Information about the Corona pandemic

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

Tuesday, May 5th 2020

Antibody Tests - an Update

Dear patients,

all currently available antibody tests for Corona virus are not sufficiently tested for quality and the pivotal questions:

- Did others than the manufacturers of the test already check it for accuracy (sensitivity/specifity)?
- Does the test react to only this virus (SARS-CoV-2) and no other Corona virus?
- Are these antibodies protective and avoid a renewed infection or are they just "collateral" antibodies as in HIV: They appear but do not protect.

As soon as a validated, quality approved test is available, the next question will be:

Who should be tested?

We should keep in mind not test these who first say "me!" but those who really need it for medical reasons.
The result of such a test should always be followed by medical decisions and actions. A test should never be done out of curiosity although I absolutely understand everyone's desire and impatience to know their status.


Sunday, April 26th 2020

Dear patients,

in the last couple of weeks the pandemic hast been pushed back very well, and we all contributed to that. 
Nevertheless it is not over, on the contrary: According to virologists and epidemiologists (way) less than 5% of the population in Germany has been through the Corona infection.

Consequently, this means that this is just the beginning. The main part of the virus spreading still lies ahead. While at the beginning of March we had an inadequate panic among parts of the population, one can now observe a tendency to play down the threat by the virus. This is potentially dangerous since it can quickly destroy past efforts. Non-qualified "celebrities" believe to have a say in the media. This is inadequate and harmful. Please choose well whom to listen to and when better to switch the channel. 

Balance between fighting the pandemic and economic survival

It is difficult to find a balance between restrictions of our daily life fighting the pandemic and a certain normalization of our life and job since we have to live on something. I'm in the same situation since I also have to reduce many economically necessary actitivities to protect patients and my team.

Every single one of us bears a responsibility for human lives these days. Thus we all are obliged to adapt our behaviour and find a compromise that allows us to counter the virus and secure our own economic survival. And this challenge won't change in the months to come, thus it is recommended to prepare mentally for this long-time adjustment.

Keeping one's distance to others and face masks

Aside from keeping one's distance (6 ft), face masks seem to be a simple and effective means to protect others from oneself's germs. Therefore it is urgently recommended to carry masks when in contact with others in closed-off rooms. But this can only protect us if everyone adheres to the recommendation since masks only protect others and not the one who carries it. Someone without a mask should consequently not enter a bus.
Besides that, please note that the outer surface of the mask is to be regarded as contaminated, so avoid touching it. If you are forced to put the mask in your bag, fold it with contaminated surfaces facing each other.
I'd like to use this opportunity to thank everyone for providing self-made masks. This makes sure that every patient who enters our practice can carry a mask so everyone will be protected and infections avoided.

Latest medical findings

There is a lot of research going on now. As soon as relevant data will be available I will let you know. The next developments I expect to come are drugs countering the virus and an antibody blood tests in selected cases in clinics. 

Saturday, April 11th 2020

Dear patients,
this is an update regarding the Corona pandemic in Germany.

Limitation of contacts

The measures of the past two weeks have shown positive results. The rate of new infection has been reduced by half. Without this measure we would have twice as many patients on intensive care. So it was worth reducing our contacts and keeping distance from others.

CODIV-19 hazard assessment

80% of all infected people seem to suffer from no or only litte symptoms comparable to a common cold. The older the patient the higher the risk of a ciritical infection (see diagram). There is a steep risk increase at 60 years.

Corona testing in Germany

The number of tests in Germany (PCR, direct virus detection, see table) is very high and still increasing in comparison to Europe and the World. Thus infected patients can be detected faster and the spreading of the virus can be slowed down. Nevertheless there is no sense in testing everyone with symptoms of a cold since there aren’t enough tests for that.

Thema Antikörper-Tests

This is a topic that is being discussed intensely, but it is still too early to use it in daily practice:
1. Those tests still have to prove that they detect the right virus (SARS-CoV-2) and not one of the many other Corona viruses.
2. They have to be sensitive enough. At the moment the detection rate is at 90%, that is still not precise enough (see slide)
3. It remains unknown whether someone with positive antibodies will be immune to another infection with COVID-19. If the answer is yes, we don’t know for how long the patient will stay immune. Probably we will know more after one month. Such tests would be very useful to know if someone already went through the infection and has immunity. This is of special importance for medical staff in order to predict the risk of contracting or further spreading the infection - if antibodies are positive, immunity can be assumed and the risk of infection and spreading can be reduced.

Smartphone apps to counter the pandemic: „Datenspende“ and „PEPP PT“

The RKI (Robert-Koch-Institut) just published the App „Corona Datenspende“. It is meant to detect infection hot spots using fitness wearables (see list) that register an elevated pulse and other parameters.
(App for iOS) (App for Android)
Much more effective and presumably more relevant might be an App that tells us whether we have been close to an infected person and should therefore stay at home to avoid infecting others.
The app will use near field bluetooth of our smartphones to get information about such contacts. You can find more details about the project „PEPP PT“ here (Pan-European Privacy-Preserving Proximity Tracing). A Heise forum (in German) discusses security aspects with Linus Neumann (Chaos Computer Club).

Tuesday, March 24th 2020

Dear patients,

thank you so much for your excellent cooperation: You helped us taking care of your requests without the need to present yourself in person. You indirectly safe lives because the pandemic advances much more slowly. This keeps more ressources available in hospitals to take care of critcally ill patients.
We have cancelled our vacation from April 14th to 18th so we will be available for you.

Saturday, March 21st 2020

Transmission path of Corona

The virus is spread from person to person by little drops floating in the air especially after coughing and sneezing. It is not yet known whether it is transmissed via objects around us (see NIH: Corona on surfaces). (Source: CDC)

Get rid of the virus: Wash your hands

After being in public places please wash your hands for at least 20 seconds. Avoid touching your eyes, nose and mouth with unwashed hands. Keep a distance of 1,5-2 meters (5-6 ft) to other people to avoid a transmission.

Stay at home

Please leave your home only for the most necessary things, primarily to buy food. If home office is possible, it is strongly recommend to use it. If we stayed at home for the next 14 days the epidemic would be strongly pushed back or even stopped, just as in China, possibly also in Korea.

Sick? Stay at home and recover.

Especially now it is crucial to stay at home when you are sick - regardless of whether it is a Corona infection or not: Those days and weeks it is important to recover as quickly as possible and build up a strong immune system. Please do it for yourself but also for others.