior diagnostic test reports- blood, urine, imaging) written out to present the physician. Optimal if this can be forwarded pre-visit (FAX, secure email).
• Have your questions and concerns defined and written for the encounter.
• Try to physically distance (other than the actual physical exam) during the visit (6 feet or more from others, including the physician and staff).
• Do not be seen by medical professionals who are not wearing masks.
• Clean your hands when exiting the medical facility, in a building restroom if needed.
• Most of these measures are also relevant to an Emergency Dept, laboratory, imaging facility, physical therapy, pharmacy, and other medical service locations.
• Wash your hands thoroughly as soon as you arrive home, touching nothing else (consider keeping hand cleanser in your car, as well).

Potential COVID-19 Illness Case: It is medically irresponsible to have a person who has an illness consistent with COVID-19 come into a medical office, potentially exposing staff and other patients to the virus.

• Your physician’s staff should be asking each person trying to come in whether they have recently had symptoms consistent with COVID-19, exposure to a confirmed COVID-19 case, or themselves been found positive for COVID-19? These patients need to be turned away from an in-person office visit. The physician can arrange a phone or telemedicine (computer) visit. What if that person is really sick, with ominous symptoms, such as shortness of breath? They must be directed immediately to the hospital Emergency Department, with the doctor and the patient calling the ED staff to forewarn them of an arriving COVID-19 illness so they can sequester the patient into areas designated for such cases, protect themselves, and give directions. Such patients are not welcome at outpatient labs and imaging facilities- they do not want to be shut down because their staff have been compromised and/or infected. The rest of us do not want them closed down either, nor physicians’ offices. We need them up and running out of self-interest.

Conclusion: Stay away from medical professionals and medical facilities, but, with any problem that would normally bring you to contact your physician, do that and let them decide how to address the issue. Do not sit on something you normally wouldn’t. COVID-19 isn’t the only thing that can come to a very bad outcome.

Lastly, if your physician and staff cannot work with you in line with the aforementioned principles or they seem apathetic, dismissive, and/or ill-prepared, maybe it’s time to look for another physician.

Edward R. Rensimer, MD

COVID-19 Update No.12: “Surging” Case Numbers, Media Alerts, and Reality

So, COVID-19 “lockdowns” were eased and new COVID-19 case numbers “surged”? We should all panic. The pandemic is roaring back and we can do nothing but lockdown again. Texas’ governor, Greg Abbott, is giving that serious consideration. This, even though we know further, significant societal lockdown carries dire consequences for our economy and all Americans, while COVID-19 poses a death risk now approaching a small multiple of seasonal flu, and that for a small group of people, mostly the very elderly and medically infirm. The average age of COVID-19 death is 82 yrs, about the U.S. life expectancy for other causes. But, with the alarmist nature of the media and of breakneck, reflexive 24/7 “Media Alerts” and “Breaking News”, we don’t deliberate on the situation… we emotionally react with dread and borderline hysteria.

Lets’ try something new. Let’s calm down and think through the facts, like scientists, like physicians.

The Pandemic Goal: It never was to stop the virus. The cat was out of the bag in January and it was spreading with unprecedented speed and ease across the globe. Based on prior “novel” virus pandemics, we knew this would play out over 1-2 years until the virus slowly changed (mutated) to partner better with humans biologically, rather than kill them (which is against its own interests- a suicide virus). The virus would become the vaccine; eventually, once about 60% of the human herd had been infected and had immunity, the potential human hosts would be radically reduced, and so the pathway to those at most risk for death. The virus would become just another background occurrence in the human condition- like influence, West Nile virus, head colds.

So, we took measures to slow down the outbreak pace (“mitigation”) and to spread it out over many months, rather than over the initial 2-3 months, to allow us time to learn more about the virus and how to deal with it. More medications and management techniques. Maybe a vaccine (but don’t count on it). And, with the concern that the Fall season brings people to congregate more in close-ventilated spaces, as well as the certain annual rise of flu cases, the chief goal was to spread COVID-19 over months so the healthcare system could have staff, supplies, and equipment so no one received less than optimal care when both viruses hit.

Conclusion? Once we re-opened we knew there would be more COVID-19 spread, more hospitalizations, more deaths. It was acceptable, balanced against the sure devastation of lives and of the country with continued lockdown. So, what is happening was expected to happened, yet there is anxiety all about, fanned by the media.

Leadership needs to monitor COVID-19 hospital admissions and ICU occupancy, and adjust infection control measures to match the case numbers to resources. This is analogous to Harris County officials “bleeding off” water in phases threatening to burst the Addicks Dam during Hurricane Harvey to minimize flooding. Some property would be lost, but not all property.

Finally, despite increasing COVID-19 cases, the fatality rate has decreased, suggesting more of the cases may be in those under 65 yrs-old. If that continues, we could be moving toward the 45-60% “herd immunity” that will dramatically decrease the size of future outbreak “waves”.

Case Increases Across the South: It is unclear why this is so, but possibly the cases were at such a low number because of intelligent, effective lockdown measures initially such that we did not have the outbreak disasters seen in New York, New Orleans, etc, due to major errors in management (public transit, nursing home errors, Mardi Gras), and so less infections. As we eased lockdowns, COVID-19 is now getting to more people, but in the intended, measured way. Further, with increasing outside heat, people in Florida, Texas, and Arizona are naturally driven more indoors to air-conditioning, much like the effect of winter’s cold air arrival in the North. We know most COVID-19 infections are acquired among household members in close, prolonged contact, not people out and about.

COVID-19 Case Labelling: There is an incentive for hospitals and the medical profession to label a medical case as “COVID-19” diagnosis. Why? The government and insurers are processing payment for testing and care quickly and at good rates in order incentivize the system to prioritize care for COVID-19 cases as this has been termed “a national health emergency”- analogous to FEMA dollars for floods, hurricanes, tornadoes. The uninsured are even covered, where hospitals would normally eat the bill for them, other than a tax write-off.

So, I arrive at a hospital from a serious car wreck. Now, all patients arriving at the hospital are screened for COVID-19 to protect the staff. But, once that test is positive, I am labeled as a COVID-19 case. If I die from my injuries and was only carrying COVID-19, but not ill from it, I may be labeled as a COVID-19 death. There is a financial incentive to over-diagnose. There is also a political incentive. Make this a bigger, more ominous epidemic, governors, mayors, county judges are given more room to exert power. Be clear also that this is a presidential election year and many politicians have a big stake in not seeing the economy recover for fast and in making this natural disaster the result of mismanagement by current leadership to influence elections.

Social Distancing/ Politics: Somehow, over a thousand medical professionals disgracefully issued a letter stating that the specter of COVID-19 transmissibility during huge public protests across the nation took backseat to the cause of “systemic social justice”. I suppose the COVID-19 virus threat to individuals, which previously required draconian isolation measures by political fiat, now was not so much. I guess “Black lives DIDN’T Matter”, since many of the protestors were black and it is well-established that black death rates from COVID-19 are substantially higher than other groups. Even if mostly younger blacks were protesting, they could take virus to their families.

So, many medical professionals took a political position against their professional oaths to protect the health and medical interests of patients. This put people at risk for serious injury and death, in the name of a political protest movement which was based on a questionable, yet unproven, premise of “systemic social injustice”. Moreover, just weeks before, medical leaders advised and insisted on tight, protracted COVID-19 infection lockdowns with absolutely probable devastating effects on the lives and health across our entire population. It is unequivocal that “social distancing” is the most effective measure against COVID-19 propagation. You put yourself on a single-person raft in the middle of the Gulf of Mexico the next 2 years, you don’t get COVID-19.

Did anyone but me note that the incubation period for acquiring the COVID-19 virus to onset of illness is up to 14 days, and the uptick of cases in Houston occurred 1-2 weeks after the local mass protest gathering and funereal crowds for George Floyd in Harris Country? Yes, what was predicted and speculated is happening. But, the media has no interest in making this association, as apparently they are all-in with the “social justice” movement.

This must be stated. It will be remembered as a low-point for the medical profession and leadership who advocated against the public good, resulting in loss of “precious” lives (“Every life is precious” is, I think, what had been the mantra) out of political self-interest. A disgrace. Disgusting hypocrisy.

Edward R. Rensimer, MD

COVID-19 Update No.11-2nd Wave or Expected Blip

Recently, in some parts of the U.S., including here in Houston, TX, we have, just weeks after businesses have gradually re-opened, seen an uptrend in COVID-19 new cases. Think back to March. At that time there was a strategy of containment and mitigation of the pandemic curve’s upward tack. It was felt too late to stop COVID-19. Rather, the aim was to “flatten the curve”- to turn the new cases curve to horizontal and then gradually downward. That “mitigation” occurred by dramatic lockdown of human interactions and wearing masks, hand cleansing, and social distancing. The curve was bent and new cases as well as deaths declined.

As we saw the resulting economic devastation, a deliberate decision to re-open was made and it was presumed that with people out and about, COVID-19 activity would pick up. It had to. But, we had, for the country’s greater interests, to re-open and expect an increase in new cases.

That’s where we are. We are seeing an uptick in COVID-19 cases. Further, keep in mind that 100X more COVID-19 tests are being done than 2 months ago. This naturally will detect cases that before would have gone unseen. The result? An appearance of increased disease activity, which might actually be an increased detection of cases that were already there, all along.

In the month ahead, look to hear new information showing far more COVID-19 cases than before, many more subclinical or asymptomatic “infections”. Further, we should see the COVID-19 total case denominator grow substantially, which will decrease the mortality rate a good deal, perhaps just above seasonal influenza- say, 0.2-0.3%. If you have 10 deaths in 10 cases, the death rate= 100%. 10 deaths in 1000 cases is 1%. The denominator is everything.

Finally, if there really is some true increase in COVID-19 cases, the long-term benefit is “herd immunity”- much fewer people available to be infected for a large 2^nd wave in the Fall.

So, don’t panic, even if the media have a political agenda in keeping this thing going. Wear your mask, wash your hands, and socially distance. Enjoy the gradual re-opening, but continue to be smart in playing your role in continuing to “bend the curve”, until we are told we can go back to “normal”, which I believe is 1-2 years away.

Ed Rensimer, MD

Director, International Medicine Center

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