Category Archives: Health

Good News Monday: Writers, Think Pink!

Many of us remain isolated from friends and family during this pandemic. So imagine how difficult it would be to find yourself newly diagnosed with breast cancer — and with no support system to help you through the crisis.

An organization called Girls Love Mail has a novel way of boosting women’s spirits. Since 2011, it’s enlisted thousands of empathetic people to send words of encouragement to strangers; about 167,000 letters have been mailed to date.

Want to share a little hand-written optimism? Visit girlslovemail.com in honor of Breast Cancer Awareness month in October.

Photo by Abstrakt Xxcellence Studios on Pexels.com

Good News Monday: Statins, stat!

For us older folks with cholesterol concerns — mine’s hereditary; thanks, Dad — today’s NY Times article had some heartening info.

For Older People, Reassuring News in the Statin Debate

There is accumulating evidence that the benefits of statins far outweigh possible risks, and nearly all statins on the market are now available as inexpensive generics.

Credit…Gracia Lam
Jane E. Brody

By Jane E. Brody

  • Sept. 21, 2020, 5:00 a.m. ET

Cholesterol-lowering statin drugs, already one of the most popular medications worldwide, may become even more widely used as evidence grows of their safety and value to the elderly and their potential benefits beyond the heart and blood vessels.

Among the latest are reports of the ability of several leading statins to reduce deaths from common cancers and blunt the decline of memory with age. Perhaps such reports will persuade a reluctant 65-year-old friend who has diabetes, and others like him, that taking the statin his doctor strongly advised is a smart choice.

In addition to accumulating evidence that the benefits of statins far outweigh possible risks for the vast majority of people for whom they are now recommended, nearly all statins on the market are now available as inexpensive generics.

Full disclosure: I have a strong family history of heart disease and have been taking a statin — atorvastatin, originally marketed as Lipitor — for many years after dietary changes failed to control a steadily rising blood level of artery-damaging LDL-cholesterol. My prescription is now fully covered by my Medicare Part D insurance with no co-pay.

But cost of a medication is not the only consideration for a drug that can be lifesaving for many people. The primary indication for taking a statin is to reduce the risk of a heart attack or stroke by lowering serum LDL-cholesterol and, in some cases, also triglycerides, both of which can damage coronary arteries when levels rise above normal.

Statins offer further cardiovascular protection by stabilizing the fatty deposits in arteries called plaque that can break loose, block a major artery and cause a heart attack or stroke.

Current guidelines typically recommend statin therapy for:

  • People with a history of heart disease, stroke or peripheral artery disease or risk factors that give them a 10 percent or greater chance of a heart attack within 10 years;
  • People over 40 with diabetes and an LDL-cholesterol level above 70 milligrams per deciliter;
  • People over 21 with an LDL-cholesterol level of 190 or higher (despite dietary changes to minimize saturated fats and achieve a normal body weight).

Currently, more than 60 percent of older people in the United States who, like me, have high cholesterol take a statin to help prevent a heart attack or stroke.

Still, there’s been a long-simmering debate as to whether statins are advisable for people over 75, even though the risk of suffering life-threatening cardiovascular disease rises precipitously with age. Concerns have been raised about side effects associated with statins, potential adverse effects of the drugs on other ailments common in the elderly and possible harmful interactions with the many other medications they often take.

Writing in the Harvard Health Blog last October, Dr. Dara K. Lee Lewis noted, “The paradox that we face is that as our patients age, they are at increased risk for heart attacks and strokes, and yet they also become more sensitive to medication side effects, so it is a tricky balance.”

Statins can sometimes cause blood sugar abnormalities, resulting in a diagnosis of pre-diabetes or diabetes, and possible toxic effects on the liver that necessitate periodic blood tests for liver enzymes. A very small percentage of people prescribed a statin develop debilitating muscle pain. An elderly friend developed statin-induced nightmares. There have also been reports suggesting statin-associated memory problems and cognitive decline, already a common concern as people age.

But likely the biggest deterrent was the existence of meager evidence for the role statins might play for older people at risk of cardiovascular disease. As is true in most drug trials on new medications, relatively few people over 75 were included in early studies that assessed the benefits and risks of statins.

The latest reports, however, are highly reassuring. One followed more than 120,000 French men and women ages 75 to 79 who had been taking statins for up to four years. Among the 10 percent who stopped taking the drug, the risk of being admitted to a hospital for a cardiovascular event was 25 to 30 percent greater than for those who continued taking a statin.

Another study in Israel, published last year in the Journal of the American Geriatrics Society, involved nearly 20,000 older adults followed for 10 years. Among those who stayed on statin therapy, the chance of dying from any cause was 34 percent lower than among those who failed to adhere to a prescribed statin. The benefits were not reduced for those older than 75 and applied to women and men alike.

This year a study published in JAMA by a team headed by Dr. Ariela R. Orkaby of the VA Boston Healthcare System found that among 326,981 United States veterans whose average age was 81, the initiation of statin use was associated with 25 percent fewer deaths over all and 20 percent fewer cardiovascular deaths during a follow-up of nearly seven years.

However, none of these studies represent “gold standard” research. The results of two such studies, the Staree trial and the Preventable trial, both randomized controlled clinical trials of statin therapy to prevent cardiovascular events in the elderly, have not yet been published. Both will also assess effects on cognition.

Meanwhile, a report last year from Australia published in the Journal of the American College of Cardiology found no difference over a six-year period in the rate of decline in memory or cognitive status between statin users and those who had never taken the drugs. In fact, among those who started a statin during the study, the rate of memory decline was blunted. Another observational study by a Swedish team published in Nature found beneficial effects on reaction time and fluid intelligence among statin takers over 65.

Finally, there are several reports that a major class of statins called lipophilic (including atorvastatin, simvastatin, lovastatin and fluvastatin) may have anticancer effects. One study of nearly 2,000 survivors of early-stage breast cancer found a decreased five-year recurrence rate in women who started a statin within three years of diagnosis.

In a report presented in June to a virtual meeting of the American Association for Cancer Research, Dr. Kala Visvanathan of Johns Hopkins Medicine in Baltimore described a 40 percent reduction in deaths from ovarian cancer among more than 10,000 patients who had used statins either before or after their diagnosis. The patients who benefited in this observational study had the most common and aggressive form of ovarian cancer.

Dr. Visvanathan explained that statins inhibit an enzyme in a chemical pathway involved in the growth and proliferation of tumors. At a press briefing, Dr. Antoni Ribas, president of the association, said that if the finding is confirmed in a randomized clinical trial, “this would be a great outcome.”

Good News Monday: COVID Immunity

Reprinted from today’s New York Times

Is herd immunity ahead of schedule?

Mumbai may be among the cities that have already achieved herd immunity, scientists say.Indranil Mukherjee/Agence France-Presse — Getty Images

Today, we’re turning this section over to our colleague Apoorva Mandavilli, who has been covering the pandemic for The Times’s Science desk.

The pandemic will end only when enough people are protected against the coronavirus, whether by a vaccine or by already having been infected. Reaching this threshold, known as herd immunity, doesn’t mean the virus will disappear. But with fewer hosts to infect, it will make its way through a community much more slowly.

In the early days of the crisis, scientists estimated that perhaps 70 percent of the population would need to be immune in this way to be free from large outbreaks. But over the past few weeks, more than a dozen scientists told me they now felt comfortable saying that herd immunity probably lies from 45 percent to 50 percent.

If they’re right, then we may be a lot closer to turning back this virus than we initially thought.

It may also mean that pockets of New York City, London, Mumbai and other cities may already have reached the threshold, and may be spared a devastating second wave.

The initial calculations into herd immunity assumed that everyone in a community was equally susceptible to the virus and mixed randomly with everyone else.

The new estimates are the product of more sophisticated statistical modeling. When scientists factor in variations in density, demographics and socialization patterns, the estimated threshold for herd immunity falls.

In some clinics in hard-hit Brooklyn neighborhoods, up to 80 percent of people who were tested at the beginning of the summer had antibodies for the virus. Over the past eight weeks, fewer than 1 percent of people tested at those same neighborhood clinics have had the virus.

Likewise in Mumbai, a randomized household survey found that about 57 percent of people who live in the poorest areas and share toilets had antibodies, compared with just 11 percent elsewhere in the city.

It’s too early to say with certainty that those communities have reached herd immunity. We don’t know, for example, how long someone who was infected stays protected from the coronavirus. But the data suggests that the virus may move more slowly in those areas the next time around.

Happy Random Day

Not only is today a lot like yesterday — and probably tomorrow — but I don’t seem to be able to focus on one particular topic. A few things are buzzing around my brain. First up:

Can You Get COVID-19 Twice?

As with everything else, nobody has a clear opinion. Or they change faster than a politician’s election strategy.

Reported in today’s Washington Post:

Doctors emphasize there is no evidence of widespread vulnerability to reinfection and that it is difficult to know what to make of these cases in the absence of detailed lab work, or medical studies documenting reinfections. Some people could be suffering from a reemergence of the same illness from virus that had been lurking somewhere in their body, or they could have been hit with a different virus with similar symptoms. Their positive COVID-19 tests could have been false positives — a not-insignificant possibility given accuracy issues with some tests — or picked up dead remnants of virus, as authorities believe happened in hundreds of people who tested positive after recovering in South Korea.

Suspect Sanitizer

The FDA has warned that some hand sanitizer brands labeled as containing ethyl alcohol actually contain a much more dangerous ingredient.

The agency reported that there has been an increase in hand sanitizers that have tested positive for methanol, or wood alcohol. If methanol is absorbed through the skin, it can cause blindness and hospitalizations; even death if ingested.  For the complete list, go to FDA hand sanitizer updates.

Men and #MeToo

It’s not just women who’ve been harassed by men in power.  This fascinating article looks at how some men have suffered too. And no, they weren’t the abusers.

Life In 3-D

How about a random mantra? Decode the problem. Decide the next steps. Deliver change.

IMG_1949

(Random beach photo from a recent walk)

 

 

Good News Monday: Why Masks Work

Yes, it’s Tuesday. But, honestly, who can tell the difference between one day and the next?

This, from the Los Angeles Times, is interesting.  On the off chance that the link doesn’t work — because, mostly, they don’t since they want you to subscribe instead of reading for free — I’m pasting it here.

You’ll get the gist even if you don’t read the whole thing. (What’s a “gist”? Glad you asked. Extensive research indicates “early 18th century: from Old French, third person singular present tense of gesir ‘to lie’, from Latin jacere . The Anglo-French legal phrase c’est action gist [‘this action lies’ , e.g. occurs] denoted that there were sufficient grounds to proceed; gist was adopted into English denoting the grounds themselves.”  Now you know.

Masks offer much more protection against coronavirus than many think

RONG-GONG LIN II, MAURA DOLAN

There’s a common refrain that masks don’t protect you; they protect other people from your own germs, which is especially important to keep unknowingly infected people from spreading the coronavirus.

But now, there’s mounting evidence that masks also protect you.

If you’re unlucky enough to encounter an infectious person, wearing any kind of face covering will reduce the amount of virus that your body will take in.

As it turns out, that’s pretty important. Breathing in a small amount of virus may lead to no disease or far more mild infection. But inhaling a huge volume of virus particles can result in serious disease or death.

That’s the argument Dr. Monica Gandhi, UC San Francisco professor of medicine and medical director of the HIV Clinic at Zuckerberg San Francisco General Hospital, is making about why — if you are unlucky to get infected with the virus — masking can still protect you from more severe disease.

“There is this theory that facial masking reduces the [amount of virus you get exposed to] and disease severity,” said Gandhi, who is also director for the Center for AIDS Research at UC San Francisco.

The idea of requiring mask-wearing in public has become an increasingly pressing and politicized issue as California and the rest of the nation see a surge in new cases as the economy reopens.

California this week ordered a reclosure of many businesses, include a statewide halting of all indoor dining and a closure of bars. The state also ordered a closing down — in dozens of hard-hit counties, including L.A. County — of indoor gyms, houses of worship, hair salons, nail salons and offices for nonessential industries.

But experts say masks are essential for people to wear when they still go out in public, such as to shop or go to medical appointments, and to get exercise like heading to the beach or park.

California has mandated face coverings in public settings since June 18, and a growing number of communities said they will ticket people who disobey the rules. But there remains some resistance to the government mandating wearing masks in some corners of the state, including Orange County.

Some leaders in Orange County have pushed back against requiring students to wear masks should they return to classrooms in the fall.

In policy recommendations approved by the Orange County Board of Education on Monday, a document stated that “requiring children to wear masks during school is not only difficult — if not impossible to implement — but [is] not based on science. It may even be harmful.” Individual districts will have the final say on how schools open.

Some health experts were appalled by that language.

“This anti-mask rhetoric is mind-blowing, dangerous, deadly and polarizing,” said Dr. Peter Chin-Hong, professor of medicine and an infectious diseases specialist at UC San Francisco. “There is no evidence that it is dangerous.”

In fact, wearing masks can help prevent children from being infected and suffering serious consequences of infection, such as multisystem inflammatory syndrome, a rare condition that has been seen in children who have been infected with the coronavirus. “Kids not only transmit, but they can get sick as well,” Chin-Hong said.

While children are less likely to develop severe illness from the coronavirus than adults, they can still be infected, be contagious and transmit the virus to other people, Gandhi said.

Wearing a mask at school would not only reduce their ability to transmit the virus to other classmates, teachers and administrators, but also protect the students from getting infected with a large dose of virus from infected people.

Transmission rates for coronavirus have been rising across the state. Nearly 1,000 of San Francisco’s nearly 4,600 cases have been diagnosed in just the last two weeks, said Dr. Grant Colfax, the city’s director of public health.

In San Francisco, nearly half of all those who have tested positive in the city are Latinos, he said, even though Latino residents make up just 15% of the city’s population. Overall, the city has seen 7.8 new infections per 100,000 residents over the last seven days, far above its goal of no more than 1.8 new infections per 100,000 people.

“This, again, indicates that the virus is spreading throughout the city, particularly … in the southeast part of the city,” Colfax said.

For every one person who contracts the virus, another 1.25 people on average are now infected, he said. “We really need to drive that down to 1 or below as quickly and as soon as possible.”

The transmission rate also rose above 1 in L.A. County in June, but has fallen back to 1. “The virus currently rages on in our community,” Public Health Director Barbara Ferrer said.

The reason why masks are so important in controlling the spread of the coronavirus is that it can be widely spread by people who are not visibly sick — either because they haven’t yet shown signs of illness, or they will spend the entire course of their infections with little or no symptoms at all.

A key piece of evidence for this emerged earlier this year, on the Diamond Princess cruise ship that carried infected crew and passengers in Asia. A study published by the U.S. Centers for Disease Control and Prevention found that of 712 people testing positive for the virus, nearly half were asymptomatic at the time of testing.

“We also know that viral load is highest early during disease,” said Dr. Chaz Langelier, an assistant professor at UC San Francisco, during the panel discussion. In fact, 44% of transmissions are believed to occur when the infected person has no symptoms, according to a study published in Nature Medicine.

That’s different from the seasonal flu, where peak infectiousness occurs about one day after the onset of symptoms, Langelier said.

Masks don’t filter out all viral particles, Gandhi said. But even cloth face masks filter out a majority of viral particles.

And even if a person wearing a mask gets infected, the mask — by filtering out most of the viral particles exhaled by the infected person — probably leads to less severe disease, Gandhi said.

The idea that a lower dose of virus when being infected brings less illness is a well-worn idea in medicine.

Even going back to 1938, there was a study showing that by giving mice a higher dose of a deadly virus, the mice are more likely to get severe disease and die, Gandhi said.

The same principle applies to humans. A study published in 2015 gave healthy volunteers varying doses of a flu virus; those who got higher doses got sicker, with more coughing and shortness of breath, Gandhi said.

And another study suggested that the reason why the second wave of the 1918-19 flu pandemic was the deadliest in the U.S. was because of the overcrowded conditions faced in army camps as World War I wound down.

Finally, a study published in May found that surgical mask partitions significantly reduced the transmission of the coronavirus among hamsters. And even if the hamsters protected by the mask partitions acquired the coronavirus, “they were more likely to get very mild disease,” Gandhi said.

So what happens if a city dramatically masks up while in public?

If Gandhi is right, it may mean that even if there’s a rise in coronavirus infections in a city, the masks may limit the dose people are getting of the virus and result in them more likely to show less severe symptoms of illness.

That’s what Gandhi said she suspects is happening in San Francisco, where mask wearing is relatively robust. Further observations are needed, Gandhi said.

There’s more evidence that masks can be protective — even when wearers do become infected. She cited an outbreak at a seafood plant in Oregon where employees were given masks, and 95% of those who were infected were asymptomatic.

Gandhi also cited the experience of a cruise ship that was traveling from Argentina to Antartica in March when the coronavirus infected people on board, as documented in a recent study. Passengers got surgical masks; the crew got N95 masks.

But instead of about 40% of those infected being asymptomatic — which is what would normally be expected — 81% of those testing positive were asymptomatic, and the masking may have helped reduce the severity of disease in people on board, Gandhi said.

The protective effects are also seen in countries where masks are universally accepted for years, such as Taiwan, Thailand, South Korea and Singapore. “They have all seen cases as they opened … but not deaths,” Gandhi said.

The Czech Republic moved early to require masks, issuing an order in mid-March, Gandhi said; that’s about three months before Gov. Gavin Newsom did so statewide in California. But in the Czech Republic, “every time their cases would go up …their death rate was totally flat. So they didn’t get the severe illness with these cases going on.”

By May, the Czech Republic lifted its face mask rule. “And they’re doing great,” Gandhi said.

End of article, back to me.  If it’s good enough for hamsters, I’m definitely wearing a mask.

hamster

Photo by Juris Freidenfelds on Pexels.com

Sleep and Sex: It’s Not What You Think

Today, I’m reprinting a very interesting article from the National Sleep Foundation. 

How Sleep Is Different for Men and Women

A cup of coffee isn’t the only thing that can cause your energy levels to jump around. The other reason why you feel wide-awake at some points of the day and drowsy at others? Your circadian rhythm, an internal clock that helps regulate the cycle of when you feel sleepy and when you feel alert.

In a broad sense, circadian rhythms are similar from person to person, operating on roughly 24-hour cycles. But it turns out there are some notable differences in the sleep/wake patterns of women and men, which could explain why men tend to be night owls while women are more apt to be early risers.

The Rhythm Method

Circadian rhythms are controlled by an area of the brain called the hypothalamus. Other influences include light (which sends a message to your brain that it’s time to wake up) and darkness (an indicator to your body that it’s time to release melatonin, a hormone that helps you fall asleep). Regular sleep patterns—waking up and going to bed at the same time daily—also keep your circadian rhythm functioning normally, helping to reduce the chance of sleep trouble such as insomnia.

What’s Sex Got to Do with It?

Beyond these factors, there’s another important variable that influences your internal clock: sex.

It turns out, male and female circadian rhythms don’t exactly match up. Men’s clocks tend to run truer to a full 24-hour cycle or longer (on average, men have a circadian cycle that’s six minutes longer than for women ) meaning they may feel less tired in the evening.

In women, the internal clock is more likely to be shorter than a full 24-hour cycle, making it more likely that they will awaken earlier, which may also increase their susceptibility to early-waking sleep disturbances like insomnia.

Handling Sleep Cycle Interruptions

While eight hours per night on average is ideal for both genders, it turns out that men are harder hit by periods of deprivation. Lack of sleep causes work performance to suffer more for men than for women, and men recover less quickly from lack of sleep than women do.

On the other hand, women’s shorter cycles mean they are more likely to have a dip in energy at night, which could help explain why there’s an increased risk of work-related injuries in female shift workers.

Of course, it is possible to learn how to re-train your inner clock to help you feel more awake or sleepy at different parts of the day depending on your lifestyle needs. But left to its own devices, the body’s natural rhythms make it more likely that if you are a man, you will be a night owl, and for women, an early bird.

The Pandemic Ten

Remember the “freshman 15”, aka the pounds everyone seemed to gain their first year at college? It’s déjà vu all over again.

Back in the day, the culprits were pizza, beer (and/or weed), and nerve-wracking new experiences like late-night cramming and unprecedented freedom.

This is different, and not just because I’m older. Month after month of the same old, same old has led to inertia and tedium with a constant low hum of anxiety buzzing along underneath.

I don’t really care what the government is recommending… Dear Husband and I are staying put except for essential and unavoidable tasks. Since we can’t travel or eat out with friends, we’ve amused ourselves by cooking food from different cultures and pretending to be elsewhere. Unlike traveling, however, we are not burning calories by walking extra miles through cities, museums, and the like. Even my Fitbit is bored.  The result: packing on extra poundage like a wild animal in captivity.

Like many of you, I eat when I’m stressed even if I’m not physically hungry. And what I’ve realized, as my own little world keeps shrinking — while I’m not — is how many of my essential needs aren’t being met… which leads to stress… which leads to snacking.

  • Order and control. Toss this one right out the window. We have no idea when this will end and can’t do much about it except to continue social distancing and wearing a mask. Plus, staying informed is highly overrated when so much of the news is just plain sickening.
  • Anticipation. It’s hard to plan for a trip or special event when there’s nothing on the calendar.  And being worried about catching the virus en route does dim one’s enthusiasm.
  • Personal space.  If you’re someone who needs lots of alone time, a pandemic is not your friend.
  • Sleep. Stress and worry make sleep elusive, or fitful at best. Which in turn affects your body’s balance of the hunger hormones ghrelin and leptin. Ghrelin stimulates appetite, while leptin decreases it. When the body is sleep-deprived, ghrelin levels spike, while the level of leptin falls, leading to an increase in hunger, especially for junk food. (I don’t know how it knows, but it does.)
  • Variety of experiences. When going to the grocery store is the weekly highlight, life’s a little blah no matter how nice your home or neighborhood is.

Anyway, it’s useful to know the triggers. Now I need to get serious about my action plan, as I refuse to buy a larger-size wardrobe. Who’s with me?

photo of a burn fat text on round blue plate

Photo by Natasha Spencer on Pexels.com

 

 

 

Really Good News Monday: Hope on the Horizon?

The first coronavirus vaccine to be tested in people appears to be safe and able to stimulate an immune response against the virus, its manufacturer, Moderna, announced on Monday.

The findings are based on results from the first eight people who each received two doses of the vaccine, starting in March.

Those people, healthy volunteers, made antibodies that were then tested in human cells in the lab, and were able to stop the virus from replicating — the key requirement for an effective vaccine. The levels of those so-called neutralizing antibodies matched the levels found in patients who had recovered after contracting the virus in the community.

The company has said that it is proceeding on an accelerated timetable, with the next phase involving 600 people to begin soon. But U.S. government officials have warned that producing a vaccine that would be widely available could take a year to 18 months. There is no proven treatment or vaccine against the coronavirus at this time.

Good News Monday: An Expert Speaks

With so much misinformation out there, it’s useful to listen to people who actually know what they’re talking about. (Hint: Not politicians.)  While the below article is sobering, it does explain how we can avoid catching the virus.  And that’s good news.

[Reprinted from today’s New York Times]

Updated: 7 hours ago

The Risks – Know Them – Avoid Them

It seems many people are breathing some relief, and I’m not sure why. An epidemic curve has a relatively predictable upslope and once the peak is reached, the back slope can also be predicted. We have robust data from the outbreaks in China and Italy, that shows the backside of the mortality curve declines slowly, with deaths persisting for months. Assuming we have just crested in deaths at 70k, it is possible that we lose another 70,000 people over the next 6 weeks as we come off that peak. That’s what’s going to happen with a lockdown.

As states reopen, and we give the virus more fuel, all bets are off. I understand the reasons for reopening the economy, but I’ve said before, if you don’t solve the biology, the economy won’t recover.

There are very few states that have demonstrated a sustained decline in numbers of new infections. Indeed, the majority are still increasing and reopening. As a simple example of the USA trend, when you take out the data from New York and just look at the rest of the USA, daily case numbers are increasing. Bottom line: the only reason the total USA new case numbers look flat right now is because the New York City epidemic was so large and now it is being contained.

So throughout most of the country we are going to add fuel to the viral fire by reopening. It’s going to happen if I like it or not, so my goal here is to try to guide you away from situations of high risk.

Where are people getting sick?

We know most people get infected in their own home. A household member contracts the virus in the community and brings it into the house where sustained contact between household members leads to infection.

But where are people contracting the infection in the community? I regularly hear people worrying about grocery stores, bike rides, inconsiderate runners who are not wearing masks…. are these places of concern? Well, not really. Let me explain.

In order to get infected you need to get exposed to an infectious dose of the virus; based on infectious dose studies with MERS and SARS, some estimate that as few as 1000 SARS-CoV2 viral particles are needed for an infection to take hold. Please note, this still needs to be determined experimentally, but we can use that number to demonstrate how infection can occur. Infection could occur, through 1000 viral particles you receive in one breath or from one eye-rub, or 100 viral particles inhaled with each breath over 10 breaths, or 10 viral particles with 100 breaths. Each of these situations can lead to an infection.

How much Virus is released into the environment?

A Bathroom: Bathrooms have a lot of high touch surfaces, door handles, faucets, stall doors. So fomite transfer risk in this environment can be high. We still do not know whether a person releases infectious material in feces or just fragmented virus, but we do know that toilet flushing does aerosolize many droplets. Treat public bathrooms with extra caution (surface and air), until we know more about the risk.

A Cough: A single cough releases about 3,000 droplets and droplets travels at 50 miles per hour. Most droplets are large, and fall quickly (gravity), but many do stay in the air and can travel across a room in a few seconds.

A Sneeze: A single sneeze releases about 30,000 droplets, with droplets traveling at up to 200 miles per hour. Most droplets are small and travel great distances (easily across a room).

If a person is infected, the droplets in a single cough or sneeze may contain as many as 200,000,000 (two hundred million) virus particles which can all be dispersed into the environment around them.

A breath: A single breath releases 50 – 5000 droplets. Most of these droplets are low velocity and fall to the ground quickly. There are even fewer droplets released through nose-breathing. Importantly, due to the lack of exhalation force with a breath, viral particles from the lower respiratory areas are not expelled.

Unlike sneezing and coughing which release huge amounts of viral material, the respiratory droplets released from breathing only contain low levels of virus. We don’t have a number for SARS-CoV2 yet, but we can use influenza as a guide. We know that a person infected with influenza releases about 3 – 20 virus RNA copies per minute of breathing.

Remember the formulae: Successful Infection = Exposure to Virus x Time

If a person coughs or sneezes, those 200,000,000 viral particles go everywhere. Some virus hangs in the air, some falls into surfaces, most falls to the ground. So if you are face-to-face with a person, having a conversation, and that person sneezes or coughs straight at you, it’s pretty easy to see how it is possible to inhale 1,000 virus particles and become infected.

But even if that cough or sneeze was not directed at you, some infected droplets–the smallest of small–can hang in the air for a few minutes, filling every corner of a modest sized room with infectious viral particles. All you have to do is enter that room within a few minutes of the cough/sneeze and take a few breaths and you have potentially received enough virus to establish an infection.

But with general breathing, 20 copies per minute into the environment, even if every virus ended up in your lungs, you would need 1000 copies divided by 20 copies per minute = 50 minutes.

Speaking increases the release of respiratory droplets about 10 fold; ~200 copies of virus per minute. Again, assuming every virus is inhaled, it would take ~5 minutes of speaking face-to-face to receive the required dose.

The exposure to virus x time formulae is the basis of contact tracing. Anyone you spend greater than 10 minutes with in a face-to-face situation is potentially infected. Anyone who shares a space with you (say an office) for an extended period is potentially infected. This is also why it is critical for people who are symptomatic to stay home. Your sneezes and your coughs expel so much virus that you can infect a whole room of people.

What is the role of asymptomatic people in spreading the virus?

Symptomatic people are not the only way the virus is shed. We know that at least 44% of all infections–and the majority of community-acquired transmissions–occur from people without any symptoms (asymptomatic or pre-symptomatic people). You can be shedding the virus into the environment for up to 5 days before symptoms begin.

Infectious people come in all ages, and they all shed different amounts of virus. The figure below shows that no matter your age (x-axis), you can have a little bit of virus or a lot of virus (y-axis). (ref)

The amount of virus released from an infected person changes over the course of infection and it is also different from person-to-person. Viral load generally builds up to the point where the person becomes symptomatic. So just prior to symptoms showing, you are releasing the most virus into the environment. Interestingly, the data shows that just 20% of infected people are responsible for 99% of viral load that could potentially be released into the environment (ref)

So now let’s get to the crux of it. Where are the personal dangers from reopening?

When you think of outbreak clusters, what are the big ones that come to mind? Most people would go to the cruise ships. But you would be wrong. Ship outbreaks don’t even land in the top 50 outbreaks to date.

Ignoring the terrible outbreaks in nursing homes, we find that the biggest outbreaks are in prisons, religious ceremonies, and workplaces, such a meat packing facilities and call centers. Any environment that is enclosed, with poor air circulation and high density of people, spells trouble.

Some of the biggest super-spreading events are:

  • Meat packing: In meat processing plants, densely packed workers must communicate to one another amidst the deafening drum of industrial machinery and a cold-room virus-preserving environment. There are now outbreaks in 115 facilities across 23 states, 5000+ workers infected, with 20 dead. (ref)

  • Weddings, funerals, birthdays: 10% of early spreading events

  • Business networking: Face-to-face business networking like the Biogen Conference in Boston in March.

As we move back to work, or go to a restaurant, let’s look at what can happen in those environments.

Restaurants: Some really great shoe-leather epidemiology demonstrated clearly the effect of a single asymptomatic carrier in a restaurant environment (see below). The infected person (A1) sat at a table and had dinner with 9 friends. Dinner took about 1 to 1.5 hours. During this meal, the asymptomatic carrier released low-levels of virus into the air from their breathing. Airflow (from the restaurant’s various airflow vents) was from right to left. Approximately 50% of the people at the infected person’s table became sick over the next 7 days. 75% of the people on the adjacent downwind table became infected. And even 2 of the 7 people on the upwind table were infected (believed to happen by turbulent airflow). No one at tables E or F became infected, they were out of the main airflow from the air conditioner on the right to the exhaust fan on the left of the room. (Ref)

Workplaces: Another great example is the outbreak in a call center (see below). A single infected employee came to work on the 11th floor of a building. That floor had 216 employees. Over the period of a week, 94 of those people become infected (43.5%: the blue chairs). 92 of those 94 people became sick (only 2 remained asymptomatic). Notice how one side of the office is primarily infected, while there are very few people infected on the other side. While exact number of people infected by respiratory droplets / respiratory exposure versus fomite transmission (door handles, shared water coolers, elevator buttons etc) is unknown. It serves to highlight that being in an enclosed space, sharing the same air for a prolonged period increases your chances of exposure and infection. Another 3 people on other floors of the building were infected, but the authors were not able to trace the infection to the primary cluster on the 11th floor. Interestingly, even though there were considerable interaction between workers on different floors of the building in elevators and the lobby, the outbreak was mostly limited to a single floor (ref). This highlights the importance of exposure and time in the spreading of SARS-CoV2.

Choir: The church choir in Washington State. Even though people were aware of the virus and took steps to minimize transfer; e.g. they avoided the usual handshakes and hugs hello, people also brought their own music to avoid sharing, and socially distanced themselves during practice. A single asymptomatic carrier infected most of the people in attendance. The choir sang for 2 1/2 hours, inside an enclosed church which was roughly the size of a volleyball court.

Singing, to a greater degree than talking, aerosolizes respiratory droplets extraordinarily well. Deep-breathing while singing facilitated those respiratory droplets getting deep into the lungs. Two and half hours of exposure ensured that people were exposed to enough virus over a long enough period of time for infection to take place. Over a period of 4 days, 45 of the 60 choir members developed symptoms, 2 died. The youngest infected was 31, but they averaged 67 years old. (corrected link)

Indoor sports: While this may be uniquely Canadian, a super spreading event occurred during a curling event in Canada. A curling event with 72 attendees became another hotspot for transmission. Curling brings contestants and teammates in close contact in a cool indoor environment, with heavy breathing for an extended period. This tournament resulted in 24 of the 72 people becoming infected. (ref)

Birthday parties / funerals: Just to see how simple infection-chains can be, this is a real story from Chicago. The name is fake. Bob was infected but didn’t know. Bob shared a takeout meal, served from common serving dishes, with 2 family members. The dinner lasted 3 hours. The next day, Bob attended a funeral, hugging family members and others in attendance to express condolences. Within 4 days, both family members who shared the meal are sick. A third family member, who hugged Bob at the funeral became sick. But Bob wasn’t done. Bob attended a birthday party with 9 other people. They hugged and shared food at the 3 hour party. Seven of those people became ill. Over the next few days Bob became sick, he was hospitalized, ventilated, and died.

But Bob’s legacy lived on. Three of the people Bob infected at the birthday went to church, where they sang, passed the tithing dish etc. Members of that church became sick. In all, Bob was directly responsible for infecting 16 people between the ages of 5 and 86. Three of those 16 died.

The spread of the virus within the household and back out into the community through funerals, birthdays, and church gatherings is believed to be responsible for the broader transmission of COVID-19 in Chicago. (ref)

Sobering right?

Commonality of outbreaks

The reason to highlight these different outbreaks is to show you the commonality of outbreaks of COVID-19. All these infection events were indoors, with people closely-spaced, with lots of talking, singing, or yelling. The main sources for infection are home, workplace, public transport, social gatherings, and restaurants. This accounts for 90% of all transmission events. In contrast, outbreaks spread from shopping appear to be responsible for a small percentage of traced infections. (Ref)

Importantly, of the countries performing contact tracing properly, only a single outbreak has been reported from an outdoor environment (less than 0.3% of traced infections). (ref)

So back to the original thought of my post.

Indoor spaces, with limited air exchange or recycled air and lots of people, are concerning from a transmission standpoint. We know that 60 people in a volleyball court-sized room (choir) results in massive infections. Same situation with the restaurant and the call center. Social distancing guidelines don’t hold in indoor spaces where you spend a lot of time, as people on the opposite side of the room were infected.

The principle is viral exposure over an extended period of time. In all these cases, people were exposed to the virus in the air for a prolonged period (hours). Even if they were 50 feet away (choir or call center), even a low dose of the virus in the air reaching them, over a sustained period, was enough to cause infection and in some cases, death.

Social distancing rules are really to protect you with brief exposures or outdoor exposures. In these situations there is not enough time to achieve the infectious viral load when you are standing 6 feet apart or where wind and the infinite outdoor space for viral dilution reduces viral load. The effects of sunlight, heat, and humidity on viral survival, all serve to minimize the risk to everyone when outside.

When assessing the risk of infection (via respiration) at the grocery store or mall, you need to consider the volume of the air space (very large), the number of people (restricted), how long people are spending in the store (workers – all day; customers – an hour). Taken together, for a person shopping: the low density, high air volume of the store, along with the restricted time you spend in the store, means that the opportunity to receive an infectious dose is low. But, for the store worker, the extended time they spend in the store provides a greater opportunity to receive the infectious dose and therefore the job becomes more risky.

Basically, as the work closures are loosened, and we start to venture out more, possibly even resuming in-office activities, you need to look at your environment and make judgments. How many people are here, how much airflow is there around me, and how long will I be in this environment. If you are in an open floorplan office, you really need critically assess the risk (volume, people, and airflow). If you are in a job that requires face-to-face talking or even worse, yelling, you need to assess the risk.

If you are sitting in a well ventilated space, with few people, the risk is low.

If I am outside, and I walk past someone, remember it is “dose and time” needed for infection. You would have to be in their airstream for 5+ minutes for a chance of infection. While joggers may be releasing more virus due to deep breathing, remember the exposure time is also less due to their speed.

While I have focused on respiratory exposure here, please don’t forget surfaces. Those infected respiratory droplets land somewhere. Wash your hands often and stop touching your face!

As we are allowed to move around our communities more freely and be in contact with more people in more places more regularly, the risks to ourselves and our family are significant. Even if you are gung-ho for reopening and resuming business as usual, do your part and wear a mask to reduce what you release into the environment. It will help everyone, including your own business.

This article was inspired by a piece written by Jonathan Kay in Quillete:

COVID-19 Superspreader Events in 28 Countries: Critical Patterns and Lessons

About the author

Erin S. Bromage, Ph.D., is an Associate Professor of Biology at the University of Massachusetts Dartmouth. Dr. Bromage graduated from the School of Veterinary and Biomedical Sciences James Cook University, Australia where his research focused on the epidemiology of, and immunity to, infectious disease in animals. His Post-Doctoral training was at the College of William and Mary, Virginia Institute of Marine Science in the Comparative Immunology Laboratory of late Dr. Stephen Kaattari.

Dr. Bromage’s research focuses on the evolution of the immune system, the immunological mechanisms responsible for protection from infectious disease, and the design and use of vaccines to control infectious disease in animals. He also focuses on designing diagnostic tools to detect biological and chemical threats in the environment in real-time.

Dr. Bromage joined the Faculty of the University of Massachusetts Dartmouth in 2007 where he teaches courses in Immunology and Infectious disease, including a course this semester on the Ecology of Infectious Disease which focused on the emerging SARS-CoV2 outbreak in China.

Wistful Thinking

There are so many things I miss these days, from the prosaic to the profound.  Among them:

  • Free samples at Costco and Trader Joe’s
  • Visiting with my kids
  • Dinner out with friends
  • Responsible government leadership
  • A proper haircut
  • A decent pedicure
  • My group exercise class
  • Anxiety-free sleep
  • News that’s actually news
  • Space to roam
  • My waistline

But perhaps the one thing I miss most of all is the anticipation of upcoming travel.  For those of us who love a change of scenery — whether exotic or familiar — there is something deeply satisfying about planning a trip down to the last detail, while leaving lots of room for unexpected developments. (The good kind, not the “oh s*** I’m suddenly quarantined in a foreign country” kind.)

I’m enjoying vicarious adventures through other bloggers’ posts, but we all know it’s hardly the same.  Having cancelled our London trip planned for March, and now deciding not to play “beat the odds” with the trip to France we’d scheduled for this summer, I feel a bit adrift.

And wondering… what do YOU miss most these days?

airplane window view of airplane wing and clouds

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