Information about the Corona pandemic

Wednesday, January 13th 2021
A Corona vaccination makes sense for everyone

Dear patients,
 
if we think about the question whether it makes sense to vaccinate against Corona or not, there are two points to think about:
 
-         What will happen if I’m vaccinated? More precisely, what risks does the vaccination imply?
-         What will happen if I’m not vaccinated? More precisely, what risks does the disease imply?
 
To answer these questions, we will look at data from two large clinical trials with 35.000 vaccinations: The Biontech/Pfizer vaccine trial and the Moderna vaccine trial.

No side effects worth mentioning in 35.000 vaccinations

In my last two articles you could read that in two large clinical trials (Biontech/Pfizer and Moderna) no serious side effects have been observed. Test individuals suffered from pain at injection site and other minor effects that were harmless, transient and without further consequences.

One allergic reaction in 100.000 vaccinations after approval

After approval and public use of vaccines, it is possible that side effects will be observed which haven’t appeared in the trials, but that will happen in only few cases, by probability less than 1 case in 35.000 vaccinated individuals.
After the approval of the first two vaccines, allergic reactions have happended in about 1 in 100.000 vaccinations (review article). Such an allergic reaction has to be taken seriously. Swift measures have to take place (injection of anti-allergic drugs). Nevertheless, an allergic reaction can be taken care of quickly and in most cases easily. No further consequences have to be expected. 

Vaccine damage hypothetically in one of one million vaccinations

Side effects appear in the first months after vaccinations and usually not later (podcast with Prof. Krammer).
Anti-vaccinationists often stoke fears about vaccine damages. But those damages are much more seldom than they make them appear: In the years 2005-2009 about 40-50 million “non-private" patients have been vaccinated in Germany. The number of patients with a vaccine damage was around 40 per year (original data).
Thus, the number of vaccine damages is 1 in 1 million vaccinated individuals, based on vaccines of the past. In all current Corona vaccines, no vaccine damages whatsoever have been reported yet.

Mortality risk and health damage caused by COVID-19

The patient’s age has the strongest influence on the mortality risk of COVID-19 (original article). Certain chronic conditions and other risk factors come second.

Patients > 80 years of age have the highest risk: 1 of 7 infected with COVID  decease. Patients 60-80 years of age decease in 1 of 28 cases, 35-59 years of age in 1 of 556 cases. Young individuals 18-34 years of age also have a relevant risk: 1 of 10.000 cases decease.

One important consequence of a COVID-19 infection is seldom mentioned: People who went through COVID partly need weeks, months or even years to recover. This “long COVID” or “chronic COVID syndrome” affects up to 10% of patients (review).
A permanent health damage is to be expected when pulmonal damage caused by COVID is so severe that invasive ventilation is needed. Quality of life and life expectancy will certainly be affected in these cases, but probably also in less severe cases. In the coming years, we will have more precise data, but we have to act now.

Among 42 COVID cases in my practice, 12% suffered from an asthma-like pulmonal reaction with the need for treatment (asthma spray). None of those patients had a history of a pulmonal disease. 5 patients were hospitalised, one patient deceased.

Direct comparison of risks

Risks of COVID and risks of a vaccination can be estimated based on statistical data and trial results (Fall- und Sterbestatistik RKI, Phase III trials of Biontech/Pfizer and Moderna).
All numbers are preliminary and therefore approximations, definite numbers will probably need years.
Example: Given the age structure in Germany and a vaccine efficiency of 95%, if 1 million individuals are vaccinated, at least 17.000 lives will be saved.
Even if the worst possible vaccine is used (efficiency 50%), there will still be saved at least 9.000 lives. In comparison to that, we will probably have just one case of a vaccine damage among those 1.000.000 vaccinated individuals (no cases of vaccine damage reported yet).

Summary

The risk caused by the vaccination is minimal. However, the damage caused by a Corona infection is huge.
Lethality in individuals aged 70+ is 1:28 up to 1:7, but even young individuals under 35 years of age still have a lethality that is ten times higher than the probability of the worst side effect of a vaccination: an allergic reaction.
Long-term health damage caused by COVID will keep us occupied for the coming months and years.
Thus, answering our question is very easy: Get vaccinated!

Sunday, January 3rd 2021
Publication of the Corona Vaccine Trial: Moderna „mRNA-1273“

Dear patients,
 
the original data of the “second” Corona vaccine has now been published on December 30th 2020 (original publication).
 
Results:
 
- 30.420 individuals were included, one half (14.134) received the verum (true vaccine), the other half a placebo (14.073), a minority was excluded. The minimum age was 18 years.
- 185 cases of COVID-19 were observed in the placebo group and only 11 cases in the verum group, resulting in an excellent efficiency of 94% of the vaccine. Thus, efficacy is equivalent to the Biontech/Pfizer vaccine.
- 30 cases of severe COVID-19 were observed in the placebo group, one individual deceased, whereas in the verum group no cases of severe COVID-19 or deaths were reported.
 
Further details:
 
- 2.2 % of individuals had already suffered from COVID-19 before receiving the vaccine. No complications were observed in those cases.
- Panel A shows the frequency of local reactions like pain at injection site, redness and swelling.
- Panel B shows the frequency of other side effects: fever, headache, fatigue, muscle pain, joint pain, nausea and vomiting, chills.
- In summary, side effects were very similar to those observed in the Biontech/Pfizer vaccine and other common vaccines.
- No allergic reactions were observed since the number of test individuals was too small. A later analysis estimates the (preliminary) incidence of allergic reactions at 1:100.000 (original publication)
- The vaccine can be stored at 2-8°C (36-46°F).
- However, these data cannot show whether the vaccination will prevent an asymptomatic infection. Consequently, a vaccinated individual will be protected from a severe course of infection with a very high probability, but if an individual will contract the coronavirus, he might still be contagious to others despite the vaccination. Therefore, wearing a mask will still be necessary to protect those who can’t receive the vaccine, e.g. children, pregnant women and individuals with severe immune deficiency.
- Long-term side effects can’t be excluded; however, I personally agree with the assessment of vaccine specialists that the risk of a health damage from an infection with COVID-19 will outnumber any long-term side effects of the vaccine.
 
Conclusion:
 
The Moderna vaccine is highly efficient and safe. It protects from a severe COVID-19 infection much better than expected (94% achieved, 50% demanded by WHO). Side effects are in the usual range.
Results are excellent; thus, I have no objections to this vaccine.

Sunday, December 13th 2020
Publication of the Corona Vaccine Trial: Biontech/Pfizer „BNT162b2“


Dear patients,
 
after the announcement of preliminary data about the above-mentioned vaccine in a press release on November 18th, the original data has now been published officially on December 10th (original publication).
 
This publication confirms the data from the press release:
 
- 43.661 individuals were included, one half received the verum (true vaccine), the other half a placebo.
- 162 cases of COVID-19 were observed in the placebo group and only 8 cases in the verum group, resulting in an excellent efficiency of 95% of the vaccine.
 
We have now more detailed data about side effects:
 
- 37,706 participants provided at least 2 months of safety data to assess side effects. 49% were female, 21% had a least one coexisting condition, 42% of participants were older than 55 years of age.
- Panel A shows the frequency and severity (in percent of participants) of pain at injection site, redness and swelling, respectively for individuals 16-55 years of age and above 55 years of age.
- Panel B shows the frequency and severity of other side effects: fever, fatigue, headache, chills, vomiting, diarrhoea, muscle pain, joint pain, respectively for individuals 16-55 years of age and above 55 years of age.
- In summary, side effects were very similar to those observed in other common vaccines.
- However, these data cannot show whether the vaccination prevents an asymptomatic infection. Consequently, a vaccinated individual will be protected from a severe course of infection with a very high probability, but if an individual will contract the coronavirus, he might still be contagious to others despite the vaccination.
- Long-term side effects can’t be excluded; however, I personally agree with the assessment of vaccine specialists that the risk of a health damage caused by an infection with COVID-19 will vastly outnumber any side effects whatsoever of the vaccine.
 
Conclusion:
 
The Biontech/Pfizer vaccine is highly efficient and safe. It protects from a severe COVID-19 infection much better than expected (95% achieved, 50% demanded). Side effects are in the usual range.
Further data will be collected. Until further notice, I have no objections to this vaccine and will report about my personal experience as soon as I will be vaccinated.
Estimations are that it will be protective 3 weeks after application. A vaccinated individual will probably be protected for at least several months, possibly up to 1.5 years.
 

Monday, November 30th 2020
Info about the coronavirus vaccine in Germany

On "tagesschau.de" you can find (preliminary) information about when there will be a vaccine in Germany, how effective it will be, what side effects are to be expected and other topics (in German).

Thursday, November 19th 2020
Press release of Biontech/Pfizer regarding the corona vaccine „BNT162b2“

Summary of the press release on November 18th, 2020 (source):
 
The phase 3 study included 43.661 patients worldwide. Among those, 41% were 56-85 years old. The minimum age was 12 years.
 
One half of individuals received the real vaccine (verum group), the other half just a placebo (placebo group).
 
170 cases of COVID-19 have been reported among both groups to date. Among those 170 cases, 8 were found in the verum group, 162 in the placebo group. The resulting efficiency of the vaccine amounts to 95%. This means that in the group with the real vaccine, much fewer individuals suffered from COVID-19 than in the placebo group (8 versus 162).

Among COVID-19 cases, 10 severe cases have been reported. 9 of those 10 cases have been observed in the placebo group, and just 1 in the verum group. This means that in the group with the real vaccine, much fewer individuals experienced a severe course of COVID-19.

Regarding severe side effects (so called “grade 3” adverse effects), just two have been reported in at least 2 % of individuals: fatigue in 3,8% of cases, and headache in 2 % of cases.
 
In conclusion, the vaccine makes a good impression: It seems to be highly efficient in avoiding COVID-19, and also in reducing a severe course. Side effects seem to be little and acceptable, and they are same as in other vaccine studies.
Nevertheless, the complete scientific data is still to be published. I will comment on that in due time.
 

Sunday, November 8th 2020
Additional information about SARS-CoV-2 Vaccines

Dear patients,

please find some more information about Corona vaccines in the New York Times (comprehensible and appealing!) and on the CDC website:

Sunday, November 1st 2020
Topic: SARS-CoV-2 Vaccines ("Corona Vaccine")

The following information is based on a review article by Prof. Florian Krammer, a vaccinologist (specialist on vaccines, original review article) from New York.
Currently 180 Corona virus vaccines are being developed world-wide. This text analyzes seven of these specifically addressing the following:

1.      Whether it is technically possible to cut short the vaccine development by several years without a loss of safety of the vaccine?
2.      Which vaccines are being developed now? What results are known about efficacy and safety?
 

1. Acceleration of the development of a Corona virus vaccine

Diagram 1: Steps in the development of a vaccine: traditional and SARS-CoV-2 vaccine
A vaccine development has to run through the following steps (diagram 1):
 
a)      Design and testing in animal models: This process usually takes years and could be almost entirely skipped since there is already sufficient data from the development of vaccines for coronaviruses in 2003 (SARS) and 2012 (MERS).


b)      Preclinical and toxicology studies: This step also takes years and could be cut short due to very similar data from the above-mentioned SARS and MERS vaccine studies.

c)      Phase I, II and III studies: Progressively increasing sample size of volunteers and human subjects aimed at testing efficacy (does the vaccine work) and ascertaining whether any side effects are tolerable. At phase I usually up to 100 individuals are included while in phase III you will find tens of thousands. Usually those phases run after each other to wait for the results of the previous phase.
For economic reasons you often find delays: The studies have to be funded, and that takes time. Moreover, a pharmaceutical enterprise has to check time and again whether the investment into the next phase still makes sense, regarding the actual market conditions and a demand for the product.
Thus, phase I to III studies usually take 5-7 years.
Current proceedings are different:
- Huge fundings and investments from governments worldwide are available.
- The three phases are being planned in a cascade instead of one after the other. Normally, such a proceeding would pose an unacceptable economic risk: If a serious problem arose in an earlier phase so that the study had to be cancelled, all investments into later phases would be lost. Thanks to governmental funding, the cascade planning can take place without a loss in quality.
- Otherwise competing companies are now cooperating and sharing resources and tasks, thus saving time in development and testing.


d)      Assembly-line production: Normally this would happen at the end of a vaccine development. Now we find that companies have already started production lines, even at the risk of failure with the consequence of having to destroy all produced vaccines. Under normal circumstances, a company couldn’t afford such a high risk, but in our current situation this economic risk is taken to accelerate the whole process.

e)      Vaccine approval: The usual time for a drug or vaccine to be approved by the FDA, EMA and other pharmaceutical regulatory bodies is 1-2 years since authorities have to assess and approve a very wide range of products. In the current crisis, assessment and approval of a SARS-CoV-2 vaccine would have the highest priority and would therefore be immediately assessed.
 
Prof. Krammer stresses that an acceleration of the vaccine development process is mainly possible by taking high financial risks. Nevertheless, no intolerable compromises are being made about the safety of the vaccine.
If intolerable side effects were observed, it would mean the end of a vaccine. Therefore, pharmaceutical companies work with the utmost care not only because of ethical, but also because of simple economical reasons not to lose the market to rival companies.

2. Description of seven potential vaccines under development

  • Fig. 2: Coronavirus, spike protein in red
  • Fig. 3 : Replication cycle of SARS-CoV-2: Virus particles dock onto the cells surface using its spike protein. The virus injects the mRNA, which will be transported to the ribosomes. There, virus proteins will be produced and will form new viruses.
a)      Company: Sinovac. Vaccine designation: CoronaVac.
Inactivated vaccine (inactivated SARS-CoV-2) with aluminium hydroxid as adjuvant. Two doses were administered with 2-4 weeks in between. The safety profile (absence of serious adverse effects) was described as excellent. 90% of test individuals showed antibodies against corona, thus proving a working vaccine within that time period. However, antibody levels were quite low, and younger individuals had higher levels than older ones. The phase III trial has started.
 
b)      Company: Sinopharm.
Inactivated vaccine (inactivated SARS-CoV-2) with aluminium hydroxid as adjuvant. Two doses were administered with 2 or 3 weeks in between. Antibody levels were in the average range. Side effects were comparable to CoronaVac (see above). The phase III trial has started.
 
c)      Company: CanSino
That vaccine contains an adenovirus (harmless common cold virus), that has been modified so it will not be able to propagate. I will carry the SARS-CoV-2 spike protein.
The spike protein is the structure on the coronavirus’s surface which enables it to enter a human cell. The immune system recognizes that spike protein and produces antibodies against it.
A single dose of this vaccine was administered. Antibody levels were low. The following side effects were observed: Fatigue and headache, in 50% of cases pain at the injection site, fever in 9% (high vaccine dose) respectively 1% (low vaccine dose).  The phase III trial has started.
Explanation: Replication-incompetent adenoviruses will be recognized and destroyed by the immune system. This adenovirus has no means to defend itself let alone to harm the human body since the genes it needs to replicate have been removed.
Thus, the adenovirus is just a carrier that presents the spike protein to the immune system so it can produce antibodies.
This vaccine type has been successfully applied against Ebola in central Africa.
 
d)      Company: AstraZeneca
Again, this vaccine uses an adenovirus, that is unable to propagate and will carry the SARS-CoV-2 spike protein.
The majority of individuals received a single-shot, the minority a second dose after 28 days. Antibody levels of the single-shot group were in the average range while they were higher in the group with a second dose.
Common side effects were fatigue (> 70% of individuals) and headache (> 60% of individuals). Fever or a feverish sensation have also been observed.
The phase III trial has started.
 
e)      Company: Moderna
A new vaccine type has been implemented: Lipid nano particles (LNPs, “lipid bubbles”) contain an mRNA, that works as a “construction plan” for a protein, in this case the spike protein of SARS-CoV-2.
Background knowledge: In human cells, mRNA is a non-identical, but same-sense copy of a DNA sequence (genes in the cell's core). The mRNA is being transported to ribosomes outside the cell’s core but still within the cell. Those ribosomes produce the protein that is described in the mRNA’s “instructions”. After completing the protein, the mRNA will be dissolved. (see Fig. 3).
Operation principle of an mRNA vaccine: LNPs transport the mRNA into the body and the cell where the mRNA finds its way to the ribosomes. After ribosomes produce the spike protein, the mRNA is being dissolved. The spike protein is recognized by the immune system which will lead to the development of antibodies. After that, the spike protein will also be dissolved.
The spike protein cannot do any harm without the rest of the virus. This mRNA is just a construction plan and no virus. It doesn’t have any contact with the cell's DNA let alone influence on the DNA.
mRNA vaccines are also being developed for use against Zika virus and CMV virus.
About the Moderna vaccine: Two doses were administered with 4 weeks in between. Antibody levels were in an average to high level, comparable to levels found in individuals who recovered from COVID-19. In contrast to vaccines with inactivated virus, beyond the production of antibodies even a T-cell response could be proven. This is relevant since a broader and sustained immune response can be expected. Thus, an individual with such a vaccine will probably have a better and longer protection against SARS-CoV-2.
Regarding side effects, fever has been reported in 40% (after first shot) and 57% (after second shot).
The phase III trial has started.
 
f)       Company: Pfizer / Biontech (Mainz)
Again, LNPs (Lipid nano particles) are being used to transport an mRNA into the body. In this case, the mRNA is a “construction plan” just for the receptor binding part of the spike protein (RBD, receptor binding domain) and not the whole spike protein.
Two doses have been administered with 3 weeks in between. Average to high antibody levels were observed which were comparable to patients who recovered from COVID-19. Fever has been reported as a side effect.
A second vaccine from Pfizer is in development, also using LNPs and mRNA, but the mRNA codes for a complete spike protein. In this case fewer side effects were observed.
The phase III trial has started.
 
g)      Company: Novavax
A different vaccine type is in use here: A complete spike protein is produced in insect cells and afterwards inserted into a micelle (kind of globule) (original article). Parts of the protein will still be “visible” to the immune system on the micelle’s surface.
Two doses were administered with 3 weeks in between. Only after adding an adjuvant, relevant and very high antibody levels could be observed. In addition to that, a T cell response could be detected. As mentioned before, this might produce better and longer lasting protection against coronavirus.
Side effects included: fatigue, malaise, headache, pain at injection site, muscle ache, joint ache, nausea, vomiting, fever.
The phase III trial has started.

Concluding assessment: SARS-CoV-2 vaccines

Fig. 4.: vaccine candidates in detail
Conclusively, Prof. Krammer assesses the actual state of vaccine development as cautiously optimistic.

All mentioned above vaccines trigger antibodies of a certain type called “IgG”. These antibodies are capable of protecting the lower airways (lungs). Unfortunately these vaccines don’t lead to a sufficient production of “IgA” antibodies that mainly protect the upper airways (throat, nose, sinuses).
Therefore, such vaccines will only protect from a severe infection of the lungs but not from an infection of the upper airways. Consequently, I expect that face covers will still be necessary even after receiving a vaccine.
 
The development of a live, attenuated vaccine that will be applied via the nose (exists for influenza) would have the advantage that it can trigger the production of either IgG and IgA. Unfortunately those vaccines are in a very early stage of research and have not yet made it to clinical trials.
 
At the moment it is still unknown how well older individuals will response to a vaccine. Furthermore, older patients need higher antibody levels than younger ones for a sufficient protection (experience from influenza research).
 
Prof. Krammer concludes that the vaccines developed by AstraZeneca, Moderna and Pfizer will have a sufficient efficacy with a high probability, thus an approvement of those vaccines is to be expected provided that side effects remain minor.
 
I would like to add that serious complications of vaccines are generally overestimated and have to be clearly distinguished from common side effects like headache, fatigue, joint pain and fever. In the last 9.5 years we have administered around 12,000 vaccination without a single complication and just the usual side effects. We forget too often that millions of lives are being saved and harms to our health avoided by vaccinations: 
The measles vaccine has saved 17 million lives in the years 2000-2015 (WHO about measles). And only a vaccine could eradicate smallpox that hat cost 300 million lives in the 20. century (WHO about smallpox).
 
Finally, I personally believe that the development of a corona vaccine will be remembered as a unique and unprecedented international cooperation and achievement. We will probably owe participating scientists and other persons involved our respect and gratitude.

Saturday, August 22nd 2020

Dear patients,

please keep paying attention to social distancing, hygiene and face masks. Germany is experiencing a mild second wave. Our neighbouring countries are facing similar or worse circumstances.
The map shows infections per day of a country (original data). Rising numbers are easily to notice. On the second diagram you can see that cases are also rising in Wiesbaden (original data). We all shouldn't neglect necessary measures even if it isn't easy to stay disciplined.

Tuesday, July 28th 2020

Dear patients,
 
please be extra attentive in the coming days and weeks and pay attention to „social distancing, hygienic measures and face mask“.
Neighbouring countries seem to undergo a beginning or a definite second wave. The diagrams show the number of infections per day (Original data). As you can see, following a first wave is the first part of a second rise as seen in Luxembourg and the Czech Republic, our immediate neighbours.
For that reason, the Robert-Koch-Institut had held a press conference today to call for caution.

Sunday, July 26th 2020

Dear patients,
 
at the moment we can enjoy a quite calm time in Germany regarding the Corona pandemic. This gives us the opportunity to recover from the stress, enjoy the nice weather and finally meet again with friends – of course in compliance with safety rules (find more on CDC.gov).
In case there will be an increase of cases this autumn, our motivation to isolate ourselves again will certainly be better if we will have used this summer as well as possible. For psychological reasons I therefore regard it as very important to allow oneself this little break from the pandemic.
 
Today I would like to address these topics:

- Corona warning app (in Germany)
- Face masks

There is still no ground-breaking news about vaccines, antiviral drugs, antibody tests and antigen tests. Results simply need time. Also there is currently no evidence of a crucial influence of virus mutations (see original article) and the blood group of patients (see original article).

Corona-Warn-App

This app has been accepted in Germany better than in other European countries, it has been downloaded 16 million times  (see diagrams). The more people take part, the better this app can help us to avoid strong measures like closing shops and restaurants again. Instead, this app can inform contacts of infected persons and thus sending the right people into quarantine. This way there would be no need to send the whole population into isolation.
For more information about the source code of this app and data protection issues please look in heise.de (in German).

Face masks

Wearing a mask is no big deal and according to current data it has a proven effect in reducing infections. Therefore I clearly recommend using those masks.
Mainz University and others have shown how infections have been avoided by wearing masks in the German town of Jena (see diagram), this analysis is easy to understand (look here).
There are multiple other trials with the same findings, e.g. examining the situation in Italy (see second diagram).
A quite graphic example has been reported about in the Washington Post and also in Der Spiegel: Two hairdressers had continued to work in their salons, unknowing about their Corona infection. Obviously thanks to wearing masks, not a single infection has been observed in 140 of their clients.
Interested readers can find a more complex but very detailed analysis in The Lancet.

3 million saved lives in Europe

This impressive analysis published in Nature shows us that lockdown measures were essential and successful: They saved about 500.000 lives in Germany and 3 million in Europe.
The second diagram from the Financial Times shows what happens when measures against the pandemic are not strict enough: The US were not successful in overcoming the first wave. Numbers are still rising steeply. Let us hope for our friends and colleagues there that science and facts will prevail.

Monday, June 22nd 2020

Success of lockdown measures in plain numbers

Dear patients,

For us all the lockdown has been a difficult time in psychological and economic terms. We all have avoided many coronavirus infections and thus saved lives. Meanwhile there are adequate mathematical models to calculate how many infections would have taken place if the lockdown hadn’t happened.

A recent study (see below) looked at the situation in the following countries: China, South Korea, Italy, Iran, France, USA. It shows that an additional number of probably 530 million people would have been infected with the coronavirus if the lockdown hadn’t taken place (in comparison to 3 million infections in all six countries at present time).

This illustrates and emphasizes how important lockdown measures have been. (Original article)

Sunday, June 21st 2020

"Corona-warn-app"

Dear patients,
 
since Tuesday the „Corona-warning-app“ („Corona-warn-app“) is ready for download. This application for smartphones is meant to warn the user after close contact with people within the previous two weeks who have registered themselves as Corona positive. In such a case the user can put himself into a voluntary quarantine.
 
The application is sufficiently safe regarding data protection (see article at heise.de). The source code (the „programming“) is open source so every expert can look at details and functions. Please find instructions of use at heise.de.
 
This app gives the population the chance to get local outbreaks quickly under control without the need for extensive restrictions and lockdowns.
The recent outbreak in a meat processing factory near Gütersloh could probably have been stopped much earlier with such an app and might have avoided infecting over 1000 people.
 
Thus, I recommend the use of this app and of course installed it on my personal smartphone. There is good scientific evidence for the advantages of such an app (see original article).
 
You can download the app here.

Monday, June 1st 2020

Dear patients,

today I would like to address these topics:

- Current situation of the corona pandemic in Germany
- Presentation of information by the media
- „R value“ and comparing corona virus with influenza
- The COVID-19 infection – what do we now yet?

Current situation of the corona pandemic in Germany

Everyone in Germany including politicians and health care professionals have made it possible to push down the first wave of corona virus infections. As you can see on the diagram, the number of actually infected people has gone down (red line), not to be mixed up with the number of those who have or had the disease (blue line). At the moment there are only 8000 people infected with COVID-19.
This is a very positive result, thanks to the majority of sensible citizens. They succeeded in neither overestimating nor underestimating the threat posed by the corona virus. Contrary to that, the behaviour of a minority on demonstrations is dangerous: The spreading of false information leads to wrong behaviour and thereby endangers the lives of others.
There has been an outbreak of corona virus infections in a retirement home in Wiesbaden. This shows that it isn’t over yet.

Presentation of information by the media

Science is a slow process that needs time and patience. But the media needs fast information and sensation, otherwise they might be ignored. This contrast leads to the misunderstanding that there are conflicting recommendations following each other in a short time.
Therefore, I recommend not to take every little news as confirmed knowledge but to wait until facts from trials confirm or contradict that information.
Nevertheless I would like to stress that it makes sense to get your information from trustworthy main stream media and newspapers. Please do not turn away from that media and get your information from self-pointed “gurus” on YouTube or rumours on Facebook, WhatsApp, Twitter etc. This will only lead you astray. You might also ask someone on the street how to treat corona virus.
Please find reliable information here:
https://www.coronavirus.gov
https://www.cdc.gov/coronavirus/2019-nCoV/index.html

„R value“ and comparing corona virus with influenza

The New York Times has published a descriptive diagram (see picture). The R value is the number of people being infected by one patient. This is shown on the lower axis. Thus, measles will be transmitted to more people by one patient that SARS-CoV-2 (“new coronavirus”).
The left axis shows the lethality. As shown on the diagram, Ebola is more dangerous than SARS-CoV-2.
The diagram also shows that it doesn’t make any sense to say “corona is (just) as dangerous as a flu”.
Influenza can have a lethality that differs very much from one season to the other. The “bird flu” is extremely dangerous and comparable to Ebola while the 2009 flu was as harmless as a common cold.
SARS-CoV-2 is shown as a read area instead of a dot because we still lack precise data.
Nevertheless, the lethality of corona virus is high enough to make health care collapse especially if the threat isn’t taken seriously.

The COVID-19 infection – what do we now yet?

The virus attacks the upper airways first, hence nose and throat (stage I on the diagram). The most common symptoms are fever and coughing. A loss of the sense of tasting might be typical but is also associated with a common cold.
In the second stage the virus reaches the lungs. A throat swab will often turn out negative for SARS-CoV-2 now although the patient has the virus. Shortness of breath can appear. The patient has the typical signs of a pneumonia.
The third stage is characterized by an over-reaction of the immune system. As a consequence, the body is harmed by itself. Therefore, there are ongoing trials to find a way to slow down the immune system in that phase of the infection.
Moreover, in stage III inflammations of the myocardium are found, possibly leading to cardiac failure. Also thrombosis and pulmonal embolisms appear, caused by a hypercoagulation.
 
This is what is known yet about COVID-19. Other observations are only preliminary. The media tend to present such observations as confirmed facts, but this is not the case. For example, there had been reports about certain syndromes in children. But it is much too early to assess that situation. Two observations might appear at the same time without a causal link, and quite often in science there will be following data that will contradict the first data.
Therefore, I recommend to wait patiently and let science do its job. (Find diagram paper here)

Sunday, May 15th 2020

Dear patient,

I would like to talk about several topics today:

  • Staying smart in the pandemic
  • How to know where the virus comes from?
  • Is Corona really that “bad”?
  • Why is mortality so different in various countries?
  • Why does it take so long with developing a vaccine?
  • Anything new about the antibody test?
  • Is there a medication for Corona yet?
  • Live your lives! – with social distancing, masks and hygiene

Staying smart in the pandemic

In an exceptional situation as this Corona pandemic it is of utmost importance to keep a cool head, use our brain and get our information from safe sources: from experts.
This is the best way to manage our lives in such times since it will last on until a vaccine will be available. Neither panic nor negation are helpful.
 
How to know where the virus comes from?

Every virus has its genetic fingerprint. If the fingerprints of the Corona virus in different countries worldwide is being compared with the ones found in different animals, the source can be identified.
Such fingerprints are shown on the diagram. The green line shows a virus endemic in bats, the red line shows the worldwide pandemic virus in humans. As you can see, the fingerprints of those two viruses are mostly identical. Little differences are normal since viruses change in their cycle of propagation.
Thus the origin of the virus can be regarded as identified.
 
Is Corona really that “bad”?

Numbers are abstract, it’s difficult to have an image in your mind. Therefore, let me give you a report from real life: I receive reports from befriended physicians in the Rhein-Main area, Germany and the whole of Europe. They are on the “front line”, working in hospitals, partly on intensive care. I studied with many of them and know their competence and reliability.
All of them tell me that the current situation is much different from what we know of past years and decades of influenza and other epidemics. Depending on the region they live in, there is a much higher flow-in of patients. Capacities are partly under stress (Germany), but partly medical care is not possible anymore for all incoming patients (London). A makeshift hospital with 4000 beds had to be built.  (Article on Business-Insider).
COVID-19 patients are much longer on intensive care and ventilated longer that those with an influenza or common pneumonia, thus capacities of beds and respirators are blocked longer than usually.
There are antibiotics to treat bacterial pneumonias and Oseltamivir to treat influenza, but with SARS-CoV-2 (“Corona”) there is no comparably efficient drug. Doctors can only wait and hope.
A befriended married couple of doctors in London sends me dramatic reports. The inflow of patients is extremely high, a normal medical care is not possible anymore. There aren’t enough beds, respirators, medical staff.
When she (internist) tells me that three nurses known to her in the age of mid-fifties died in her hospital and another six nurses and physicians survived on intensive care, there is no doubt to me that the situation is very serious and we don’t ask too much from people to simply wear masks.
It would prove fatal to believe that this couldn’t happen to Germany. We can be thankful that doctors and politicians acted much earlier than in the United Kingdom or the US where the existence of a threat had been doubted in highest positions in politics even when the pandemic was already fully running. Consequences are obvious: Those two countries have witnessed a sheer explosion of infections while in Germany there are “only” minor outbreaks.
The whole world is lucky that Corona is “only” as bad as a “severe influenza without a vaccine”. If we had to deal with an Ebola pandemic, our masks would prove more or less useless and mortality could be around >68% (see last Ebola outbreak).
 
Why is mortality so different in various countries?

There are several reasons for that:
-          Number of tests: In Germany, mildly sick patients have been tested while in Italy only moderate to severely sick patients received a test. The more mildly sick patients you have, the lower the mortality rate.
-          Access to a test: In the US, for numerous week you had to pay for a test while in Germany it has been and is for free.
-          Way of life: In Italy, many people live in larger families. Thus, the elderly is being infected by younger generations. In Germany we rather find small families so the elderly is “isolated” from the others.
-          Hospital capacities: The number of beds, respirators and medical staff has been sharply reduced in the last couple of years in the United Kingdom and Italy. This has been done to safe expenses. Germany has also reduced capacities, but not to that extent as in above mentioned countries.
Last not least many patients are afraid to enter a hospital although it might be necessary. And inside hospitals the focus is shifted on Corona so there is a risk that other diseases get out of sight.

 
Why does it take so long with developing a vaccine?

There are no Corona vaccines from past experiences so there is no basis to build on. This is a crucial difference from the situation with influenza vaccines: They can be designed and produced within months.
Nevertheless, parts of other vaccines can be used as a basic element and modified to work as a Corona vaccine. Thus, the development of a Corona vaccine will (hopefully) not take 5-10 years as this is the usual average time for a vaccine development.
Testing a vaccine for efficiency and tolerability takes most of the time. A vaccine that is being tested in Mainz will be used in healthy volunteers for several months. After that, it will be tested in older volunteers with pre-existing conditions.
Some people erroneously believe that one day they will receive an untested vaccine. Nothing could be more wrong: E.g. in Mainz a first vaccine is already there but due to the need of thoroughness and safety, such a vaccine will be tested for a long time. In other words: Only after making sure that a vaccine has been tested thoroughly enough for efficiency and safety, it will be offered to the public.
As soon as such a vaccine will be available, I expect it to be distributed to risk groups first, just as in the swine flu pandemic in 2009.
 
Anything new about the antibody test?

At the moment, I do not recommend to have an antibody test for Corona. The information about the reliability of that tests stems from the company that produces it. The data base for reliability calculations has been rather small (69 Corona patients, see diagram).
Moreover, antibodies do not necessarily have to be protective antibodies: Patients P1 to P10 did have antibodies, but those antibodies couldn’t neutralize the virus (no visible columns on the diagram). The rest of patients (P11 to P175) showed different levels of neutralizing potency from way below 500 up to 20.000.
In certain situations, antibodies can prove harmful: After having gone through Dengue fever, you might develop antibodies that will make a later, second infection with Dengue virus even much worse. Thus, antibodies are not always the same.
Lastly, an immunity against a disease is not only caused by antibodies but many others parts of the immune system including “trained” T-type lymphocytes. And that makes the situation more complicated.
Long story short:
-          If a patient has a positive antibody test, he doesn’t know if he will be immune to Corona virus, thus he has to continue to protect himself by wearing a mask etc. since he can still be infected.
-          If a test turns out negative, the patient has to protect himself by wearing a mask etc.
Since the result is the same, I do not recommend doing a test now. And remember that you would have to repeat such a test every week. My recommendation will certainly change in the future, but not today.
If someone still wants to do such a test, I expect a test centre to be opened at the end of May, but costs have to be paid by the patient himself.
I strongly advise against thinking that a patient will be immune because of a positive antibody test. If someone visited his parents or grandparents without the necessary protection, this could have fatal results for them.
 
Is there a medication for Corona yet?

Remdesivir has the best data. In a US study (see diagram) it showed a certain efficacy that lead to its approval in the US a week ago while this step still being evaluated in Europe.
Remdesivir alone is not efficient enough. More substances are being tested.
 
Live your lives! – with social distancing, masks and hygiene

Since the Corona pandemic will last on for months, presumably another year, we can’t remain in a state of emergency because of psychological reasons. We need a certain amount of normality, otherwise the stress will be too much for us.
On the one hand, we need to follow protective measures without even thinking about them because they have become daily routine: distancing, masks, washing hands. On the other hand, we need to get back to our daily routine and way of life. Thus, we can feel that life goes on.
Research is working hard to find solutions. This might me invisible for non-physicians. New substances are being developed, trials performed to find out more about how the virus spreads so we will have more precise information how to protect us and at the same time have more freedom. And vaccine trials are on the way.
Nevertheless this “bad dream” will only be over when we receive a vaccine. I will keep a close eye on those developments. Initially I spent 10 hours a week with online presentations and conferences on Corona virus, at the moment it is only a couple of hours per week. This way I can continue to seek out the most important information of this complex topic, summarize it and put it in a shape that can be easily understood.

Diagrams