Health & Fitness – mymilieu.org

The Tsunami (Wave) of Covid – What can we do?

The Tsunami Wave of Covid – What can we do?

I am in touch with all the different corners of the country. The unsurmountable fire of Covid has engulfed every nook and corner. The stories of death and desperation are so common that not a single call is devoid of the deep realization of the country’s anguish and pathos.

I realize two distinct sets of institutions, and I see a distinct dynamic response from both these institutions. First, the Government as an institution and second and foremost, ‘WE the People’.

Let us talk about the Government since we so much believe in our sense of entitlement. I am taking a neutral position and not siding or opposing with intent by design.

There was a sense of complacency and pragmatism in diverting the vaccines as well as the medications such as Remdesivir or Favipiravir to other countries that were suffering. In today’s integrated and dynamic world, national interests are subserved by commending global leadership. After Indira, we have an astute leader in Modi who understands this and has the knack and panache to drive that.

The age of vaccine diplomacy

During this age of vaccine nationalism, when most western powers huddled into vaccine nationalism, Modi took a moral stand of supporting the global cause. We have to understand, I did not see a sense of abandonment but a vision to expand and extend the national cause.

Corona – A global Slayer

SARS CoV2 has the enigma for a surprise attack and ambush. It’s different, and it has caught all by surprise the advanced nations and the advancing nations with the same level of temerity. Estimation models, intelligence, and expert instincts have all failed across the spectrum – from advanced, advancing, to those making attempts at advancing their nation.

India’s story is very distinct and different, and a significant onus lies with us as ‘We the People.’ First, it’s a massive country with a population of over 1.3 billion people. Next, it’s a free democratic country, where an extra sense of entitlement prevails. To add to this, it’s highly diverse, geographically, culturally, ethnically, ideologically, and politically and economically. With such a melting cauldron of diversity, it becomes incredibly challenging to provide a standardization of care across all strata.

We the People

Why are we hoarding? Why are we preemptively reserving resources when those are not indicated? Why are we black marketing resources despite knowing the crisis hours? Where is our faith in equitable and fair distribution when we break the queue and create pandemonium to grab necessities? Barring a few, have we ever shown trust, and confidence in the processes rather than bypassing those?

In a country where the rights belong to us and where I have bequeathed morals as someone else responsibilities, how can we expect our Government to function orderly and deliver?

These are pandemic times, and these are times of pandemonium, but definitely not armageddon. Hope and faith are the foremost things during a tempest. Let’s ride through this in an orderly way. Let’s trust and activate our inner moral compass that follows that will guide us with our responsibilities and our rights. Let’s follow an equitable process and trust fair practices, and most importantly, let’s pray and practice patience and activate our inner endurance to bear this calamity with courage and patience. Let us focus on us as the prime object of change, and a change in the system will follow.

I wish an early recovery through these tormenting and tortuous times.

Shashank Heda, MD
Dallas, Texas

https://pib.gov.in/PressReleasePage.aspx?PRID=1712710

The case of a swollen node?

(Note: this message is drafted for the nonmedical audience)

What’s a swollen node? Lymph Nodes are your primary line of defense leveraged by your inbuilt immune mechanism. Everyone has it (rarely are people born with a defect with the immune mechanism).

Suffice to say, whenever you have an infection or hurt in that part of the body, the lymph nodes enlarge to contain and control the infection.

The same happens when vaccines are given. With Moderna, the incidence of ipsilateral node enlargement is 11% to 16% with a first and second jab, and with Pfizer, it is significantly less. Johnson and Johnson, in its emergency approval document, mentioned none.

Both Covishield and Covaxin uncommonly initiate lymph node enlargement. Such uncommon outcomes are generally in the range of 1-3%. However, with any vaccine, as more data accumulates, the figures are likely to change.

Why does it matter?

Two things are crucial with swollen nodes. First, they are sometimes tender and or painful, with resulting discomfort. Most enlargements are self-limiting and subside on their own. However, occasionally few persist. Of course, it goes without saying that you need to consult your doctor.

The second and most crucial aspect is the persistence of nodes in a female patient that may need a mammogram. Sometimes these nodes are revealed not clinically but on an accidental CT or MRI. It becomes a cause of concern that needs further workup, but in most cases, nothing significant comes out after investigations. However, it is best to investigate despite knowing the pre-investigation probability.

Learning lesson:

Beware of an enlarging lymph node on the side of the vaccine shot.
Generally, these are self-limiting and will subside eventually.
If swelling persists or keeps enlarging, it is pragmatic to get investigated.

Commonly used terms in the illustration below

Shashank Heda, MD

Founder and Chief Executive

CovidRxExchange

Email: info@covidrxexchange.org

Phone: +1 (650) 996 6745

(A global nonprofit organization for disseminating expertise and insight in the medical care of COVID patients)

Manage COVID After A Recess

While the US, EU, UK, Brazil and South Africa were smoldering with the newer variants of COVID, many in India thought COVID was done and dusted. Life was back to normalcy, hardly realizing that India was in the same stage of ignorance as it was exactly an year ago. COVID is back, and this time it will be with a vengeance. What do we do now? I have discussed the relevant principles so that you can make changes to your lifestyle in accordance with the emerging threat from the newer variants.

A few weeks back, when I talked with several Commissioners and Administrative officers from Maharashtra, Tamil Nadu, and at the Center (Delhi), the palpable feeling was that Covid is “done and dusted”. Life was back to normalcy, and all cautions were out of the window.

I cautioned that it is not yet out, and I shared a blog called a tale of two worlds (link shared below) along with a few reports on the raging pandemic in the US, EU, UK, Brazil, and South America. The ignorance was high, and most felt that they had achieved herd immunity. ICMR reports indicated 24-26% national seroprevalence; Chennai’s reports indicated 40% seroprevalence, which again meant inadequate herd immunity. However, facts are generally relegated, and sentiments take precedence. Once again, I wrote another blog on Herd Immunity (link cited below). Always remember TWO MOST principles of herd immunity –

The entire population should be 60-80%
The epitope (in this case, the viral protein) should be constant, not changing

It is in the nature of this virus that the structure is changing every few weeks. Another blog that was written a long time back on this nature of virus was shared with the medical community. To summarize, the covid virus has a defect with RDRP, an enzyme that helps in multiplication. It creates typos, like the one we unintentionally do while typing. However, with covid, those typos change the structure (changes to S or Spike protein is an example) that renders the immunity from previous infection less effective.

Thus previous infections or vaccines are likely not to provide the anticipated immunity. Besides, this virus’s immunity lasts for 3-6 months, as against the smallpox vaccine, which lasts life long.

So, what do we do next?

Should we stop all our social activities?
Should we stop interacting with our professional friends, coworkers, staff, and others?
Should we quarantine and put ourselves in lockdown?

None of these are practical and pragmatic. Before I tell you what is appropriate, let me share what is inappropriate. Yesterday, I talked with a prominent businessman from Nagpur. He said he uses the alcohol-based hand cleaning solution, cloth-based face masks, and takes a shower after returning home, and puts the laundry clothes.

All except face masks are not required. This is an airborne virus, not a virus spreading through fomites (bugs on your clothes or body via touch).

What is airborne and aerosol? When an infected person sneezes, he/she blows almost over 50 million copies of the virus in one bout of coughing/sneezing. These are invisible and disperse in the air around you. An aerosol is similar to airborne, except that you can see those droplets.

Either way, noninfected people end up inhaling those viruses and ultimately increase their risk of getting infected. There are several factors involved between the sneeze/cough bout and infection by normal people. Closed space versus open space influences the outcome. Similarly, centralized air conditioning circulates the virus via the duct system, thus exposing people in other contiguous areas.

Using n95 or similar masks is THUS CRITICAL. I generally add another layer of the surgical mask when i presume exposures are likely to increase.

Social distancing helps, but it is not a panacea. Just imagine, I am not on the same floor as the infected person but connected via centralized air ducts. Will it help? No. I am logically in the same environment though I am in a different place physically. That also means you have to focus on the principles and not just the practices. Understand the principles and act accordingly.

Lockdown or Quarantine?
The most considerable toll this pandemic has taken is from lockdown. Even during the first lockdown implemented in March/April 2020, I was firmly against global lockdown. The answer is never global lockdown; it is always micro lockdown.

What is Micro Lockdown?
Only lockdown that part of the city or segment where the incidence is likely to be high. However, even micro lockdowns are easier said than done. It is difficult to identify a community of infected (but asymptomatic) people and quarantine them against a traveler arriving outside (by flight, vehicle, or train). Remember, once lockdowns are implemented, they ideally last 3-5 weeks, unlikely to be gone in one week. However, it is best to contain and segregated those suspicious of carrying the virus, be it communities, individuals, or activities.

Curtail all Social Activities
Certain activities are unavoidable, critical business, social activities (marriages, deaths, illnesses, and adverse events). However, remodeling our way of interaction is always possible. Certain principles are absolute and non-compromising (wearing a good quality mask); yet, remodeling can be done for the day’s activity, the place, the interaction, etc.

Let us understand those and tailor our activities.

Dr. Shashank Heda, MD
Founder and Chief Executive
CovidRXExchange
(A US global non-profit initiative for disseminating medical expertise and insight; working for Covid since March 2020)

Links to the blogs below –

If only we proactively spread the message within our network, engage in an active dialog, resolve the misgivings around the vaccine, start Fastrack the process to curtail the virus. Our ability to bounce back, as a nation and as a community, depends upon how we counter the virus. https://mymilieu.org/2021/02/01/evangelizing-vaccination/

The variants with the infectivity, implications on testing, therapy, and vaccines. https://mymilieu.org/2020/12/26/emergent-variants-and-infectivity/

That provides a simple explanation of how vaccination will halt the spread of the virus. https://mymilieu.org/2021/01/28/a-triple-whammy-variant-vaccination-and-complacency/,

It is an ultimate hope that the vaccine provides herd immunity or the virus comes to a state of symbiosis with humanity. Luck is never the best strategy, but it had to happen. We wish to stumble across a variant that is as good as Common Cold, leaves minimal health impacts, and possibly with minimal mutations to stabilize. In the search for this haplotype, I shared this perspective https://mymilieu.org/2021/01/10/in-search-of-a-haplotype/

COVID- A tale of two worlds

A Triple Whammy – Variant, Vaccination, and Complacency

Evangelizing Vaccination

COVID- A tale of two worlds

Breaking the transmission cycle by interrupting these traversals of the virus is critical. Travel restrictions, strict screening and surveillance, and mass vaccination and precautions are all CRITICAL to the successful CONTROL of COVID. Let’s keep our fingers crossed and follow all the right protection.

COVID- A tale of two worlds

(Words – 678; reading time 3-4 minutes, Why should you read? The pandemic is not over and out, do not drop the guards)

While the western world is dealing with one of its worst phases of Covid – 19, the so-called Covid-2, several nations, including India, are almost calling the game is over. Let’s revisit and understand the pandemic’s delicate dynamics and the evolving mutant variants of the virus.

As of late January 2021, hospitals in London and its suburbs were out of any beds for admitting the patients infected with Covid. The modeling predicted one of the worst shutdowns in the history of the great kingdom. Boris Johnson, a nationalist and a populist by inkling (a Trump category leader) too, caved into the worst pandemic. My doctor colleagues from Kent are working almost continuous long hour shifts (18 hours at a stretch). Elsewhere in the UK, the scenario was no different.

Brazil has just surpassed India as the second-worst country after the US to be affected by the virus. Europe, with its defining economies, is jettisoned with the virus. France, Germany, Spain, Italy, and all the Scandinavian countries are on the highest alert, with restricted and severely clamped down inbound and internal traffic, almost reducing the countries to secluded pockets.

Here in the US, of course, statistics are grim, the economy has bounced back a little, but guards are not down, like in India and its peninsula. A quick view of the hospital bed availability for most regions, states, and cities are still red, not to mention LA and its suburbs, which is chronically deprived of beds for almost a few months.

Let us unfold the mysterious virus.

While the simmering stories in the western world are true, it is equally true and a reality that life in India (and the peninsular countries) has bounced back to normalcy.

What can be the reason?
Yes, its is an existential dilemma, that has created a completely divided world with distinct response and behavior to the virus.

Continuous mutation and evolution of the virus
While we know all the mutations such as B 1.1.7, D614G, N501, and its variants, and several subspecies of the evolving new generation-of the virus, what is least understood is that avowed variant that is circulating in those countries where life has bounced back to normalcy. Let’s call this hypothetical mystic variant “Benign Covid-21” (I just coined this word, so no Google search will yield any additional documents). This haplotype, if widely circulating in these populations, maybe an answer to the nature mitigation of the virus. Ultimately, as my friend and a noted prominent vaccine expert Dr. Anand Kawade said, the virus has to live amicably with its hosts. It, too, has to find a symbiotic relationship to survive. This metaphysical aspect cannot be discounted though it needs scientific validation.

Should we drop our guards?
It is too early to say if those in India (and countries with a similar pattern of Benign Covid -21, should drop their guards. One thing is clear, global lockdowns (and lock-jams) are definitely not an answer. At the outset of the pandemic, i had called out the hypothesis if the degree of separation concept, retrospectively, in hindsight, it seems obvious to lean and review that model. Summarily, the degree of separation talks about the interaction amongst the population and not the distance that influences the outcome of the disease dynamics during the covid pandemic. Thus, putting entire cities, regions, and states in mass lockdown is not a pragmatic idea.

Shashank Heda, MD
Dallas, Texas
Founder and Chief Executive,
COVIDRxExchange, a global nonprofit initiative for disseminating the expertise and insight for doctors in the care of COVID)

To Visit our repository of over 1000 best practice documents, please visit – http://www.covidrxexchange.org

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In Search of a Haplotype

The new variant of the virus has already spread out to over 45 countries. While scientists are understanding the impact of the mutant variants, what should we do as individuals and societies to counter the potential threat from the virus?

In this article, I have provided an insight on personal and administrative/social preparation that needs attention.

(Word Count 942, reading time 4 -5 minutes).

By now, we all know the virus is mutating, and mutating every few weeks. For those who are not aware of what a mutation is, it is a change in the genetic program embedded within the virus. However, only a few mutations have possible implications on the infectivity, ability to induce severity, response to the drug, and the response to vaccines. All of these are critical for individuals, families, and society in general. Of course, everything is intertwined and ultimately has an impact on the socioeconomic structure. We have seen the devastation of several families. When the virus went on the rampage, we saw how the economies faltered and GDP’s collapse.

Variants and their implications

We all know that the UK, EU, and the US are badly reeling under the virus. Hospital beds and ICU bed availability in many regions are critically stretched, and so are the human resources like HCW. London Mayor Sadik has already implemented a lockdown with punitive citations for overriding the lockdown. Rightly so, despite our freedom mongering and yearning for personal freedom, we ultimately land up with the hospitals.

At least three variants are known with possible implications on the infectivity, severity of the disease, resistance to drugs, and efficacy of the vaccines. N501, B1.1.1.7, D614G and A222 are mainly prevalent in the UK, South Africa, and the EU. All these variants are known to be more contagious than the wild type, that is universally prevalent. Also, a collaborative study between Duke University, Los Alamos National Laboratory and Sheffield University has revealed that D614G variant is associated with higher viral loads in the upper respiratory tract. As of now, we are not yet sure if there is a variant that exists in LA and other parts of the US that are reeling under the virus. At least 45 countries have so far reported the presence of these new variants as of Jan 10, 2021. The National Laboratories from individual countries are searching for the virus’s existence within their societies and implications if any.

Japanese National Institute of Infectious Disease has similarly identified a new strain after the Japanese Government realized passengers’ arrival with the variant viruses. Naturally, the imposition of a ban on incoming flights from infected countries is the first knee jerk response. Many countries have reimposed the ban on travel from those countries with the presence of this virus. While the respective Governments are working to identify the new virus variants, individuals and the administration should gear up to deal with the increased threat level.

Credits: News Medical Lifesciences, Dr. Liji Thomas, MD. D614G mutation now the dominant variant in the global COVID-19 pandemic

Individually, we all should follow the precautions stringently. Masks, social distancing, and containment strategies such as quarantine are basic. However, never presume that asymptomatic individuals are non-infectious. Research has proven without a doubt that asymptomatics are the ones who are spreading the virus. It goes beyond saying that kids harbor more viruses and remain asymptomatic. Kindergarten and schools can be the potential source of spread. While many schools have opted to go into virtual schooling, it is challenging for the daycare centers to do so. It is best to huddle into your bubble and only interact when it is essential or critical, understanding that those interactions should follow the strictest precautions mentioned above.

Vaccines
Vaccines are derived based on a certain genotype of the virus. If the virus changes its structure, the vaccines may have a potential dent in its efficacy. Second, vaccines, even if they are efficacious, may protect only the ones who are vaccinated. Vaccinated individuals may still harbor the virus. Thus, protection has to continue despite vaccines.

City and Corporation Planning – Many cities, especially in South East Asia, are basking and boasting their success with COVID-19. COVID-19, as well all know, can strike back anytime. Complacency is not alone a defunct but also a counterproductive strategy. Europe and other countries undergoing a severe COVID-19 pandemic spike have realized how the spike overstretches the HCW. Doctors are overburdened, and so are the supporting staff.

Realistic modeling of the unfolding second spike is critical. R Naught, which was widely used at the pandemic initiation, has been revealed to have several flaws. It only threw our economy into shambles and society into unrequired chaos. Newer modeling that is closer to realism is the need of the time.

Second, the infrastructure that was propped up during the pandemic’s initial phase helped but was not necessarily sufficient. We need to identify a more long term viable solution to our healthcare services to deal with the virus. Using the same knee jerk response is unlikely to provide an adequate safeguard. Mere lockdowns are too insufficient and, at best knee jerk; we need more than a rational response, now that we know the pandemic better from our recent experience.

Society – Herd Immunity
Sweden, the UK, and the US are great examples that serve as potent examples that herd immunity is not enough. It does not offer protection without collateral. The collateral is the death and devastation of an individual with a permanent compromise with residual sequelae on health. Those who survived COVID-19 are physically either compromised in functioning or occasionally rendered dependent on supplemental oxygen.

The only and ultimate panacea would be a natural selection of a haplotype (a genotype) that would be less infective, cause inconsequential disease, and still respond to drugs and vaccines. The emergence of such strains is a natural selection process. The virus will possibly realize that if it has to cohabitate like several other bugs, in a symbiotic relationship with human beings.

Shashank Heda, MD.
Dallas, Texas
(For COVIDRxExchange, a global nonprofit initiative for disseminating insight and expertise in the care of COVID)

https://www.lanl.gov/discover/news-release-archive/2020/July/0702-newer-variant-covid-dominates-infections.php

https://www.news-medical.net/news/20200925/D614G-mutation-now-the-dominant-variant-in-the-global-COVID-19-pandemic.aspx

Rubber Meets the Road.

Let’s start where I want to end this topic, and I know you won’t like me saying this. The pandemic is likely to swagger around more than anticipated. If we anticipated it to end sooner, if not early 2021, it bores disappointment. It’s just not the delay in rolling out the vaccine. Let’s see the multitude of issues why the pandemic is likely to last longer.

Vaccine Nationalism is an integrated world is unlikely to protect a nationality unless the borders are strictly closed. Well, any isolationism and walls are unlikely to stop the Humboldt of global integration. If the rich or the have (those with technology), are planning to cover their nationals, the virus is likely to linger longer in those deprived.

What are the consequences?

Most of us are aware of the new mutations in the virus that imposed an immediate lockdown in the UK. This mutant variant is secondary to the virus gaining survival by mutating and escaping. Such mutants are like to hamper our interventions right from screening to vaccination.

Is it a global vaccine rollout?

Of course nor, the vaccine rollout has started in the EU, UK, US, Brazil, Mexico, Canada, Japan, China, and a select few countries. However, several countries are lagging behind either because they have no funds or no technology or logistics to deploy a complex vaccine delivery program. Add to that the regular protagonist of the ‘conspiracy theory’ school, and you compound the problem to a level of practical reality.

Surprise – Many doctors are evading vaccine

I was surprised to see practicing doctors avoiding vaccines. This is not an isolated but a pervasive phenomenon. There are still lingering doubts about the virus getting integrated into the human genome, which is unlikely to happen. Another misconception is heavy metal contamination of the vaccine. You and I are more exposed to the unknown quantity of heavy metals in our produce from Mexico or the disposable material we are exposed to. First, I may disagree if such contaminations are possible with the vaccines, and even if those were, it is unlikely that you get a significant dose to perturb your system. Another misconception that is going around – that the vaccine is made in cow or pig. I just piety these folks who work on churning the rumors mills devoid of research, reasoning, and rationale.

The cold chain and logistics

It is a formidable challenge to manage the cold chain in a diverse world like ours, even if we presume that vaccination will be adopted uniformly. Having worked as a molecular oncology fellow, I know that especially the RNA vaccines from Moderna and Pfizer need a distinct cold chain, and any disruption is likely to compromise the efficacy of the vaccine significantly. Now consider the vast and remote corners where the vaccines have to be carried out if we were to target complete eradication of the virus.

These are not easily surmountable challenges and devoid of a strategy and execution plan that is customized to individual locales (countries, regions, etc.), it is unlikely to achieve the desired goal of covering 60%-80% population. If the virus lingers, it will mutate and likely stay with humanity for longer than the expected period of time. It will evade our detection gold standard, such as RT PCR. It may create resistance to drugs such as Remdesevir, or worst, become more aggressive and, last, render our vaccines useless. That’s why we vaccinate ourselves annually for flu.

Let us hope for the best.

Hope is not the best strategy; instead, hope is the worst strategy. A thorough understanding of the global target population dynamics vis a vis the vaccination program is required. Strategies alone cannot help; execution of the plan will be the harbinger to success. Until then…

I wish you all a very safe 2021!

Shashank Heda,

Dallas, Texas

Humanity Needs a Hand

Religion and technology represent two different yearnings of mankind, each representing a stride. While we are marooned in the past with our utter conviction to our faith, we take a stride forward with technology and fall. For a real progress, we truly need evolution and progress on our ideologies and faith, rather than technological advances. Only when we sync up the steps that we, as humanity, will be able to walk into the future.

When I review radicals and ultra-right-wing or conservatives’ history, i feel humanity’s one leg is shackled and marooned in the long past. One leg taking a massive stride towards logic and technology. This stride has created an unstable gait for humanity for us to falter and fall.

By no means is religion written dictums or rules that we have to follow ardently. Those are the principles and guidelines provided to society and human beings for peaceful coexistence during those times. Rituals and artifacts are all the more superficial. Those are meant for cementing the abstract for the commoner to embody himself/herself. They also offer a sense of identity and a vivid recollection and subscription to faith and ideology.

Over a period of time, however, we have fossilized the rituals and artifacts and petrified the system by willful ignorance and erosion of the principles.

At each epoch, we had divine enlightenment from people such as Lord Krishna, Lord Ram Gautam Buddha, Lord Mahavir, Jesus, Md. Paigamber, who taught us the way of living. They knew the daily hustle and bustle of living are not conducive to reflecting on the finer and cognitive and supra cognitive aspects of living.

I sometimes wonder and pity humanity that we have not adopted the right way of life as enshrined in those religious tenets’ principles despite such supreme deliverances. Instead, we recede into the ideological conflict of imposing “my rightful ideology over your rightful ideology,” a moral fraud. We act not as simple animals but as rascals, if not demons, and destroy humanity with those divine injunctions.

No religion is barred from this radical regression, not to name any, we all have consigned to just the superficial, the tangible as it appears and lost the substance. Some religions are more intolerant than others, but all have genuinely lost the path of religion and faith, have failed to evolve, adapt, and adopt. Such is moral perfidy and erosion that it takes us a thousand years and a messiah to enlighten the next generation. Until then, we will be locked in this disturbing chasm of stride and fall.

Shashank Heda
Dallas, Texas

Iran’s Supreme Leader: Who might succeed Ali Khamenei?
https://www.bbc.co.uk/news/world-middle-east-55257059

Ahh, I so much love China!

Ahh I love China. A totalitarian state never has to deal with the dilemma of a democracy. Life if simple, just lease your intellect to the state and work like a hen in the poultry. You have the best of the living conditions, nutrients, also a few micronutrients and absolutely controlled temperature. I love life in Chicken Farms! They have everything to serve the state (owner) and can live their stipulated life until the state desires. Let me admit, more than the blog, I liked the links shared, especially from Freedom House, Philosophy forum and the Economist.

Ahh, I so much love China and Russia

Well, liberal democracy has to walk along with all the stakeholders, unlike a totalitarian state. However, when it comes to imposing critical and essential restrictions, as was done by New York that Gov. Andrew M. Cuomo, to contain and control Coronavirus spread in New York, it was struck down by the conservative supreme court bench in favor of the Orthodox Jewish Organization and the Roman Catholic, the former having a high incidence of COVID.

As I read from the New York Times (link cited below), “The restrictions are strict. In shifting “red zones,” where the coronavirus risk is highest, no more than 10 people may attend religious services. In slightly less dangerous “orange zones,” which are also fluid, attendance is capped at 25. This applies even to churches that can seat more than 1,000 people”. “The Constitution does not forbid states from responding to public health crises through regulations that treat religious institutions equally or more favorably than comparable secular institutions, particularly when those regulations save lives,” Justice Sotomayor wrote. “Because New York’s Covid-19 restrictions do just that, I respectfully dissent.”

I am not sure how these numbers arise? 10, 25, 50, 100 etc. I have seen such flaunt numbers from different administrations, only to create fault lines and not fix the solution. At least my simple logic dictates that these numbers are irrelevant, and should directly be correlated with the index case or the sentinel case.

Is a numeric threshold right?

I was talking with my uncle back in India and I realized, the small village where our farms are, have no COVID in their vicinity. Obviously, I was concerned for the second crop and other agricultural activities. The best practice is to quarantine the cities and not the countryside, which as free of disease. Let the commerce flow and let the business flourish if the impact is minimal.

When I talk with my network in China, I see that the lockdown has strictly adhered to. Well, who is right? Liberal democracy with one foot backward and one foot forward, or a totalitarian state with both feet aligned?

There can never be a cookie-cutter approach or a standardized way to resolve this conundrum. Our only recourse is to evaluate each situation separately? A lot of human intelligence (Can AI help?). Irrespective, it is an individual choice versus the state responsibility towards all. Science cannot be ignored despite knowing its incompleteness. However, we can only see on the basis of current visibility.

It is obvious, that a bench is favoring a decision despite its lack of requisite (medical) background, competence and expertise to assess public health and its accountable for the people. At least for now, the public concern is thrown out of the window.

It is hard to customize and still retain the luster of the fundamental amendments (the first, second, etc.). However, it is a rope walk and if you ask a lazy person like me, I love China!

Shashank Heda

United States Government: Why form a government?

https://thephilosophyforum.com/discussion/6368/centrist-and-small-government-debate

https://freedomhouse.org/report/special-report/2017/breaking-down-democracy

https://www.economist.com/essay/2014/02/27/whats-gone-wrong-with-democracy

School Closure and Kids Infectivity?

Excerpts:

Are my kids susceptible?

Now that COVID has started raging once again across the US, it is very possible that the schools in your area may decide to close or remain open. Select states may choose to keep the schools open, whereas others may decide to close. Is there any data to support the spread of disease with the schools opting to remain open?

It is important to understand if the Kids are infectious? Are they likely to be an asymptomatic carrier? Are they more susceptible? Do they have enough antibody response? A map of the US with states mandated school closure is provided in this blog. (Word count 795, reading time 3-4 minutes).

Are kids “Briefly Infectious”?

Now that some states have mandated the schools to reopen, and though the kids have the option to physically attend or participate remotely, it is important to understand the implications for the family.

3% or 9% Threshold? What’s Right?

NY Mayor Bill D Blasio imposed a 3% moratorium on the case positivity rate to keep the school system open. You may see your state or local officials changing their decision to keep the schools closed if they see a rising number. The debate of 3% or 5% is seemingly not important. These numbers are related to the incidence of test positivity on a daily basis. Presume, you have 100 people visiting for testing, and 9 are positive (9%). Now presume, you have 500 people visiting for testing, and 3 per 100 are positive (3% but a total of 15 cases). Obviously, the absolute number matters most. However, New York Governor Andrew Cuomo or Iowa, Gov. Kim Reynolds has set the state’s closure threshold at 9 percent and 15 percent respectively. Why is the difference?

Hospital Beds influence the policy decision

The absolute numbers posted above make it clear that the more the number of the population infected, the more the number of beds required to treat the population. In fact, if the severity of the cases rises, another parameter that frequently influences the decision is the total number of ICU beds. If the system is inundated, these beds become significantly crunched and so lockdowns are enforced.

These exact sentiments were communicated by Dr. Celine Gounder, Adviser to President Elect Joe Biden, when she said, “there may come a tipping point where you do need to go back to virtual schooling. But I think the priority is to try to keep schools open as much as possible, and to provide the resources for that to happen”.

Impact of Lockdown

Lockdowns have a significant impact on the daily lives and economic health of a nation or state. It has been observed that Lockdown has rendered a significant portion of working women to discontinue work and focus on the kids. This almost significantly reduces household income and increases stress and unhappiness due to an inability to meet family needs. Across the globe, educational planners are concerned about the pandemic inflicting an indelible harm to the academic development to the kids.

Are kids more susceptible?

Recent research points to the Type 1 IFN that offers protection with the innate and adaptive immune response. As we age, the functioning is likely to get compromised and make us vulnerable. That is the reason, kids are less affected, whereas the elderly are more likely affected due to COVID. Second, children, have powerful innate immunity that mounts a severe and rapid response to the viruses, thus not allowing the viruses to gain a foothold, thus sparing them from severe disease.

Do Children have a less protective response?

Research from Karolinska Institute in Stockholm has demonstrated that the antibodies produced by kids are IgG type whereas, those produced by adults are of several types. The IgG antibodies bind to the S protein, whereas the diverse range of antibodies produced by adults bind to various proteins and help better neutralization of the virus.

The range of antibodies that children produced differed from those of adults. Children primarily made one type of antibody, called IgG, that binds to the spike protein on the surface of the virus. Adults, by contrast, made several types of antibodies that bind to the spike protein and other viral proteins, and these antibodies were more powerful than IgG at neutralizing the virus. Adult COVID-19 cohorts had anti-spike (S) IgG, IgM, and IgA antibodies, as well as anti-nucleocapsid (N) IgG antibodies, while children with and without MIS-C had reduced breadth of anti-SARS-CoV-2-specific antibodies, predominantly generating IgG antibodies specific for the S protein but not the N protein.

Are Schools the Superspreaders?

According to a report from Ney York Times, very little transmission happened in schools. The latest data shows that random testing since October has produced a positivity rate of just 0.17 percent. Please visit an article cited below from the Journal of Pediatrics, an official journal of the American Academy of Pediatrics.

Take-Home Message:

Kids may have better immunity burst to deal with SARS CoV2 but they may not have a complete armamentarium of antibodies to deal with every aspect of the virus.
Kids may be less susceptible to the virus, but that does not rule out a possibility of MIS-C.
Elderly parents at home are susceptible to infections from the kids, even if you presume, the kids are likely to have less probability of the disease. Grandparents and other senior elderly family members should be segregated from the kids to provide adequate protection.

https://www.edweek.org/ew/section/multimedia/map-coronavirus-and-school-closures.html

https://www.nature.com/articles/s41590-020-00826-9

Compiled on behalf of COVIDRxExchange, a Nonprofit initiative

Note: This is not a medical advice or recommendations. Please consult your doctor or local policy planner while making a decision. This is author’s personal Opinion and readers are strictly advised to consult medical professionals. Follow your local official advice and guidelines while trying to prevent the spread of coronavirus.

Visit Vaccine and Drones (https://mymilieu.org/2020/11/16/vaccines-and-drones/) to learn more about the effectiveness of the vaccines.

Click to access peds.2020-031971.full.pdf

https://pediatrics.aappublications.org/content/pediatrics/early/2020/10/16/peds.2020-031971.full.pdf.

https://www.edweek.org/ew/articles/2020/03/20/when-americas-schools-shut-down-we-all.html

Can I Get Severe COVID?

Are you vulnerable to develop a severe COVID-19? How to predict if you are likely to get a mild disease or a severe disease? Since the onset of COVID-19, we know that 80% of those affected are likely to have mild disease, 15% a moderate disease and 5% have severe disease. We never knew why only 5% had a severe disease. Also, we knew that elderly patients had more mortality and male gender was more affected because of the disease.

This fact kept the medical community guessing the cause, until we found out that certain genes have mutations or certain antibodies develop in this high risk patients that counter the protection offered by our innate immune mechanism. At least for now, a piece of puzzle is solved.

This article talks in detail revealed by latest research that help us understand those changes that makes these vulnerable population for a severe disease. You may want to know if you have those intrinsic vulnerability?

Silence of the Genes or their products

Why Some Patients Have Severe COVID? Why More Males dies of COVID and Why the disease is more mortal in elderlies? The genetics underlying severe COVID-19There is a crucial role of type I IFNs that offers protective immunity against SARS-CoV-2. After the initial infection, small amounts of IFNs are induced by the virus that become crucial in offering a protection against severe disease. However, few patients have developed neutralizing auto-Abs against type I IFNs, like inborn errors of type I IFN production. This sways the balance in favor of the virus and results in devastating disease due to absence of innate and adaptive immune responses.

Two pathways in which these genes can be perturbed are –

1) Genetic mutations resulting in deletion or functional compromise of the type I IFNs.
2) Development of antibobodies to type I IFNs. The immune system is complex and involves many genes, including those that encode cytokines known as interferons (IFNs).

Individuals who lack specific IFNs can be more susceptible to infectious diseases. Furthermore, the autoantibody system dampens IFN response to prevent damage from pathogen-induced inflammation. Adaptive autoimmunity impairs innate and intrinsic antiviral immunity.

A crucial role of type I IFNs in protective immunity against SARS-CoV-2. These auto-Abs against type I IFNs were clinically silent until the patients were infected with SARS-CoV-2—a poor inducer of type I IFNs which suggests that the small amounts of IFNs induced by the virus are important for protection against severe disease. At least 10% of patients with life-threatening COVID-19 pneumonia have neutralizing auto-Abs against type I IFNs. Two studies now examine the likelihood that genetics affects the risk of severe coronavirus disease 2019 (COVID-19) through components of this system. Genetics may determine the clinical course of the infection. High titers of neutralizing autoantibodies against type I IFN-α2 and IFN-ω in about 10% of patients with severe COVID-19 pneumonia. These autoantibodies were not found either in infected people who were asymptomatic or had milder phenotype or in healthy individuals. Together, these studies identify a means by which individuals at highest risk of life-threatening COVID-19 can be identified.

A B cell autoimmune phenocopy of inborn errors of type I IFN immunity accounts for life-threatening COVID-19 pneumonia in at least

a) 2.6% of women and
b) 12.5% of men.

Provide an explanation for the excess of men among patients with life-threatening COVID-19 and the increase in risk with age. They also provide a means of identifying individuals at risk of developing life-threatening COVID-19 and ensuring their enrolment in vaccine trials. Finally, they pave the way for prevention and treatment, including plasmapheresis, plasmablast depletion, and recombinant type I IFNs not targeted by the auto-Abs (e.g., IFN-β).2) At least 10% of patients with life-threatening COVID-19 pneumonia have neutralizing auto-Abs against type I IFNs. With our accompanying description of patients with inborn errors of type I IFNs and life-threatening COVID-19, this study highlights the crucial role of type I IFNs in protective immunity against SARS-CoV-2.These auto-Abs against type I IFNs were clinically silent until the patients were infected with SARS-CoV-2—a poor inducer of type I IFNs which suggests that the small amounts of IFNs induced by the virus are important for protection against severe disease. The neutralizing auto-Abs against type I IFNs, like inborn errors of type I IFN production, tip the balance in favor of the virus, which results in devastating disease with insufficient, and even perhaps deleterious, innate and adaptive immune responses.

At least for now, a piece of puzzle is solved. We now know that if Type 1 IFN develop auto-antibodies, or have mutations in the genes, or any (gene) silencing ensues, then it is possible, you may have individual vulnerability. The last aspect, silencing of the genes through methylation, though not yet proven may be potentially possible. Let us wait for science to unravel more.

Translational Medicine

What is typically called as translational medicine, it takes time to transfer the technological advances from laboratories to bed side. However, with COVID-19, we have seen a significantly reduced latency from lab to bed side (bed side here means for common use in practice).

Science 23 Oct 2020: Vol. 370, Issue 6515, eabd4585; DOI: 10.1126/science.abd4585

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-age.html