My thoughts on masking.

I do not like wearing masks, in fact as soon as I get into my office and close the door, off comes the mask. However, I am still planning on wearing a mask when I am in a public indoor space and cannot stay physically distanced from other people. The following is why:

First and foremost, since the beginning of the pandemic, I have considered masks as a way to protect other people from me (or, as my graduate student put much better than I “I like to keep my germs for myself”). Unless you have a well-fitting N95 (better termed a respirator than a mask) or equivalent and all of the air that you breathe in goes through the mask, (this is why fitting is critical), then you are not well-protected against possible infection from SARS-CoV-2 (or other respiratory pathogens for that matter). Given that I have a beard and have not cut it off during the pandemic, any mask that I wear will only protect me slightly. On the other hand, if any of the air that I breathe out goes through a mask of any kind, then, if I am spreading any respiratory pathogen, I will be spreading less of it. I have had 3 doses of vaccine, which protects me quite well from acute COVID-19 disease but does not protect me from getting infected by SARS-CoV-2. Being vaccinated probably means that if I am infected then I will produce less virus than I would have if I were not vaccinated. But I could still spread virus and I don’t know if I have been infected.

So, I could be infected and possibly breathing out some respiratory pathogen. When I am outside (which I try to be as often as possible when interacting with other people) any pathogen that I breathe out will be rapidly diluted and not be dangerous to other people. On the other hand, if I am in an enclosed space and particularly close to other people whom I do not know well for long periods of time (>15 minutes), I could, possibly infect someone else. If that other person is vaccinated and the vaccine is working for them as it does for me, the risk to them (and to me) is quite low. However, there is no way for me to know if that person is immune-compromised, is living with someone who is immune compromised, or has some condition that makes them at higher risk for COVID-19 (the disease). Wearing a mask lowers, but does not eliminate, any possible dose that I could be spreading. I also consider wearing a mask as being respectful to other people.

There are a few scientific studies that have looked at the effectiveness of masking at slowing the spread of COVID-19 (a nice recent Twitter thread on two recent publications is here: https://twitter.com/roby_bhatt/status/1502244997764157442 ). I am also concerned that many mask mandates are being lifted without clear communication that mask mandates may need to be reinstated if a new variant arises or vaccine effectiveness decreases. I am particularly concerned that basing masking on hospitalizations instead of random screening of wastewater or asymptomatic persons may miss a rapid increase, since hospitalizations are a “lagging indicator”. When hospitalizations go up, cases will have already been going up for a long time and it may be too late to “flatten the curve” since growth is exponential and the earlier interventions are made the better. Most of the developing world has not been vaccinated yet and I am sure that there will be new variants, I just don’t know if these new variants will cause more disease.

So, until we have a lot less virus around (<10-20 cases/100,000), I will be wearing a mask when I am in enclosed spaces with other people whom I do not know, mostly so that I have less chance of infecting them. I will also wear a mask when I have any respiratory symptoms even after COVID-19 levels get much lower than they are now . I will also always wear a mask when anyone asks me to or says that they would prefer for me to wear one, without asking a reason. This is why, even though I don’t like wearing masks, I will continue to do so.

PS. COVID-19 numbers are increasing in Europe, so it may not be long before numbers are increasing again here as well. There are still over 1000 people per day in the USA who are dying from COVID-19 and over 1000 children have died from COVID in the USA since the beginning of the pandemic (data from the CDC).

What are my thoughts on "booster shots"?

Here are a couple of thoughts on COVID-19 vaccine “booster shots”. I do not see a safety issue with an additional dose, but I have not yet seen data that convinces me that they are more protective against disease than the current vaccine schedules. I also think that is is much more important that unvaccinated people; those under 12, those in the USA who have not been vaccinated, and in the rest of the world are vaccinated first.

I do not expect a safety issue with boosters (or 3rd doses which is another way of looking at it), there have been clinical trials on immune-suppressed people and a 3rd dose of mRNA vaccines definitely boosts the amounts of antibodies that the person has. I have not seen data on whether the 3rd shot is actually protective against disease (or for that matter infection). There are quite a few vaccines that have multiple doses (for DTaP 5 doses are recommended), so three is not unusual.

My main concern is that, in most studies (with the possible exception of Israel, but there are some issues with those data that still need to be clarified, in my opinion), show that vaccination with 2 doses of the mRNA vaccines (and one dose of the J&J vaccine, but very few people talk about that one) protects very well against disease (COVID-19). It appeared that some of the mRNA vaccines (and to a lesser extent J&J) protect somewhat against infection by SARS-CoV-2 (not the same as disease) and that protection against infection may be waning, particularly relative to the delta variant. However, infection is not equivalent to disease, the latter of which the vaccines do an excellent job of protecting from (not 100%, but nothing is 100%).

I also have personal issues with "rich" countries distributing 3rd doses before many countries in the world do not even have one and (at least in some of those "rich" countries with relatively low vaccination rates) also people who have not even had one shot. I think that mandates for 1st doses would be much better than offering 3rd, but that is an opinion (although there is some modeling that indicates that getting more people even partially vaccinated would be much better than getting people 3rd shots). It is also pretty clear that as long as SARS-CoV-2 continues to circulate anywhere in the world, more variants will arise, hopefully none that can avoid vaccines, but who knows, so EVERYONE needs to be vaccinated.

Take home message, if you are immune-compromised (there is a very clear definition of this on the CDC website), get a 3rd shot. If not (and I fall in this category), I am not in any rush.

Thoughts on schools, vaccines and the delta variant

RE: Schools. In my opinion (and there are reasonably good, but not great, data to back this up) schools can be open and be safe, even with circulating virus. Before there were vaccines, schools were open and in person in many places in the world, some of which had higher rates of community spread than we do now here in Oregon/Multnomah county. These schools had strict mask mandates in schools, upped ventilation and had regular random testing. The thing that I feel is missing (and I have been preaching this for a while) is wide access to low cost or free testing, even at home testing. More of an issue when these schools were open seemed to be transmission outside of the schools, such as playdates, birthday parties, family gatherings, etc. (Schools are easier to control, unless you have politics getting in the way. . . .). Personally, however, I would be concerned about teachers being vaccinated if my kids were under 12 (both are older and have been vaccinated). That being said, bring on the vaccines for kids ASAP!

RE: Vaccine Approval. I don't know why it is taking the FDA and CDC so long to approve/recommend vaccines for 6-12 year olds. Personally I am surprised that it is taking so long, but I am not a regulatory expert. Probably because they want as much data on safety as possible, given the rare cases of endocarditis and unusual clotting with some vaccines. That being said, as far as I know, there is nowhere in the world that any COVID-19 vaccine is approved for 6-12 year olds. I think that the USA was one of the first to approve vaccines for 13-16 year olds.

RE: Infections, disease and vaccines: One thing that I always try to emphasize, but often seems to be lost, is that infection is not the same thing as disease. I admit that I was skeptical when the WHO named the virus SARS-CoV-2 and the disease caused by the virus COVID-19, but now I think that it helps to understand that the vaccines were designed and tested and approved for protection against the disease (COVID-19) not against infection by SARS-CoV-2 (this is one of many reasons that I really dislike the term "breakthrough infection", but that probably needs to be another blog post). Unfortunately most people talk about the COVID-virus, which is not correct. One analogy that I like is that the vaccine is like a fire extinguisher, it does not stop a fire from starting (infection), but it can stop a fire once it starts (disease).

RE: Delta variant. As far as the Delta variant is concerned, it is still SARS-CoV-2, and a Coronavirus, so all of the non-pharmaceutical interventions work just as well with this variant as all others, i.e. masks, distancing and ventilation. From epidemiological studies and a few case studies, it appears that Delta can spread from person to person sooner after infection, and MAY be somewhat resistant to pre-existing immunity, either from vaccination or previous infection. But it is not clear at all what causes this and how much has to do with people "letting down their guard". The big outbreaks in India were after major large group events, and in the USA after July 4th, and when people basically seem to have thrown away all of their masks (I am less sure about the spike in the UK, maybe the European Soccer championships). Still, just like for all of the other variants of SARS-CoV-2, vaccinated people do much better than non-vaccinated people when infected with the Delta variant of SARS-CoV-2. On average, the vast majority of people with severe COVID - from whatever variant - are non-vaccinated.

Why COVID-19 mRNA vaccines would not be reverse transcribed into DNA.

Some astute observers note that retroviruses use viral RNA and reverse-transcribe it into double stranded DNA and insert this DNA into the host genome. This is how retroviruses reproduce. The viral RNA in retroviruses is very similar to mRNA, since it has a cap and a poly-A tail and is made by cellular DNA-dependent RNA-polymerase. So, if a cell is infected with a retrovirus and a mRNA vaccine gets into that cell, maybe the mRNA from the vaccine could be reverse-transcribed into double stranded DNA and inserted into the cell’s genome, thereby changing the host DNA. There are also some endogenous retroviruses that are already in the genomes of all of our cells.

There are a number of reasons why this mRNA vaccine to DNA process would not happen. The first is that reverse transcription of viral RNA starts from a cellular transfer RNA (tRNA) primer that has to bind to the viral RNA. The mRNA vaccines do not have binding sites for a tRNA, so there would be nowhere for the reverse-transcriptase (the enzyme that copies the RNA into DNA) to start. The second is that all retroviruses have 2 copies of the viral RNAs that bind to each other through a special sequence called a kissing loop. Having two copies attached to each other through this kissing loop is essential for virus replication. The mRNA vaccines do not have this “kissing loop” sequence.

The third, and probably most important, reason is that reverse transcriptase stops when it tries to copy a RNA that contains a pseudo-uridine (a special modified base that is present in the tRNA primer that the reverse transcriptase used to start reverse transcription) instead of the normal uridine. This stopping is essential for the reverse transcriptase to make a double-stranded DNA that can be inserted into the genome (check out my Retrovirus lecture on YouTube for an explanation). The mRNA vaccines contain pseudouridine (actually 1-methyl pseudouridine) instead of the normal uridine to protect the vaccine from stimulating the immune system before it can do it’s job. So any reverse transcriptase that is trying to copy an mRNA vaccine into DNA, would stop before it had a chance to make double stranded DNA.

So, because the mRNA vaccines a) do not have a primer binding site, b) do not have a kissing loop structure, and c) contain pseudouridines instead of uridines they will not be copied into DNA by reverse transcription.

Will the COVID-19 (SARS-CoV-2) Vaccines change your genetic material?

The short answer is no.

The answer to why depends on which vaccine you are talking about.

I will start with the mRNA vaccines (Moderna/NIH, BioNTech/Pfizer). The whole concept of mRNA vaccines is that they will be translated in the cytoplasm of cells by ribosomes and never enter the nucleus, so are always in a different subcellular compartment than our genetic material (DNA in the nucleus) so cannot modify it. mRNA is also unstable, it gets degraded in cells after it gets translated into protein. That protein (the S-protein of SARS-CoV-2) is then detected by your immune system to train the immune system to react to a SARS-CoV-2 infection in future.

Then there are the viral-vectored vaccines (J&J and Astra-Zeneca). These use a disabled adenovirus (E1 and E2 deleted) which has DNA that encodes the spike protein inserted into the adenovirus genome. This disabled adenovirus genome then gets into the nucleus of a cell. (The reason for using adenovirus is that it is very efficient for getting DNA into cells, much more efficient than the mRNA vaccines.) So there is now extra DNA in the nucleus in the same place as our genetic material. However (as we talked about in class), adenoviruses do not integrate into the host genome, so do not change our genetic material. There are 2 reasons why adenovirus DNA does not integrate. First the genome has proteins bound to the ends, so it does not integrare. There are also no areas of sequence similarity between the adenovirus genome and our genome so homologous recombination (which is one way that external DNA can integrate into genomic DNA). Finally, this disabled adenovirus does not have the machinery to make more of the virus, so it is also only around for a short time, not as short as mRNA, but still a short period of time.

I hope that this helps.

This is from basic molecular biology that has been studied for over 50 years.

-Ken Stedman

COVID Vaccine FAQ Mini-Videos.

At the end of March, I recorded a couple of video answers to some vaccine (mostly SARS-CoV-2/COVID-19) FAQs. I posted them on YouTube, but thought that I should post them here too:

1. How were the vaccines developed so fast? https://lnkd.in/gt8sFqE
2. Are there likely to be long term side effects of the vaccine?
https://lnkd.in/gpRBzsz
3. What if I am hesitant to get a vaccine?
https://lnkd.in/guR4spw
4. Is one vaccine better than another?
https://lnkd.in/gS656E7
5. Why do vaccines have to be kept cold?
https://lnkd.in/gvgrjRH

Please feel free to share and let me know if you have any questions!

Thoughts on "FEND" (hellofend_dot_com) for COVID-19

I am EXTREMELY skeptical. This looks like a slick marketing campaign and a way to fleece (understandably) scared people = scam! Where are the clinical trials, data and FDA approval? (None of this is on their website)? This looks to me like it is being marketed as Medical Device, which should be approved, but it is apparently not. Here is their disclaimer (from their website):

“The Company does not provide any medical advice on the website or along with the product, and the information provided should not be so construed or used. Using, accessing and/or browsing the website does not create a physician-patient relationship, and no information is to replace the services of a licensed, trained physician or health professional or to be a substitute for medical or advice of a physician or trained health professional licensed in your state. You should not rely on anything contained in the website and you should consult a physician licensed in your state in all matters related to your health. You hereby agree that you shall not make any health or medical related decisions based on whole or in part on information provided on the website or along with the product.”

Any time that I see "Harvard scientist" (who is not listed as faculty on their website but as an "Associate"), no data, and someone trying to sell something I am skeptical. This is probably about as effective as a much cheaper and equally ineffective salt gargle that people were pushing at the beginning of the pandemic (I wrote about this on my blog).

It would be a LOT cheaper and data shows to be a lot more effective to get some good N-95 masks, make sure that they fit and wear them instead of this expensive BS.

My $0.02.

Soapbox off.

Thoughts on "Wonder drug" combination Hydroxychloroquine and Azithromycin

I (and a lot of other people) was really excited about this paper when it originally was released. It appeared to show that a combination of Hydroxychloroquine (an anti-malarial drug that can slow SARS-CoV-2 growth in a test tube) and Azithromycin works wonders in COVID-19 patients. Unfortunately this has led to some people stating that this combination of drugs, or just hydroxychloroquine is a miracle cure and has led to shortages of hydroxychloroquine and even one death from someone who thought that they were protecting themselves from COVID-19 by consuming chloroquine phosphate (pool cleaner) but ended up killing themselves https://www.cnn.com/2020/03/23/health/arizona-coronavirus-chloroquine-death/index.html, there is up to date information on chloroquine and hydroxychloroquine at the CDC: https://www.cdc.gov/malaria/new_info/2020/chloroquine.html. Hydroxychloroquine is an FDA approved drug for certain immune deficiencies, including lupus and now these patients are having trouble getting drugs that they need and work.

It is really hard physically and ethically to do clinical trials to prove that a drug works during a pandemic, but people are trying very hard. So far the data on chloroquine and hydroxychloroquine as treatments for COVID-19 are inconclusive. The “gold standard” for a clinical trial is a double-blind placebo-controlled trial where neither the patient nor the provider know if the patient is getting the drug or a placebo (a sugar pill, or something similar that has no medicine in it, but is otherwise similar to the medicine). It is also important that a clinical trial has sufficient numbers of people who are as comparable to each other as possible in order for the trial to be statistically significant and sufficiently convincing to be used by medical professionals (which I am not!).

The trial which got all of the press about a week ago has a number of issues. One is that it was an “open label” trial, where all of the patients got to choose if they got drug or not, so they were self-selected and not really comparable to each other. There were also only 6 patients reported in the Hydroxychloroquine and Azithromycin part of the trial at the end. Apparently at least 1 person in this treatment group died and 5 others left the trial for unclear reasons. The manuscript itself was submitted for peer review (where other, presumably independent, scientists critique the manuscript) one day before it was accepted. Generally peer review takes weeks or more, not a single day. The chief editor of the journal is also an author on the paper, which could be a conflict of interest, as it is the chief editor who decides what gets published or not in the journal. Another group has done a far better job than I commenting on the paper link below.

Take home message: Hydroxychloroquine plus Azithromycin is NOT a wonder drug/treatment yet, and far more trials (many of which are ongoing with both Chloroquine and Hydroxychloroquine, 20 at last count) are required before it can be show to be effective and used in medical practice, I hope to see them soon. So leave the Hydroxychloroquine for the people who need it, those with lupus and other autoimmune diseases.

(See https://www.youtube.com/watch?v=8A3jiM2FNR8) and https://www.cebm.net/covid-19/chloroquine-and-hydroxychloroquine-current-evidence-for-their-effectiveness-in-treating-covid-19/

https://zenodo.org/record/3725560#.Xn_tVdNKiYU

Transmission and airplanes

The other question mark to the uninformed like me--transmission.  Airline passengers and crew in the immediate proximity of Corona patients have not caught the disease, despite not knowing that precautions should have been used.  All 19 people who brought Corona to the Hawaiian islands left, and so far, there has been no fall out.  In Italy, with stringent isolation policies in place, Corona deaths are continuing to escalate after more than a month of quarantine.  South Korea, who does industrial strength cleaning of all public places daily, but does not have quarantine (that I know of) has quelled the outbreak. 

Airplanes probably have better air circulation (and better filters) than many places (busses and trains for instance). I do not know of any airline crew who have tested positive, but that does not mean that there are not any.  I think that crew are more likely to be exposed, as they travel and move about airplanes much more than passengers. I do think that the worry about transmission via surfaces is much more than it needs to be, the majority of cases appear to be by direct respiratory transmission by respiratory droplets, unfortunately in some cases apparently by people who do not appear to be (or feel) sick.  This could be from talking, not only sneezing or coughing.  The data so far show that the majority of transmission is in families and in medical settings (where people are very sick and are producing a lot of virus).  I do not know about the Hawaiian situation, I suspect that there are possibly many cases there that have not been detected yet. Italy's stringent isolation was probably too late (the virus has quite a long incubation period, so what we are seeing in hospitals now is due to infections that happened weeks ago).  South Korea has excellent testing and is isolating and quarantining people who are known to have the virus, since they have much better testing than we do, this is a strategy that works. We know so little about who has the virus and who does not here, that general isolation procedures are probably our best bet. 

Food safety in the time of COVID-19 - Take Out/Delivery

A nice well-researched and well though-out article from a chef in the SF Bay Area that states it better than me:

https://www.seriouseats.com/2020/03/food-safety-and-coronavirus-a-comprehensive-guide.html

Take home messages, support your local restaurants, take out and delivery is very low risk (probably lower than visiting the grocery store).

Question on Coronaviruses in local bats:

To my understanding, there are Coronaviruses in US bats (not sure about OR and WA), but not closely related to SARS-CoV (1 or 2).  Here is an article about it: 

• http://wwwnc.cdc.gov/eid/article/13/9/07-0491_article.htm 

There may be some other papers on the subject, I do not know.  I discuss this in my Coronavirus lecture on my YouTube channel, (YouTube.com/c/KenStedman) if you are interested in more details. 

-Ken Stedman

On Sun, Mar 15, 2020 at 12:02 PM wrote:

Dr. Stedman,Considering your statement that COVID-19 originated in bats from China, is it possible that Oregon and Washington bats carry similar viruses?

SARS-CoV-2 on surfaces MedRxiv preprint.

A preprint (a scientific article that has not yet undergone peer-review, so is not considered “vetted” yet) was recently posted on MedRxiv and has generated quite a lot of press. https://www.medrxiv.org/content/10.1101/2020.03.09.20033217v1.full.pdf I wanted to put this work in some context.

To start with, this is very important work and it cannot be done by most scientists. It has to be done in a high security laboratory, also known as BioSafety Level-4 (BSL-4) because we currently have no treatment for SARS-CoV-2 (they call it HCoV-19 in the preprint, which is a little confusing) and it can be deadly. The work was done at the National Institutes of Health BSL-4 lab in Hamilton, Montana at the Rocky Mountain Labs.

The researchers put the virus in a nebulizer with some liquid to put the virus into small liquid droplets, kind of an artificial cough or sneeze. The droplets they made are smaller than 5 micrometers, so called aerosols. They also put the virus directly on various surfaces, copper, stainless steel, plastic, and cardboard. After they did these things to the virus, they waited and tested to see if the virus could make cells sick. To do this, they put the virus on cells in a petri plate (not exactly a petri plate, but similar). Then they used smaller and smaller amounts of the virus (dilutions) until it no longer made the cells sick. This is called a TCID50 test, (Tissue Culture, Infectious Dose 50% test). It is a pretty easy test to do, even I have done some (not with SARS-CoV-2, with flu vaccine!). You can tell how active or “viable” (the term used in the preprint) the virus is by how much you can dilute the virus before it stops making the cells sick. All of these experiments were done in controlled laboratory conditions (65% relative humidly (RH) and 21-23C for aerosols, 40% RH for surfaces).

The researchers found that the virus lost about 90% of its viability in aerosols after 3 hours. The virus lost about 99.9% of its viability, on plastic by 72 hours and on stainless steel by 48 hours but was still detectable. On copper the virus lost over 99% of its viability after 4 hours, and could not be detected after 4 hours. No virus could be detected after 24 hours on cardboard. Loss of viability in all conditions was exponential, so much more viability was lost earlier. The half-life (time until 1/2 of viability was gone) for aerosols was about 2.5 hours, for copper 3.5 hours, for cardboard 8.5 hours, for stainless steel 13 hours and for plastic 16 hours.

These viability values are all very similar to SARS-CoV-1, which is more deadly than SARS-CoV-2 but spreads much less well. So it is not clear why SARS-CoV-2 seems to spread much better than SARS-CoV-1, it does not appear to be due to it’s stability on aerosols or surfaces. The researchers state that SARS-CoV-2 transmission via aerosols (very small droplets) and surfaces is possible. They do not state, but I understand, that this means that the main means of transmission is probably directly through respiratory droplets, so keep your distance and cover your cough! Since transmission via surfaces is possible, also WASH YOUR HANDS!

There are a couple of caveats about this paper, all acknowledged by the researchers. All experiments were done in a controlled lab environment, what happens in the “real world” is less clear. More importantly, you may have noticed that I used viability instead of infectivity (as did the authors). We do not know what the infectious dose for SARS-CoV-2 is [N.B. I have been reminded, thanks Charles Haas, that infectious dose is a bit of a misnomer, it is really more of a statistical issue, but I did not want to get into details]. So maybe when the virus is in an aerosol or on a surface it could lose too much viability to be infectious, even if it is still detectable with this TCID50 test. These are very important numbers to know, but will be hard to test, since we can’t infect people with the virus in an experiment.

Comments on: “What I am doing for the upcoming COVID-19 (coronavirus) pandemic” e-mail.

Here is another “viral” e-mail.

Subject: What I am doing for the upcoming COVID-19 (coronavirus) pandemic

Dear Colleagues, as some of you may recall, when I was a professor of pathology at the University of California San Diego, I was one of the first molecular virologists in the world to work on coronaviruses (the 1970s). I was the first to demonstrate the number of genes the virus contained. Since then, I have kept up with the coronavirus field and its multiple clinical transfers into the human population (e.g., SARS, MERS), from different animal sources. The current projections for its expansion in the US are only probable, due to continued insufficient worldwide data, but it is most likely to be widespread in the US by mid to late March and April.

Here is what I have done and the precautions that I take and will take. These are the same precautions I currently use during our influenza seasons, except for the mask and gloves.:

1) NO HANDSHAKING! Use a fist bump, slight bow, elbow bump, etc.

2) Use ONLY your knuckle to touch light switches. elevator buttons, etc.. Lift the gasoline dispenser with a paper towel or use a disposable glove.

3) Open doors with your closed fist or hip - do not grasp the handle with your hand, unless there is no other way to open the door. Especially important on bathroom and post office/commercial doors.

4) Use disinfectant wipes at the stores when they are available, including wiping the handle and child seat in grocery carts.

5) Wash your hands with soap for 10-20 seconds and/or use a greater than 60% alcohol-based hand sanitizer whenever you return home from ANY activity that involves locations where other people have been.

6) Keep a bottle of sanitizer available at each of your home's entrances. AND in your car for use after getting gas or touching other contaminated objects when you can't immediately wash your hands.

7) If possible, cough or sneeze into a disposable tissue and discard. Use your elbow only if you have to. The clothing on your elbow will contain infectious virus that can be passed on for up to a week or more!

What I have stocked in preparation for the pandemic spread to the US:

1) Latex or nitrile latex disposable gloves for use when going shopping, using the gasoline pump, and all other outside activity when you come in contact with contaminated areas.

Note: This virus is spread in large droplets by coughing and sneezing. This means that the air will not infect you! BUT all the surfaces where these droplets land are infectious for about a week on average - everything that is associated with infected people will be contaminated and potentially infectious. The virus is on surfaces and you will not be infected unless your unprotected face is directly coughed or sneezed upon.  This virus only has cell receptors for lung cells (it only infects your lungs) The only way for the virus to infect you is through your nose or mouth via your hands or an infected cough or sneeze onto or into your nose or mouth.

2) Stock up now with disposable surgical masks and use them to prevent you from touching your nose and/or mouth (We touch our nose/mouth 90X/day without knowing it!). This is the only way this virus can infect you - it is lung-specific. The mask will not prevent the virus in a direct sneeze from getting into your nose or mouth - it is only to keep you from touching your nose or mouth.

3) Stock up now with hand sanitizers and latex/nitrile gloves (get the appropriate sizes for your family). The hand sanitizers must be alcohol-based and greater than 60% alcohol to be effective.

4) Stock up now with zinc lozenges. These lozenges have been proven to be effective in blocking coronavirus (and most other viruses) from multiplying in your throat and nasopharynx. Use as directed several times each day when you begin to feel ANY "cold-like" symptoms beginning. It is best to lie down and let the lozenge dissolve in the back of your throat and nasopharynx. Cold-Eeze lozenges is one brand available, but there are other brands available.

I, as many others do, hope that this pandemic will be reasonably contained, BUT I personally do not think it will be. Humans have never seen this snake-associated virus before and have no internal defense against it. Tremendous worldwide efforts are being made to understand the molecular and clinical virology of this virus. Unbelievable molecular knowledge about the genomics, structure, and virulence of this virus has already been achieved. BUT, there will be NO drugs or vaccines available this year to protect us or limit the infection within us. Only symptomatic support is available. I hope these personal thoughts will be helpful during this potentially catastrophic pandemic. You are welcome to share this email.

Good luck to all of us!

James Robb, MD FCAP

While I have a great deal of respect for Dr. Robb, a respected pathologist, he states at the beginning of the e-mail “Since then [the late 1970s, 40 years ago], I have kept up with the coronavirus field and its multiple clinical transfers into the human population (e.g., SARS, MERS), from different animal sources.” and then at the end “Humans have never seen this snake-associated virus before and have no internal defense against it.” He does not appear to have published on Coronaviruses since 1981 (then again, I have never published on Coronaviruses, so you can decide).

The evidence for SARS-CoV-2 having anything to do with snakes has long been debunked and leads me to question the “I have kept up with the coronavirus field” statement.

That being said, I agree with most of his precautions, I find the use of gloves and wipes to be excessive. Gloves can be contaminated as easily as hands, so they must be discarded, which in my opinion is rather wasteful. Hands are easier to wash. However, I disagree with the stocking and other comments. The ACE2 receptor that SARS-CoV-2 binds to is also present on gut epithelial cells, which is probably why viral RNA can be found in fecal matter and closely related viruses may replicate in bats (not snakes!) in the gut. See my previous blog post about surfaces. Surgical masks are usually misused and are only really preventative when someone is ill.

It is also unlikely that someone else will be rubbing the elbow of your shirt/blouse in their face, the main reason to cough into your elbow is so that you don’t spread your droplets to other people.

I would love to see data on Zinc in a properly controlled blinded trial (lozenges without zinc and lozenges with zinc). To my knowledge none exist. I am pretty certain that zinc lozenges have no effect on disease progression due to SARS-CoV-2 infection. I also am extremely skeptical when a brand is mentioned.

Critical reading of COVID-2 "Advice" letter

The letter below or some variation thereof has been circulating on the Internet. There are a number of issues with the letter that I will outline below the letter.

I received this from a friend of mine who’s brother is on the Stanford hospital board. This is their feedback for now on Corona virus: The new Coronavirus may not show signs of infection for many days. How can one know if he/she is infected? By the time they have fever and/or cough and go to the hospital, the lung is usually 50% Fibrosis and it's too late. Taiwan experts provide a simple self-check that we can do every morning. 1) Take a deep breath and hold your breath for more than 10 seconds. If you complete it successfully without coughing, without discomfort, stiffness or tightness, etc., it proves there is no Fibrosis in the lungs, basically indicates no infection. In critical time, please self-check every morning in an environment with clean air. Serious excellent advice by Japanese doctors treating COVID-19 cases: 1) Everyone should ensure your mouth & throat are moist, never dry. Take a few sips of water every 15 minutes at least. Why? Even if the virus gets into your mouth, drinking water or other liquids will wash them down through your throat and into the stomach. Once there, your stomach acid will kill all the virus. If you don't drink enough water more regularly, the virus can enter your windpipe and into the lungs. That's very dangerous. Please send and share this with family and friends. Take care everyone and may the world recover from this Coronavirus soon. Part 2 on CORONAVIRUS- Last evening dining out with friends, one of their uncles, who's graduated with a master's degree and who worked in Shenzhen Hospital (Guangdong Province, China) sent him the following notes on Coronavirus for guidance: 1. If you have a runny nose and sputum, you have a common cold 2. Coronavirus pneumonia is a dry cough with no runny nose. 3. This new virus is not heat-resistant and will be killed by a temperature of just 26/27 degrees. It hates the Sun. 4. If someone sneezes with it, it takes about 10 feet before it drops to the ground and is no longer airborne. 5. If it drops on a metal surface it will live for at least 12 hours - so if you come into contact with any metal surface - wash your hands as soon as you can with a bacterial soap. 6. On fabric it can survive for 6-12 hours. normal laundry detergent will kill it. 7. Drinking warm water is effective for all viruses. Try not to drink liquids with ice. 8. Wash your hands frequently as the virus can only live on your hands for 5-10 minutes, but - a lot can happen during that time - you can rub your eyes, pick your nose unwittingly and so on. 9. You should also gargle as a prevention. A simple solution of salt in warm water will suffice. 10. Can't emphasis enough - drink plenty of water! THE SYMPTOMS 1. It will first infect the throat, so you'll have a sore throat lasting 3/4 days 2. The virus then blends into a nasal fluid that enters the trachea and then the lungs, causing pneumonia. This takes about 5/6 days further. 3. With the pneumonia comes high fever and difficulty in breathing. 4. The nasal congestion is not like the normal kind. You feel like you're drowning. It's imperative you then seek immediate attention. SPREAD THE WORD - PLEASE SHARE."

I am always skeptical when people use anecdotal evidence;  "friend of mine whose brother", "Taiwan experts", "Japanese doctors", friend's uncles. I also don't like when an e-mail states "please share".  I trust the WHO's symptom's page (below) which says that sore throat is a "sometimes" symptom.  Dry cough and fever are the most common symptoms.  Here are a couple more points: 

• I have a big issue with the 26-27C statement, the virus replicates in the lungs which are at 37C.   

• Lung fibrosis is lung damage, the problem with COVID-19 is pneumonia (liquid in the lungs) not fibrosis.  

• There is also an issue with stomach acid inactivating the virus, as some Coronaviruses, particularly bat Coronaviruses, where SARS-CoV-2 probably came from, are known to replicate in the gut (we don't know about SARS-CoV-2, which is the current problem). In fact people have found SARS-CoV-2 sequences in human stool samples, not sure if they have found infectious virus yet, but it does NOT appear that fecal transmission is a major route of transmission for SARS-CoV-2, it is a respiratory virus.  

• The data for virus survival on surfaces is a little less clear.  There have been some recent experiments with SARS-CoV-2 on surfaces that show that it can still infect cells in a petri dish after being on different surfaces for varying lengths of time, up to 10s of hours.  Whether the virus is infectious to humans after that time is less clear.  It does lose infectivity in the petri dish test over time. 

• No idea about cold vrs. hot water, in general hydration is good, I would love to see some data on this other than anecdotes (reminder the plural of anecdote is NOT data).

• I would say wash your hands after touching surfaces that might be contaminated before touching your face, every 5-10 minutes seems excessive (>150 times a day), unless you are touching lots of common surfaces and are very close to a sink all day. 

• Same issue with gargling, I have not seen any data on this.