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An Updated Big Picture on the Epidemic

By August 7, 2021Commentary

Could be a number of new readers, thanks to Phil Kerpen on Twitter, who recommended that people follow me, and another column in the Strib.  That column should have been written by a physician and I don’t know why someone hasn’t stepped up to provide better education to the public and better expectations.  As always, when people don’t like the information or commentary, they go after your “credentials” instead of attempting to demonstrate why you might be wrong.  I believe it was Martin Luther King who encouraged us to strive to judge a person not “by the color of their skin but by the content of their character”  My addendum would be let’s judge people by the quality of their ideas and analysis, not the string of letters they have behind their name.

But for new readers, let me just say that my background includes 50 years of experience in health care, including working as a nurse’s aide and running multi-hundred million dollar businesses.  I understand health care data and analytics.  I have been reading health research for 40 years and writing a blog on health care research and policy for over ten years.  So I know how to read and understand and critique data sets and research.  With the help of Dave Dixon and others, we have been able to provide more insight into the course of the epidemic in Minnesota and nationally and give people easy to understand graphical representations of that course.  Among the areas I have become familiar with in the course of my career are epidemiology and immunology.  So when the epidemic began and I saw the horrific public response, I felt well prepared to try to provide people with information that would help keep them balanced and rational.  And yes, some of my commentary is biting, even harsh, but also I believe adds a little humor to a dark situation.  Hopefully the blog has met that objective.  And once again, let me express the deepest possible appreciation for readers, every one of you, including those who often disagree with me.

Now, as I have said repeatedly in the last couple of weeks, I thought we would be done by now, and I wouldn’t be writing much on this topic.  But the coronamonomania terrorists seem to have other ideas.  So once again, let me attempt to provide a big picture understanding of this epidemic and the policy responses to it.  For those of you who want more detail, I would refer you again to my epidemic presentation which is up on YouTube, a little dated but the basics are accurate.  (Video Link)

Coronaviruses are very common; we all are exposed to them regularly; what are referred to as seasonal coronaviruses are one of the usual sources of colds.  The good news about this is that most of us, especially children, have some adaptive immune response to attempted coronavirus infections.  Twice before CV-19 in recent decades, coronavirus strains that were more deadly had jumped from an animal host to humans, but those contagions were relatively limited.  It will be hard to ever definitively determine how CV-19 arose, the Chinese have no incentive to be and will not be forthcoming in that regard.  At this point, it appears more likely than not to me that the Chinese took a coronavirus which was already well on its way to becoming more transmissible in humans, modified it further and experienced a lab escape.  Once the virus was out, whether it arose naturally or by lab modification, given global travel patterns and other factors, an epidemic was a foregone conclusion.  Early transparency by the Chinese would likely have facilitated a faster and more effective response, but given what we now know about CV-19, it was going to spread, and is still spreading, almost regardless of efforts to suppress it.

CV-19 is a serious public health threat.  No one should minimize that.  It can and has caused a lot of very serious illness and deaths among people it has infected.  But we should also understand that it is not the bubonic plague and that the response to the epidemic should be measured by the actual threat.  Understanding some basics helps to shape a reasonable response.

I always caution that it is important to think carefully about the meaning of even basic terms like “infected” and “infectious”.  An infected person is one who has been exposed to the virus, inhaled (in almost all cases) it, and the virus has gained entry into cells and begun replicating and releasing new virus particles from those cells.  People can be exposed, but not infected.  They can inhale the virus, but their immune system may immediately disable or kill it, or even something as basic as a sneeze may immediately expel it.  A person is infectious when they are infected and the new virus particles their cells are creating make their way into the respiratory tract and are expelled.  Those virus particles can then be a source of infection for other persons.  The number of infectious persons is to me a critical measure by which to follow the course of an epidemic.  These are the people who keep the epidemic alive.  When their number is growing, cases are going to grow; when their number shrinks, the epidemic will decline.  So I regularly post charts of active cases in Minnesota, the people who are actually infectious.

Respiratory viruses obviously largely enter the body through the mouth and nose, and then attempt to proceed to the lungs and other organs and tissue.  A virus has only one real goal:  replication.  They use receptors to gain entry to cells in the nasal passages and more importantly, in the lungs.  Once inside a cell, the virus hijacks the protein-making machinery of the cell to make copies of the virus, which can be done in astounding numbers.  These new virus particles then exit the cell and seek additional cells to infect.  You can imagine how quickly a person can have an overwhelming load of virus.  Some of these virus particles float more freely in the respiratory tract and are expelled into the air, where if they survive long enough, they can be inhaled by another person and start the cycle all over again.

The disease is caused by the malfunctioning of all these infected cells, which are unable to carry on their normal work, and importantly, by our immune system’s reaction to the infection.  The immune system wants to stop the infection, kill the virus or disable it, but in the course of those efforts will kill body cells and otherwise cause release of chemicals which can further damage bodily tissues and functioning.  Most severe CV-19 disease actually is caused by an immune system over-reaction.  Early on a lot of mechanical ventilation was done to try to treat the disease.  Mechanical ventilation is extremely dangerous for a number of reasons, and fortunately physicians soon abandoned it for many patients, but it caused a lot of early deaths.  Recommended treatment patterns have improved greatly and limited the burden of illness.  People who are infected develop an adaptive immunity, described more below, which will limit their ability to be infected again, and provide substantial protection against serious disease even if they do get re-infected.  Re-infection rates appear to be very low.

At a macro level, an epidemic obviously occurs when a pathogen is being spread substantially in a population.  There are still not fully understood basic aspects of this epidemic.  We don’t know, for example, how many virus particles are typically sufficient to infect someone.  Surface transmission appears to be limited.  Airborne transmission is the primary mechanism for spread, but airborne particles range greatly in size and survival time in the air.  We still don’t have a very good picture of exactly how most transmission occurs–is it through larger droplets, or is a substantial amount via small aerosols that remain aloft for very extended times.

Why do some people get infected when exposed, but not many others?  It is very clear that there is enormous variation in susceptibility to infection and infectiousness.  One of the greatest failures of the modeling was not incorporating this variation.  Why does it exist?  The most obvious answer is immune system variability.  Some people have strong innate immune systems, which have a generalized response to pathogens.  Some appear to have a form of adaptive immunity stemming from seasonal coronavirus infections and that immunity limits their ability to be infected by CV-19.   This immune system variability has an interplay with other factors like age and general health status.  The elderly, especially the frail elderly in nursing homes, have greatly weakened immune systems and are susceptible to any disease.  People who are obese or who have other serious health conditions tend to have weaker immune systems.  So as you might expect they are much more likely to get infected and to suffer serious illness and death.  And they are more likely to have high viral loads which make them more infectious.  And we see a pattern in this epidemic where a relatively few people with very high viral loads account for the great majority of transmission to other people.  And the much higher susceptibility in the frail elderly and those in poor health leads to exactly what we see as the age structure of the epidemic, serious illness and deaths are concentrated in those groups.

So the course of an epidemic as measured by cases, hospitalizations or deaths, is shaped by many factors, including the variation in susceptibility and immune system robustness described above.  Other factors which clearly play a role are population age structure, population density, population health status, obesity levels, and access to health resources.  Another notable feature of this epidemic, as with many respiratory viruses, is the presence of waves which tend to vary by geography and season.  When you see these patterns you have to suspect meteorological factors, such as temperature, hours of and intensity of sunlight, humidity, even wind speed and particulate pollution levels. Those factors could operate on the virus itself, which is quickly disabled in sunlight, on the human hosts–time indoors, dryness of the upper respiratory tract, vitamin D levels, etc., or on the act of transmission–do aerosols survive long in warm or cool air or in dry or wet air?  Although not well formulized, there clearly appears to be some seasonal, geographic pattern, which now that we have year-over-year comparisions, seems to persist.  For example the southern and southwestern US states’ case surge is occurring this year at pretty much the same time it did last year.

An epidemic generally ends when enough people have been infected to develop adaptive immunity.  Adaptive immunity involves the body’s ability to recognize the chemical sequence of parts of the virus and develop what are referred to as B and T memory cells that will identify the pathogen if there is a future exposure.  These immune cells are then able to signal and marshal a response that either prevents or significantly limits infection.  Adaptive immunity can be created by infection or by vaccination.  Vaccination presents the body with sequences which it will recognize as likely pathogenic and then develop that memory response to.  It appears based on the research that actual infection creates an immune response at least as strong and durable as that created by vaccination.  When the proportion of people with some form of adaptive immunity gets high enough, the virus obviously has fewer and fewer opportunities to infect vulnerable people and keep that cycle of replication and infection going.  I think it unlikely that we can eliminate exposure and infection, but it will recede to a background level.

As I note above, features of this epidemic include extreme bifurcation in age structure–almost all the deaths are clustered in the very old, and the young have very, very few.  Another noteworthy feature is what I call front-loading, which can give a misleading picture of the burden of illness impact of the virus.  The virus doesn’t randomly sample a population.  Infections early on are clustered in the most susceptible and most vulnerable to serious illness.  One explanation for the wave appearance of the epidemic may be that because a few people are particularly susceptible and also particularly infectious, those people tend to get infected early, spread a lot early, but when many of them have been infected, there are fewer for the virus to reach, and the wave begins to rapidly recede.

Finally, mutations.  Every respiratory virus is numbered in the trillions or even more.  Every replication event is an opportunity for a change in the basic chemical sequence of the viral genome.  Replication involves copying that genome accurately and evolution actually favors allowing errors, sort of way of experimenting to see if a change creates advantages in survival.  The same thing happens in evolution of any living creature, including humans.  So at any given time, millions and billions of replication events are occurring, as are mutations or changes in the original genetic sequence.  Some of the changes will inevitably confer some advantage, and that advantage will allow greater presence of the new strain.  We have seen this continually with CV-19.  But despite early panic about the effect of several new strains, including now the Delta one, over time it becomes clear that they are not more dangerous and usually not even that much more transmissible.

The public policy response to the epidemic alarmed me from the start and as I noted above, is what prompted my writing about it and beginning to summarize data and research for readers.  It is literally unprecedented to shut down businesses and schools and tell people to stay home in the way that we did.  We have had some very serious flu epidemics and we never engaged in these suppression activities.  Not only were these largely futile, but they obviously have inflicted tremendous social, health and economic damage on populations.  These measures were adopted largely out of panic, hysteria and a herd mentality among our political leaders and so-called public health experts.  The countries, such as Sweden, and the states, such as Florida, that adopted a more rational and balanced approach have incurred no greater toll from the epidemic, and in many cases a lesser toll, than those who went full suppression.

I coined the term coronamonomania to describe this absurd fixation on the notion that you even could suppress a respiratory virus in a large, densely populated, developed nation.  Public health officials should be concerned about the health of the entirety of the population, and political leaders should be concerned about the general welfare of everyone in the country.  And they should recognize the limits and failures of various attempts to suppress spread and find alternatives when those are not working.  Instead in the US alone we have seen tens of thousands of deaths attributable not to the virus, but to the suppression efforts which deterred people from seeking needed health care, from isolation of the elderly, especially those with Alzheimers, and from increased drug and alcohol abuse.  This health toll will continue long after the epidemic recedes.  Study after study shows that we are ruining the lives of a generation of children; serious mental health issues are up substantially and suicides increasing as we deprive children of meaning social and educational experiences.  A recent McKinsey study re-emphasized what many other studies have found, the loss of education among children creates lasting harm to their economic and social well-being, and this is especially pronounced among minorities and children in low-income households.  And we have created unprecedented economic turmoil.

And these suppression efforts didn’t work.  They didn’t work in part because they were based on horrible data and modeling.  Using completely unreliable data from China, modelers, first in the UK and then here in the US, painted a picture of a virus running completely amok and killing tens of millions of people.  The modelers ignored obvious early signs that the virus was primarily dangerous to the frail elderly and those with serious pre-existing health conditions and that there was wide variation in susceptibility to infection and infectiousness. They said their models showed that these extreme lockdowns would stop the epidemic.   So politicians went into panic and cover-my-ass mode.  The terror has been sustained by over-attribution of hospitalizations and deaths to CV-19, using unprecendented notions of if you have any presence of the virus, regardless of lack of symptoms, your hospitalization or death must have been caused by the virus.  And the measures made no difference, we see the same classic epidemic curves everywhere.

From the very start, I have tried to encourage a realistic assessment of the situation.  This is a wide-spread, highly transmissible virus that cannot be expunged.  It will be here, we have to adapt.  We can do so with vaccines and effective treatments.  We are fortunate that unlike flu, it does not seem to inflict serious illness on children and younger adults with any frequency.  The deaths are largely among those with limited life expectancy and have almost entirely substituted for flu deaths.  We cannot endure a continued upheaval of educational, social and economic life.  It is not good for our collective psyche to be subjected to round after round of terror and hysteria.  So brace up, and accept our inevitable fate of enduring periodic epidemics and be thankful that we do have the technical capability to fight CV-19 effectively, but also insist that the comprehensive welfare of the public as a whole be the polestar by which our fight must be guided.  No more lockdowns, no more school closings, no more mask mandates, no more of the futile, virtue-signaling measures which are not supported by data or any credible research.

Join the discussion 30 Comments

  • L. E. Watkins says:

    Excellent “common sense” application of a complex situation. Politicians who make bad decisions on limited knowledge while under stress should be forgiven. Those who make bad decision while ignoring sound knowledge should be removed. We need to be involved in the politician removal business. That was the concept of our founding fathers. Only an informed electorate can preserve our liberties!

    Thanks again for your efforts at sharing with the public!

  • Debbie says:

    Well done, Kevin! Thank you again for a brilliant synopsis of the dreaded CV-19. I have followed you since last spring and you always reassure me that I’m one of the sane ones. I also am happy to see you acknowledge that vaccines AND therapeutics will help curb the spread. On a personal note, my spouse and I have recently been un-invited to two social events because of our vaccination status. We both have recovered from Covid ( mild cases at age 67, and & 70 thank goodness), have possibly a better immunity at this point from Delta than those vaxxed, and yet we are penalized.

    The narrative needs to change. Unfortunately, I don’t see that in the near future. I am so over this virus. Calgon take me away to …Florida or Sweden.

    Keep the commentaries coming…they sustain my need for normalcy!

  • Mark Culham says:

    I’ve been following your updates all along. This is a good summary of what you’ve been saying all along. Well done.

  • Richard Allison says:

    Great Executive Summary! Maybe someone in the CDC will read and, with some luck, maybe even comprehend. Thanks for what you do with your blog.

  • Mike says:

    Bravo, well said. Living in Savannah watching our summer surge. Life isn’t stopping and despite more infections we see fewer serious illness and death. The hospitals are full locally but we are not seeing any increase in our death rate. I wish we could get better details but local county health department is giving out less data and breakdowns than we got in the Spring.

  • CSP says:

    Dayum. That’s a wall of truth. Thank you.

  • Colonel Travis says:

    All we get in the media here in Texas is PANIC, PANIC, PANIC!!! MASK, MASK, MASK!

  • Christopher Foley MD says:

    This is an edited version of my previous comment that had some typos.

    As someone with as much or more experience in healthcare, clinical management, and immunology, I would agreee with 90% of what Kevin says. However, I myself have been speaking up to my community under the fear of scrutiny for spreading “disinformation”.

    Again, many thanks for an erudite discussion. Kevin understates the value of vitamin D, however, and several other micronutrients that are critical in terms of the determination of who get sick and who doesn’t. Melatonin levels are also among the several reasons why younger people do not get sick. Now that we know that adaptive immunity from infection is almost 700 times better at creating immunologic resistance or immunity than the vaccine, it’s hard for him to say unequivocally that the “vaccine works”. It most definitely does not “work” when it comes to reducing transmission, and it provides a petri dish for additional variations and virologic perfection.

    I completely disagree with the attempt to “prevent the spread” with massive amounts of social isolation, cloth masks, social distancing, etc. The lockdowns clearly did not work, and the criticism is welcome and should be shouted out. However, vaccine mandates are completely silly. They are even worse when imposed on those who have had infection with this virus or something similar. In fact, I would suggest that the vaccine is contraindicated in those people. The vaccine seems to mitigate morbidity but that provides a much longer period of time in the host for perfection and spreading. This has been articulated by numerous virologists with far greater experience in this particular science than Kevin or myself.

  • John Oh says:

    I would be eager to learn more about the tests for covid. There’s a great deal of hysterics about an increase in positive results, but what does it really mean? If a test result is positive does it mean the individual is infected and infectious. And how do asymtematic people fit in? If a person is not sick how would they know? I also wonder how reliable the tests are, and if we’re making important decisions based on a lot of false positives. Please don’t tell me the test kits are made in China.

  • Dan says:

    Kevin,

    Can you please comment on Long Covid? I saw this quote from a doctor “ If you get the virus, there is something like a 10% to 20% chance that you will have “long Covid” symptoms. That is not doom porn, it is just the facts. ”. If this is really true it would seem to make a good case for everyone getting the vaccine.

  • Alvasman says:

    I appreciate this article very much and find it easily followed by a layperson, such as myself. What has perplexed me from the earlier days of this matter, and continues to do so as I have yet been given an adequate response, is why there has been so little broadcast about how persons could bolster the immune system.

    Now, there are persons who think this is a simple question and are quick to dismiss any discussion. However, if we can strengthen our immune system, then was has then been mostly ignored except for a comparative few?

  • Will says:

    Just one aside. Is it true that the obese have weakened immune systems(aside from some more obvious health problems) or is this just an assumption because they are over represented as victims of this disease?

  • Corrie says:

    I was applauding this article and your common sense approach until the “no more mask mandates” line. I lived in Japan for several years where folks voluntarily mask up when they feel unwell and are going to be in close contact with others. This to me is common sense. You are right Kevin, it shouldn’t require mandates. We should have cared enough from the beginning to recognize the common sense notion having something, anything, in front of your nose and mouth is going to protect yourself and others more than not having something in front of your nose and mouth. It’s why we teach our kids to use their elbows when they sneeze. Its also why Seattle’s Children’s Hospital is considering requiring visitors to mask up from now on. I think businesses and schools could and should have been kept open (I have a 5 year old) but we just aren’t willing to look out for each other in the common sense way that the Japanese do – by masking – without fanfare, obfuscation, public outcry, virtue signaling, politicization or indignant “rights” defending.

  • John Ronning says:

    While panic is indeed promoted to the public, I’m more and more convinced that the response of our leadership is more like cold blooded murder. It is difficult to identify a single public policy that does not serve one or both of the twin goals: (1) consolidation of power by governments and international corporations and agencies (the “never let a crisis go to waste” factor); (2) $ $ $ $ $ $ to the drug companies, which goes to them and their shareholders, and is spread around to everyone who influences public policy, from editorial boards of medical journals, to lobbyists and politicians, directly to public agencies (and I thought public agencies were funded by the public and worked for the public good – silly me), to doctors, to hospitals, etc. Explains why early treatment with cheap generics and just good old vitamin D (people with adequate levels aren’t dying) are suppressed in favor of expensive and worthless hospital treatments (Remdesivir is used BECAUSE it is expensive, not because it works). They say history is written by the winners – we must not let these frauds/criminals win.

  • Kevin Roche says:

    I don’t agree with that at all, obviously for-profit companies are supposed to make money, the margins on these vaccines are not as high as on most drugs, and anyone who reads the blog knows how I feel about the factors which allow excessive profits. But that has nothing to do with the public policy response. if anything we are witnessing the usual government incompetence, which always does its worst in a crisis.

  • Kevin Roche says:

    Okay, you need to look at the Japanese epidemic curve, which you can find in a lot of places and explain how near universal masking affects that curve. Right now all that masking is producing one of the steepest curves anywhere in the world. I love it when people say it would be worse if it weren’t for the masks. Really, how can it be worse, look at the steepness of the curve and explain to me how it could possibly be any worse.
    The reason I oppose mandates is because masks don’t work to slow community spread, and all the believing they work in the world doesn’t change the fact that there is not one solid piece of real research that shows they do. In health care we typically don’t recommend, much less force an intervention without clear evidence from multiple trials that it works. There is not one trial that supports that. Oh wait, but there is one, in Denmark, a randomized controlled trial, that shows that they did not slow transmission.

    And the Japanese have a very different culture than we do, one that is completely obeisant to authority, whether the authority is right or wrong. At this point they know masks don’t work too, so be interesting to see how they react.

    It sounds so nice to say well we should just all look out for each other. How is it looking out for each other to do something that makes no difference. I have explained over and over to people that what the physical flow research shows is that over any extended period of time a mask basically stops nothing in the size range of the aerosols that carry CV-19 virions. And the research that shows that virus live longer on mask surfaces than on any other surface but one that was tested by the Public Health Agency of England, and that period of time wa almost a day. I call masks virus collection devices for a reason–what do you think happens to all that virus that masks are supposedly catching–it just dies immediately.

    This mask stuff drives me crazy, it is pure religion and politics and has no basis in science at all. And to do it to children is abuse. Pure and simple.

    Thank you for reading, sorry to vent, but read the research and use your common sense.

  • Kevin Roche says:

    No, truly obese people have altered immune systems that are more prone to inflammation and other malfunctions.

  • Kevin Roche says:

    yes, i agree, maybe taking vitamin D helps, obviously a good diet and plenty of exercise can help keep your immune system in good shape.

  • Kevin Roche says:

    Such a lie, there is no evidence that any significant number of people truly suffer very long-term symptoms from CV-19 disease. I posted on a study regarding children this week that among other things found that children without CV-19 had more long-term symptoms similar to CV-19 than did those who had the disease. So lots of people have lots of symptoms all the time. Not clear CV-19 causes anything different from the background rate. We are seeing a flood of misleading scary information about CV-19, largely designed to terrorize people into getting vaccinated. It is disgraceful. We treat the public like idiots. Tell them the full truth and help them make an informed decision. Instead we lie and manipulate.

  • Kevin Roche says:

    There is reason to be concerned about PCR tests. Thresholds for positivity are routinely used that do not actually detect infectious people. In a low prevalence environment, false positives as a proportion of positives increase.

  • Kevin Roche says:

    Chris, stop spreading lies about the vaccines or your comments go in the Trash. These are absolute lies about deaths. You have no clue what you are talking about and it is extremely damaging to individual decision-making and the welfare of people who are vulnerable to serious CV-19 disease when you report this misinformation. I am not having it on the blog.

  • rob says:

    This was really an excellent summary, very helpful, this is one they should print in the StarTribune.

  • Jody Ivan says:

    Great work as usual. I would recommend that everyone read the book ‘The Great Influenza’ by John M. Barry. It is a fantastic description of the 1917 pandemic and will provide lots of good background info that can be helpful when reviewing the current ‘pandemic’. I just happened to read it in January of 2020 and it has helped me to a great deal in my understanding of the overblown response to the current sickness.

  • Debbie Larson says:

    You are so eloquent Kevin. Thank you. I really enjoy your thoughts and perspective.

    As I was reading the blog today, a question surfaced. At what point does a variant become another seasonal coronavirus (Covid – 21 as an example). In other words do variants become the next seasonal Coronavirus?

    Maybe Covid – 19 is actually now Covid – 21? Was there a Covid – 18? Why should we think that all Coronaviruses going forward are as problematic as Covid – 19?

    Would changing the name (if appropriate) to Covid – 21 help us move forward and stop looking at everything through Covid – 19 glasses?

  • Kevin Roche says:

    I do think that eventually, if we are sane, some strain or strains of CV-19 become like the seasonal coronaviruses and just circulates regularly.

  • Russ Paige says:

    Kevin, from my armchair, you already to be understating the irrationality of the official response. Isn’t it also true that 95% if COVID-19 deaths include multiple co-morbidities (averaging 2.6 co-morbidities the last time I saw the data mentioned)?

    It has seemed to me that we knew in March of 2020 that if you’re not BOTH *very* old AND *very* sick, COVID-19 is simply not a significant health risk?

    Thanks to Scott Johnson of the Powerline blog for linking this.

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