Church worship is essential: How to do it safely (Part 2)

112 out of 180 church goers got Covid-19 after attending a “very dynamic worship” in a Baptist Church in Frankfurt, Germany. It may come from a nursery school teacher. It is facing a criminal investigation since it violates the reopen laws, which are simply guidelines in America (CDC calls it suggestion).

“CDC offers these suggestions for faith communities to consider and accept, reject, or modify, consistent with their own faith traditions, in the course of preparing to reconvene for in-person gatherings while still working to prevent the spread of COVID-19.”

I myself may not be in favor of a criminal prosecution for such a violation by a church having a divine service, a reprimand at most. But this clearly shows the Germans are serious, not half-hearted in fighting to contain the spread of coronavirus. This will never happen in the U.S. under Trump's watch. This may also reflect the cultural difference. Although we need to keep in mind that Germany is exemplary as the global leader in fighting this pandemic.

The case is facing criminal investigation

The church may have forgotten another set of “holy trinity” (social distancing, wearing face mask and wash the hands) according to NJ governor.

Church worship is essential: How to do it safely (Part 1)

(I'll have serial posts on the Covid-19 spread linked to a worship in a Frankfurt church, Germany. Church worship is indeed essential. With the wisdom God grants us, we need to learn how to do it safely.)

the case is facing criminal investigation

The worship at a Baptist Church in Frankfurt Germany took place on May 10, the first news of the Covid-19 broke out on May 23, at which time more than 40 cases were reported in a Der Tagesspiegel article, next day the articles in the Wall Street Journal and the New York Times reported as many as 107 cases (180 parishioners attended the service). A Frankfurter Allgemeine article on May 26, reporting the case was under criminal investigation (Baptisten-Gemeinde drohen strafrechtliche Ermittlungen). Another article on the same newspaper on May 28 reported 200 cases have been linked to this incident.

In response to the huge pool party in Missouri on Memorial Day weekend, Dr. Anthony Fauci said, “One of the things that the people who are out there frolicking need to realize is that when you do that and you see no negative effect in one week please don’t be overconfident. The effect if spreading is not going to be seen for may be two, three or even more weeks.”

The timeline of the case involving the Frankfurt church worship is obviously in line with what Dr. Fauci said.

Comparison of USA and Germany: Revisited

When it comes to the handling of the pandemic President Trump likes to compare the USA to Germany, so do I. He claimed Germany and the United States were “leading the world in lives saved per 100,000.” But according to data from Johns Hopkins University, Germany has one of the lowest mortality rates in the world, at 9.13 deaths per 100,000 people, the United States 24.31 deaths per 100,000.

The venerable Robert Koch Institute

Robert Koch Institute (RKI) in Berlin is equivalent to our CDC. Robert Koch was the first director of the institute that now bears his name back in 1882 when he discovered Tubercle bacillus that causes tuberculosis, for which he received the Nobel Prize for Medicine in 1905. His Koch Postulates (in 1884) practically began the field of the infectious disease.

There is hardly a day goes by without the RKI making an official statement during the corona-crisis: One would read the following headlines in the press all the time.

• „RKI zum aktuellen Stand“ (“RKI on the current situation”),
• „RKI fordert…“ (“RKI calls for…”),
• „RKI warnt…“ (“RKI warns…”),

When RKI speaks, everyone listens: the chancellor, government officials, public pundits and general public. The RKI website is most sought after and consulted by experts and general public alike.

Different story here in America

Upon request by the White House, CDC came up with a 17-page detailed documents of how to reopen America safely, only to be rejected by White House, labeling it “overly prescriptive”. One may suspect that the White House perceives the too cautious and conservative approach may damage the economy which is the top priority of the Twitter King, who just twitted against Pennsylvania governor for the same concern.

To quarantine or not to quarantine, the two leaders in contrast

Around March 22, 2020 German chancellor Angela Merkel went into self quarantine after learning that her physician gave her a pneumonia vaccine injection and was then tested positive for coronavirus. This is a standard recommendation according to the public health officials.

Coronavirus is in the West Wing of the White House. A military valet of President Trump and the press secretary of the Vice President Pence have tested positive. Three high-ranking health officials ( CDC director Dr. Robert Redfield, FDA commissioner Dr. Stephen Hahn, and NIAID director Dr. Anthony Fauci) all went into self quarantine for two weeks, but not President Trump or Vice President Pence.

Chancellor Merkel is a physical chemist (quantum chemistry) who listens to the health scientist whereas President Trump has no knowledge of evidence based medicine and whose reckless recommendation of injection of disinfectant as a potential treatment of coronavirus drew worldwide uproar, condemnation and ridicule.

Merkel and Trump: A comparison in the age of the pandemic

I follow Dr. Christian Drosten (a German virologist, German answer to our Dr. Anthony Fauci) closely. When asked about his assessment of Chancellor Angel Merkel, he responded,

“She’s extremely well-informed. It helps that she’s a scientist and can handle numbers. But I think it mainly comes down to her character – her thoughtfulness and ability to reassure. Maybe one of the distinguishing features of a good leader is that they are not using this present situation as a political opportunity. They know how counterproductive that would be.”

That stirred my interest in reading an article (Warum in den USA die Merkel-Mania floriert?) in Der Tagesspiegel (a German newspaper) that appeared on May 6, 2020. The following is my English translation, which is verified by using various dictionaries and translators.

Angela Merkel and Donald Trump at the White House 2017

Why does the Merkel-mania flourish in America?

The rivalry between Merkel and Trump revived in the coronavirus crisis. Many see the chancellor in the leadership role in the whole world. An analysis.

When the American media put on their pink glasses they see in Angela Merkel as a learned physicist who listens to the advice of the scientists.  With 15 years in the position as the chancellor, crisis-proof, stable and experienced.

Angela Merkel turned sixty: July 17, 2014

She quickly and decisively reacts to the danger of the coronavirus pandemic. The number of the new cases and the Covid-related death have been sharply declining.

In addition: Angela Merkel is calm, moderate and is willing to compromise. Her government also recognizes the global dimension of the crisis.

More than 200 coronavirus victims from Europe—particularly from France, Holland and Italy—have been brought to Germany and have been intensively treated. Germany also provides more than one billion euros to the developing countries to support their struggle against the coronavirus.

Change to the glasses with dark-tinted lenses one draws (portrays) a different picture. There is an ex-real estate entrepreneur and big-mouthed Twitter-King who calls himself the US-president, who knows nothing about science and pandemic-fighting strategy, who first claims he has more authority than the governors of the states, but then take this responsibility alone. [the last sentence doesn't make much sense to me, but that is the best I can translate.]

Trump and Merkel at the White House in 2017

An old rivalry lives on

In addition: The contradiction of his statements does not seem to bother Donald Trump in the slightest. At one time the virus is no worse than the flu, at another time he expects the death toll would be 100,000. At one time he strongly recommends following the rules of social distancing, at another time he would praise the heavily armed opponents/protesters against the shutdown.

Trump rejected the accusation that he instructed the CDC and NIH way too late.

Merkel versus Trump

The old rivalry lives on during the coronavirus crisis. That Trump's severe criticism of Merkel's refuge policy during the American election cannot be forgotten, and that Trump refused the hand-shake when they first met [that is German perception, Trump said he didn't refuse shaking hands with Merkel], as well as Merkel's dry statement:

“The world situation must be sorted according to the US election.”

Between the two, not only is there no chemistry, but also much more than that.

Forget about Washington und Peking

But now in the face of the coronavirus tragedy in the USA, the Merkel-mania flourished. There are several recent headlines in the American media: “Forget about Washington and Peking. The global leadership comes from Berlin in these days” (from Foreign Policy). “Local, practical, unpolitical—but successful German coronavirus-strategy” (from Wall Street Journal). “in a crisis the leadership stands out” (from New York Times).

The TV CNN comments the difference of the transatlantic federal governments: While Trump was having a tough time (“biting the teeth”) over the US-Constitution, the other decentralized country that is more than 6,000 miles away is “getting a completely different leadership lesson”.

The healthcare system is stable, the death toll low, whereas in US by contrast the new cases and death toll numbers soar, and the healthcare system on the verge of collapse.

Also the usually restrained Microsoft founder, Bill Gates criticized Trump and praised Merkel's administration.

In the United States the tests for the would be suspected cases were not necessary priorities. There are no clear instructions as to the restriction of public life activities. Gates said that stop funding to WHO is wrong. Merkel, by contrast, is “a leadership and clear voice” in Germany.

A “Darwinian Situation” is emerged

The New York Times ranked Merkel in the league of those politicians that react in a crisis, “determined, courageous, with respect for the science and with empathy for the basic decency”.

Merkel is for sure not a charismatic and eloquent European leadership figure, but no one can ever doubt her decency/honesty. When she turned to her nation, there is no “pompous or bombastic” in her speech.

In Foreign Policy, the German politics will as the result fill the global leadership vacuum. Normally the United States would take the lead in a global crisis.

But those days has passed for Trump. A “Darwinian Situation” has been established, the states have been fighting one another about the medical protective equipments, medicines and compete for the access of vaccines.

The testing, and the testing only, is the thing

To paraphrase Oscar Wilde’s “The play, and the play only, is the thing” may not be entirely appropriate, but diagnostic testing is the most important thing in fighting this most infectious and vicious coronavirus plague, no doubt about it.

We are learning as we are fighting a novel virus, the learning curve is steep, the price paid is high. This is why I constantly look for exemplary “models” among the countries fighting along with us, or better yet, took the fight before we did.

Widespreading testing is the common denominator of the success
If the low death rate is selected as a measure of success, then Germany, South Korea, New Zealand and Taiwan emerge as the models. There is a common denominator for the success of these countries：wide spread testing.

Mortality rate as of 4/17/2020 according to Johns Hopkins University coronavirus resource center:

United Kingdom    15,498/115,314 (13.4%）
Italy                       23,227/175,925 (13.2%)
USA                       38,664/732,197 (5.28%)

Germany               4,459/143,342 (3.1%)

South Korea          232/10,653 (2.17%)
Taiwan                  6/398 (1.5%)
New Zealand        11/1,422 (0.7%)

Across the globe the success of the curb of coronavirus spread and the relatively low mortality rate are corresponding to the level of widespread testing.

The initial flawed test developed by CDC cost US several precious weeks
WHO delivered 250,000 diagnostic tests (designed and manufactured by German Lab, later proved to be dependable) to 70 laboratories around the world, US health officials decided to go on their own way. Unfortunately the initial test developed was flawed due to contamination; it took several weeks to correct it. CDC also didn’t send virus samples to private labs and university research centers to develop the tests until late February.

U.S. lost several precious weeks in rolling out testing at the crucial moment—at the beginning of this scourge, even Dr. Anthony Fauci so admitted in yesterday’s (4/17/2020) White House press conference.

Without testing capability the U.S. can only play mitigation, not containment

This led to all the “hot spots” to lose the chances of containment, viruses are ahead every step of the way. All they can do is chasing the viruses through mitigation. America is now poised to gradually enter the three-phased economy re-opening, containment is all the more important. Widespread testing capacity is the prerequisite of entering the Phase 1.

Whether we have testing capacity to enter Phase 1 to “open America”, it is all depends on what you read or watch. CDC messed up early on, no doubt. But it has since been ramped up tremendously and the capacity is growing everyday.

Dr Anthony Fauci

Dr. Fauci is hopeful that we have testing capacity to fight the next stage of containment

Dr. Anthony Fauci seemed to be confident that we do have testing capacity to enter Phase I, although he also admitted that his colleagues on the front lines telling him otherwise. He explained that it is most likely due to the logistics, the gap or disruption between the supply and demand. Testing can be more complicated than you thought, supply of swabs and testing reagents can be the issue.

Nobody knows what is considered the adequate testings per capita, but one thing for sure is the more the better, as testing is the only way to “see” this invisible enemy.

Wide spread testing capacity is the indispensable tool for containment, which is achieved by quickly identifying the infected, followed by isolation and contact tracing and this cannot be done without testing in a timely fashion.

The level of testing separates the countries with success and otherwise
The U.S. is not alone running into testing problems. The countries shared the mishap of testing with the U.S. are also the countries most ravaged in this horrendous pandemic, such as Italy, Spain, France and United Kingdom.

Countries (Germany, South Korea and Taiwan) are in stark contrast with the U.S. United Kingdom has medical technology know-how, but lack the scale to mass produce. The healthcare system reform over the past 10-20 years enables Germany to have nearly100 private laboratories that can be mobilized quickly. I read “drive through” test in German newspaper almost one week before I first heard in the U.S. Being a role model though Germany may be, a recent study commissioned by the government said Germany has to speed up the testing capacity in order to gain an upper hand on virus. Lothar Wieler, the head of the Robert Koch Institute (RKI)—equivalent to our CDC—shared the same view.

Dr. Christian Drosten, Jens Spahn, Dr Lothar Wieler

German Minister of Health declared worldwide pandemic on March 4, a week before WHO did on March 11.  Dr. Christian Droston (a noted virologist) is German's answer to our Dr. Fauci, but not his experience.

There was an article on March 3, 2020 the Journal of American Medical Association (JAMA), chronicling the success story of fighting coronavirus in Taiwan: proactive testing is one of the most important tools.

President Tsai of Taiwan on Time

The article in Time President Tsai of Taiwan reporting the success story.

https://time.com/collection/finding-hope-coronavirus-pandemic/5820596/taiwan-coronavirus-lessons/

Some technology issues and concern on testing

Many pharmaceutical giants and biotech companies (Roche, Abbott, Hologic, Labcorp, Cepheid, etc.) rose to the occasions in developing various testing kits. Abbott's NOW COVID-19 takes 5 minutes for positive results, 13 minutes for negative results.  Abbott has had three testing kits so far and is working on the fourth.

This New England Journal of Medicine showing how to do a nasopharyngeal swab, which is more complicated than you thought, one may have false negative result if the specimen is not obtained deep enough into the nose.

https://www.nejm.org/doi/full/10.1056/NEJMvcm2010260?query=featured_coronavirus

The standard way is doing throat and nose swab, it can be labor-intensive and the healthcare worker needs PPE. Germans are trying to do it on sputum, but it requires good sputum coughing up from deep chest and that is not an easy task.

FDA approves a test done on saliva, but a negative saliva test has to be double checked by standard throat or nose swab.

A Q-tip type test kit is being developed and it is funded by Gates Foundation and UnitedHealth. Gates Foundation is also funding 8 of the vaccines being developed, thank you, Bill and Melinda.

All of these diagnostic tests are “approved” through FDA Emergency Use Authorization (EUA), the approval process was expedited at the expense of stringent evaluation. Two days ago a UPMC pathologist reported the Abbott's rapid test can have false negative result when the virus load is low.

The right attitude to look at the projection models

I always look at the various projection models with mixed emotions; it is a love and hate affair.  I am a true believer in science, and modeling is a scientific work, yet the numbers from some of the models are so outrageously astonishing or even astronomical borders on being sensational.

all models are as good as the assumptions that you put into the model

The indispensable Dr. Anthony Fauci

While talking about not to read too much into these models, Dr. Anthony Fauci said the models should be treated with precaution, “all models are as good as the assumptions that you put into the model,”  he then said, “my colleagues [model creators] are not going to be happy with me.”

Models are essential tools
Projection models are essential tools for the governing bodies and policy makers, not for general public consumption.  White House Coronavirus Task Force, of which Dr. Fauci is a member, used 12 models.  CDC convened national experts making the model, although one will not see it on its website.

Bill Gates shares the same view on models with Dr, Anthony Fauci
In response to a question about the grim figures in the Imperial College model, Bill Gates

The incomparable Bill Gates

said the Imperial model does not match the experience in China, the parameters used are too negative, “models are only as good as the assumptions put into them.”

Not that Bill Gates doesn’t believe in models.  In 2017 the Gates Foundation gave $279 million to Institute for Health Metrics and Evaluation of Washington University (IHME or known as the Chris Murray Model, who was on CNN with Anderson Cooper yesterday), upon which the White House Coronavirus Task Force depends heavily.

White House Coronavirus Task Force press conference

Various models have different approaches
IHME is designed to be a planning tool for hospital administrators, projecting the future needs of hospital beds, ICU beds and ventilators (see graph below)

Some models depends heavily on the level of social distancing, which is a good tool to motivate people for strict adherence to avoid the worst-case scenarios.

The models are not static
It is updated every so often, even daily, based on the real world data.  A few days ago the White House Coronavirus Task Office revised downwards the possible American deaths from 80,000 to 60,000. This apparently went by IHME model, which revised downwards from 80,000 deaths to 60,415 by 8/4/2020 (see graph below).  Of note, the projected deaths is 60,067 by 5/23/2020, that is to say few deaths will occur after the end of May.

Study the models or ignore them
Models making is a scientific endeavor and complex.  Unless you have some basic understanding of a given model, knowing it’s approach, function, and purpose, and follow its update, you might as well ignore it, lest you may have unnecessary anxiety or even fear.

(You may stop reading here, the following story is to demonstrate the inherent controversy of the models and the subtle way of “fake news”.)

On March 16 a friend from Taiwan sent me a panel discussion which claimed coming from UCSF and BioHub (which was founded with Zuckerbergs’ $600 million). The panel predicted (on March 13) 40-70% of American population will be infected with COVID-19 in next 12-18 months and 1,600,000 Americans will die.

A panel discussion by credible scientists was disclaimed by UCSF
UCSF put out a statement stating the panel discussion was not sponsored by UCSF even though the expert speakers were from UCSF and BioHub.  It referred to CDC for the information on the scope of the COVID-19 pandemic.  But this kind of projection model is no where to be found on CDC online site.

UCSF was apparently trying to avoid the controversy.  However the grim figures are in line with those reported in a NY Times article (3/13/2020）based on the CDC model which has four scenarios. The CDC models predicted between 160 million and 214 million Americans could be infected over the course of the pandemic lasting months to over a year.  As many as 200,000 to 1.7 million Americans could die.  CDC refused the interview request by NY Times.

This is the inner working of CDC, serving as the guidance, calling for the all-out efforts to avoid the worst-case scenario.  這是 CDC 的內部作業 （沒有對外公開，但紐約時報拿到了那四個 scenarios of the model, CDC 拒絕 NYTimes 的 interview), 所以 CDC 知道若不採取嚴厲的行動，後果會如此。

Let's work harder and longer to prove the projection model numbers are wrong
Of course the figures don’t account for the interventions (containments and mitigations）that have been undergoing in earnest.  Dr. Fauci said the ultimate number “will be how you respond to it with containment and mitigation.” Let’s work harder and longer (social distancing) to prove those projection models are wrong, then their purposes are served.

My letter-to-the-editor exhorting everyone to wear face coverings in public

I have a letter-to-the-editor published in The Observer-Reporter today. I actually explained it better in the post in my blog as the letter writing has to be concise and to the point at the expense of more detailed explanations.

Stay home, save lives. Wear face coverings, stop the spread

https://doctorjytsai.blogspot.com/2020/04/stay-home-save-lives-wear-face.html

Not having the talent of our daughter, Jo, of making cloth face masks for others, to spread the useful messages of “stay home, save lives, wear face coverings and stop the spread” is the least I can do. This war can only be won when everyone participates in the fight. There is no better way to get the messages out in the newspaper.

The following is what a daughter of our family friend wrote in response to my post. It made me all the more happy as I did not send the email to her; people must have passed along my blog posts.

Her writings represents the love and concern of our adult children to us, and from one who truly understands the ferocity and viciousness of this horrendous virus, which I never observed in my entire professional career, simply put how easy one can get it.

(The following is her response)

Hi Dr. Tsai, 

Thanks for writing the post to your peers reminding them of the critical importance of STAYING HOME and if you absolutely must go to a place where there are other people, please wear a face mask. On behalf of all of your adult children and grandchildren, please make these changes in your daily lives. I know it is difficult because we are creatures of habit. We take joy in the simple pleasures in life. However, for just a short time (1-2 months, or even just the next 2 weeks), we're asking you to simply stay at home. This is the safest place to be.

This means:

- NO GROCERY STORES. If you *must* go, go during early morning hours for elderly folks, or try to space these visits out to 2+ wks, and WEAR A MASK (and gloves, wipe the handle of the cart down). Best is to have your kids setup online grocery delivery to your house for a few weeks.

- No bakeries, you don't need that pastry.

- No bank, depositing checks can wait.

- No drive through McDonald's coffee

- No Sam's Club or Costco or Target or Walmart

- If you need to get some fresh air, go for a walk around your block. Sunshine and fresh air are still good. Or call your kids if you're bored.

As you can see, my friends and I have had to call our parents every 1-2 days and YELL AT THEM FOR NON COMPLIANCE. The above are all the things we have collectively argued with parents about. The reason why we are all so adamant that you protect yourself and reduce exposure is because we know that if you get sick, 1) we don't get to stay with you at the hospital, 2) we don't get to visit you on the med floors, 3) we don't get to be with you in ICU. The absolute worst thing about covid19 is that patients are dying alone in ICU. The consequences for the elderly, immunocompromised, or those w underlying co-morbidities is simply too high to make it worth any of the above activities. Plus your grandchildren would like to have their grandparents around for a few more years if possible.

So please stay home! Wear a mask. It's just a few weeks, or few months. You can do it!

Thanks. XXXXX

Stay home, save lives. Wear face coverings, stop the spread

To wear the face covering or not to wear the face covering in public. It is no longer a question. Let me say a few words about the rationale of wearing face coverings in public.

It is regrettable that President Trump said, in the White House press conference, he chose not to wear mask while CDC urges everyone to wear “non-medical cloth” face coverings in public to curb the spread of coronavirus.

It is true that some sort of facial covering is effective at keeping someone from spreading the virus to others, but not the other way around. That is to say that wearing a face covering is not an effective protection to oneself, unless it is an N95.

It is also well known that symptom-free transmission is what drives this horrible pandemic. This is why CDC reversed its previous recommendation since it is no longer possible to tell who can spread the virus based on the symptoms. Any one is a potential virus spreader in a “hot spot”.

There is convincing evidence from some Asian countries that the spread of the virus declines when a majority of population wears masks. This collective benefit can only be achieved by asking most, if not all, population to wear masks.

Do not have the false sense of security just because you wear a mask, the protection comes from only everyone around you wearing a mask, thus decreasing the potential virus spreading. In other words, you wear face covering to protect others while others wear face coverings to protect you; it is a mutual protection and benefit. It is only through this practice that the benefit of wearing masks can be realized.

We are all in this unprecedented and vicious virus crisis, we are all in the same boat. With the grace and mercy of God, we'll pull through together, let us wear face coverings to protect each other.

Stay home, save lives. Wear face coverings, stop the spread.

It is admirable that our daughter, Jo, has turned her home into the cloth face coverings making factory. They are intended for the use of receptionists of doctors' office or those who are still working, or like healthcare workers, working even harder, to keep the “essential” business going.

Talented Jo even made high-fashion cloth face masks to make it more attractive to young ladies. The other day CNN Dr. Sanjay Gupta showed off a cloth face mask that his daughter made for him, I am proud to say it is no match for Jo's product, and I said it unabashedly.

Frankenmuth (MI) had online (or in the phone) Town Hall meeting organizing and coordinating the efforts to fight this vicious virus. Jo said the products (cloth face coverings) are picked up in the porch. Frankenmuth is a microcosm of America. America will prevail in this fight.