COVID is Airborne

I saw a long Twitter thread this week that was very interesting and well done. I wrote to Dr. Jose-Luis Jimenez who graciously agreed to allow me to copy it all here. I wanted it to be easily accessible for those without Twitter. I’ve only made minor edits to remove abbreviations and changed some punctuation for a non-Twitter space. The content has not changed except for where I have added wording for clarity.

What were the historical reasons for the resistance to recognizing airborne transmission during the COVID-19 pandemic? Our peer-reviewed open-access paper is now published.

Soon after COVID-19 pandemic started, it was clear to many scientists (inc. those who understand aerosols) that AIRBORNE transmission was an important contributor, e.g. as soon as we talked to the Skagit choir, it was obvious that was airborne-dominated.

However, major public health organizations such as the WHO and CDC were in complete denial, saying that airborne transmission was MISINFORMATION! (Disgracefully, the WHO has not deleted this tweet (below) or clearly stated that it was an ENORMOUS error).

How was that possible?

  • Many scientists are concluding that airborne transmission is important.
  • Major public health organizations such as the WHO say that it is misinformation!

Historical trends and errors (this thread) are important to explain this, but NOT the only reason.

This major error (IMHO one of most important errors in the entire history of Public Health) has had major consequences:

  • In early pandemic we focused on surfaces, which are minor or negligible.
  • We ignored air, which was the dominant mode.

[These led to a] lack of controlling transmission

Since then, research has clearly shown that airborne transmission is the DOMINANT mode of transmission of COVID-19:

To this day, zero proven cases of surface transmission and droplet transmission has NEVER been demonstrated, not just for COVID-19…but for ANY disease in the history of medicine! (Paper from Prof. Yuguo Li, member of WHO IPC Committee)

So how did we get into this mess?

Public health organizations tell us that unproven transmission mechanisms are dominant, and that the dominant transmission mechanism is misinformation. We’ll soon delve into the history in our paper.

But before we go into the history, there are other reasons to review. Most importantly, surface-droplet transmission is very CONVENIENT to those in power. And AIRBORNE transmission is an inconvenient truth (just like climate change, dealt with similarly).

The 2,000-year-old airborne disease theory that blinded Covid experts

There is at least one more reason for the resistance: those who made this enormous error at the WHO, its IPC committee, and at the CDC, & health ministries around the world DO NOT WANT to admit their error

A government advisor privately: “we need to find a way to allow us to save face.”

Those Public Health officials that continue to resist and obfuscate about airborne transmission are in control of the PH institutions. Aerosol scientists are almost complete outsiders, and have been almost systematically excluded to this day.

Orthodoxy, illusio, and playing the scientific game: a Bourdieusian analysis of infection control science in the COVID-19 pandemic

So what about the contribution of history to the denial of and resistance to airborne transmission by Public Health authorities worldwide? It is summarized in this diagram, which I’ll explain in this thread.

So to understand the errors that led to the denial and resistance of #COVIDisAirborne, we need to go back to Hippocrates! (~400 BCE).

Hippocrates

Hippocratic writings in ancient Greece first proposed that diseases were caused by imbalance of humors in the body, which could be triggered by a “miasma” transmitted through the air.

HIPPOCRATES OF COS, Nature of Man

Throughout much of subsequent human history, the belief persisted that diseases were transmitted through air Because the actual agents remained a mystery for centuries, explanations were given in general terms such as “miasmas,” or “bad air.”

Miasma theory

For example, the etymological root of the term “malaria” (a disease that we now know is transmitted by mosquitos) is “mala aria,” medieval Italian for “bad air.”

Some origin theories were more specific, e.g. Roman scholar Varro (116–27 BCE) wrote that swamps were a particular breeding ground for minute creatures that “float in the air and enter the body through mouth and nose and there cause serious diseases.”

Thus it became a policy of the Roman Empire to drain swamps, removing breeding grounds for mosquitos, reducing malaria, an example of a mistaken theory giving good results and increasing faith on the theory. We see this many times through history.

Bad air, amulets and mosquitoes: 2,000 years of changing perspectives on malaria

The concept of person-to-person contagion came much later, most clearly in work of Italian physician Girolamo Fracastoro in 1546 (This is actually a subject of current debate, with some scholars thinking that the role of Fracastoro may have been overstated.

Girolamo Fracastoro

What ensued after Fracastoro, however, was a centuries-long debate between “miasmatists,” who held fast to the idea that diseases floated through the air over distances, and “contagionists,” who accepted person-to-person spread of disease.

Airborne infection with Covid-19? A historical look at a current controversy

Because it was (and it still IS) very difficult to determine how, why, and from where someone became infected, the miasmas vs. contagion debate failed to reach a resolution and persisted for centuries. A middle ground was proposed, “contingent contagionism”: malaria, or cholera might be contagious in an impure atmosphere, but not in a healthy atmosphere. This idea therefore captured some grains of truth (e.g. now we know ventilation reduces airborne).

Miasma theory was dominant till the mid/late 19thy Century. Florence Nightingale (1820–1910) like most Victorians was raised to believe that diseases were caused by ‘miasma’ or foul air.

Florence Nightingale

In her Notes on Hospitals, Nightingale referred to the idea of contagion as absurd. She was nevertheless very practical and effective in reducing disease, e.g. with ventilation and phys. distance, and later accepted germ theory, as we’ll see later.

We enter a critical period around 1850. Miasma theory is still dominant, although contagion (mostly through the air) also has proponents. Microorganisms have been observed for two centuries since the invention of the microscope, but haven’t clearly been connected to disease.

Cholera strikes London in 1854. The public health establishment believed it to be caused by a miasma. English sanitary reformers (e.g. Chadwick), who initiated many modern public health practices, found miasma appealing, as it appeared to explain the prevalence of diseases in the undrained, filthy, and foul-smelling areas where the poor lived, and helped justify their efforts to address those conditions. (They had made a huge error, and they resisted accepting it, just as the WHO today).

Death and miasma in Victorian London: an obstinate belief

Edwin Chadwick

John Snow was a wealthy doctor but outsider to public health. His work in anesthesia made him familiar with the behavior of gasses. He realized that the spread of cholera was NOT consistent with what would be expected for a gas.

John Snow

Snow noticed how cases had clustered in a specific London borough and persuaded the local council to remove the handle of the Broad street water pump, which halted the epidemic.

John Snow’s Cholera data in more formats

John Snow and the Broad Street Pump on the Trail of an Epidemic

However, cholera was already in decline. The Board of Health refused to accept contaminated water, stating: “we see no reason to adopt this belief [that cholera was water-borne]” and dismissing Snow’s conclusions as mere “suggestions.”

The Board of Health had strong incentives for rejecting water as the source of cholera. To remove the sources of the miasma (filth), they had spearheaded the effort to build sewers that dumped raw sewage into the Thames, the source of much of London’s drinking water, thus effectively helping the spread of cholera. They had much to lose by admitting cholera transmitted through water. (Technology has advanced, but human nature has changed less. The WHO has avoided saying LOUD & CLEAR that #COVIDisAirborne, as their denials helped it spread.

Also around 1850, Ignaz Semmelweis in Vienna showed that handwashing greatly reduced deaths by childbed fever in a maternity clinic.

Ignaz Semmelweis

These are some of Semmelweis’ data, which would seem worth following up on: However, his ideas conflicted with established medical and scientific beliefs that STILL described diseases as due to an imbalance of humors triggered by a miasma in the air.

However, he was dismissed from his hospital and harassed by Vienna medical community, forced to move to Budapest. There he broke down, was interned and beaten by the guards, and ultimately died from an infected wound Like Snow, he died years before his theories were accepted.

Ironically, Semmelweis’ name lives on not only for advances of hand sanitation, but also in “Semmelweis reflex,” which describes the reflex-like tendency to reject new knowledge or evidence when it contradicts established beliefs, norms, or paradigms

That is especially ironic, as the chief deniers of airborne transmission (John Conly — chairman of key IPC WHO committee, Dr. Seto, Didier Pittet, and Peter Collignon) are handwashing experts following Semmelweis’ scientific advances, while forgetting about the reflex.

The 2nd half of the 19th Century is a period of rapid progress on disease transmission. Pasteur and Koch proposed the GERM THEORY of disease. Microscopic germs enter the body and are the cause of many diseases.

Germ theory was NOT accepted overnight, e.g. experiments by others in which water containing organic matter was boiled in a vessel, but microorganisms still appeared (later shown to be an imperfect seal or insufficient boiling) created controversy.

However, by the late 1880s, miasma theory was waning in popularity, and in 1888, the Institut Pasteur was created in Paris, reflecting the ascendancy of germ theory.

Florence Nightingale did accept the new ideas of germ theory, in fact before many physicians did. In 1882, she wrote

Collected Works of Florence Nightingale

Initial results on plant pathogens in 1890s & the identification of bacteriophage in 1917 paved the way for recognition of viruses. A “golden era” followed, with the identification of the actual microorganisms that cause many infectious diseases.

A century of phage research: Bacteriophages and the shaping of modern biology

The discovery and identification of the organisms causing different diseases did NOT, however, eliminate the great difficulty in conclusively determining the mode by which they transferred from one person to another. Malaria was still thought to go through the air in 1880

French physician Charles Laveran identified the pathogen responsible for malaria in 1880 (got Nobel Prize in 1907), but the manner of transmission was still thought to be through the air.

Charles Louis Alphonse Laveran

American physician Albert King proposed that malaria was transmitted by mosquitos, but encountered general skepticism In 1883, he presented a list of 19 facts supporting malaria as vector of malaria (Reminds me of 10 scientific reasons for #COVIDisAirborne).

Albert Freeman Africanus King

In 1898 British surgeon Roland Ross provided definitive evidence, confirming the presence of the malarial parasites in mosquitoes, and demonstrating transmission of bird malaria by mosquitoes. World Mosquito day commemorates him.

Roland Ross

Looking back at period 1850-1900, belief on transmission of many diseases through AIR was still strong But cholera, malaria, puerperal fever had been shown to transmit OTHERWISE. It was a fluid time. It was debated if air was actually important

What were the historical reasons for the resistance to recognizing airborne transmission during the COVID-19 pandemic?

In the 1890s, Carl Flügge in Germany set out to disprove the then-dominant transmission theory for tuberculosis, one of the major infectious diseases of the time. Most experts believed that tuberculosis was transmitted when dust of dried sputum that had landed on floors, blankets, bowls, and other objects was dispersed into air. In contrast, Flügge thought that it was not DRIED secretions from sick that caused infection, but rather FRESH secretions that people were exposed to IN AIR BEFORE they reached the ground.

Carl Flügge

Some contemporaries of Flügge such as Cornet argued that tuberculosis was transmitted only through large droplets, which were easily visible to the naked eye. Perhaps because droplets were more CONVENIENT and airborne disease VERY INCONVENIENT?

Ueber Tuberculose– die Verbreitung der Tuberkelbacillen ausserhalb des Körpers

However, although term “Flügge’s droplets” has been used to describe ONLY those large particles that fell to the ground quickly near the infected person and that were assumed to dominate transmission, that does NOT accurately capture Flügge’s results.

Rather, Flügge and collaborators used the term “droplet” to refer to fresh particles of ALL SIZES, including AEROSOLS for which the researchers waited five hours to settle from the air on their collection plates.

In 1905, microbiologist M.H. Gordon was commissioned to study the atmospheric hygiene of the UK House of Commons after an epidemic of influenza among members. He famously performed the following experiment: after gargling with a broth culture of Serratia marcescens he loudly recited passages from Shakespeare in an empty House to an audience of agar plates. Although growth of colonies was more numerous on plates near the speaker, cultures were apparent on some plates over 21 meters away.

However, experimental progress in early 1900s was hampered by the limitations of the experimental techniques available at the time. In particular high-quality measurements of large droplets & aerosols would only be routinely available decades later.

We get to the CRITICAL POINT of this history. Throughout most of human history, the dominant belief was transmission of many diseases through the air. The last half of the 19th Century proves otherwise for major diseases. Strong debate ensues: “is air major or minor?”

Charles V. Chapin was a prominent American epidemiologist. He worked only a couple of decades after Germ Theory was accepted, during a period of intense research on pathogens and their transmission.

Charles V. Chapin

The period when Chapin’s worked on disease transmission was a fluid one, following a major paradigm shift, in which it was easier to change the dominant scientific discourse than during normal times

He summarized the evidence of transmission of different diseases in his 1910 seminal book, “The Sources and Modes of Infection.” (A must read if you are interested in this subject, esp. chapter on airborne transmission).

Chapin conceptualized “contact infection,” infection by germs that did NOT come from the environment, but from other PEOPLE through DIRECT CONTACT OR CLOSE PROXIMITY.

Chapin believed contact was main mode of transmission of many diseases But he encountered resistance: “I have sometimes been told I lay too much emphasis on contact infection [although] until recently very little attention has been paid to it.”

Chapin also reviewed the possibility of airborne infection, which he conceived especially as infections from afar. Lingering belief on air infection was making it difficult to promote contact infection.

Chapin realized that airborne infection may explain infection in close proximity (CP). However, he argued that ease of infection in CP was better explained by “spray-borne” droplets, large visible droplets considered by Cornet, the same as the WHO’s droplets.

This is the key. The evidence was insufficient, but Chapin turned absence of evidence into evidence of absence, and stated that airborne disease was almost impossible, and that “mouth spray” (large droplets) are only effective at short distances.

As we have explained in another recent paper, Chapin conflates an empirical fact (“distance reduces transmission”) with a mechanism: GRAVITY, which makes the droplets fall close to the infected person.

Problem: the more correct explanation (of why distance reduces transmission) is NOT gravity but DILUTION. Like exhaled smoke, you breathe less exhaled air farther from someone. And error in PHYSICS made by MEDICAL professionals who do not study physics!

Systematic way to understand and classify the shared-room airborne transmission risk of indoor spaces

Despite the lack of evidence, Chapin was too successful. He was much better positioned than Snow or Semmelweis as the long-serving Health Officer of Providence and with success of reducing contact transmission iin a new hospital. In 1927, he became President of the APHA.

Chapin was described in 1967 as “the greatest American epidemiologist” by Alexander Langmuir, first and long-time director (1949–1969) of epidemiology branch of the CDC. As late as the 1980s, Chapin’s views were dominant there.

Alexander Langmuir

CRITICALLY, Chapin’s unproven hypothesis was accepted as true: Ease of infection in close proximity is accepted proof of transmission from sprayed droplets. This KEY ERROR conditioned the evolution of this field over the next century, and into the COVID-19 pandemic.

The 1918 flu led to lots of work and discussion in this area, but did not blunt the ascendance of of Chapin’s theory.

In the 1930s, Harvard engineering professor William Wells and physician Mildred Wells, his wife, started applying more contemporary experimental methods to the investigation of airborne transmission.

William Wells

But Chapin had successfully shifted the paradigm and his theory was now viewed as scientific progress. The Wellses were accused of a retrograde approach to science, which sought to bring back the miasma theory.

Wells was 1st to rigorously study size of sprayborne droplets vs. airborne aerosols and conceptualized dichotomy of sprayborne droplets (≳100 μm), which reach the ground before drying versus aerosols (≲100 μm) which dry before they reach ground (“droplet nuclei”).

ON AIR-BORNE INFECTION: STUDY II. DROPLETS AND DROPLET NUCLEI.

Wells understood connection w/ meteorology where this is common knowledge, stating: “A raindrop 2 mm in diameter can fall miles without completely evaporating under conditions which would cause a 0.2 mm droplet to evaporate before it had fallen from the height of a man.”

Shockingly, Public Health and Infectious Diseases have published for decades that large droplets are those heavier than 5 microns (!!), including in the latest WHO Scientific Brief on COVID Transmission that addresses this issue.

We pointed out this glaring error many times. i.e. see that even at 50 microns, they don’t fall quickly: Not too important per se, but makes glaringly obvious the ignorance of physics by those in charge at WHO and its IPC committee.

We investigated the history of the 5 micron / 2 meters error in a previous paper led by @linseymarr and the extraordinary @katierandall, with support from @EThomasEwing, Lydia Bourouiba of @MIT and yours truly.

How did we get here: what are droplets and aerosols and how far do they go? A historical perspective on the transmission of respiratory infectious diseases

I am getting slightly out of order. I’ll explain the reason for the “5 micron particles fall within the meters of the person” enormous error later in the thread, once I have explained the background. So we were talking about the work of William Wells on airborne infection.

The Wellses suspected that tuberculosis and measles were airborne, but BOTH were already believed to be droplet diseases, and they encountered intense resistance from the epidemiological community.

Measles was thought to be a droplet/fomite disease. At the time of Wells, and as late as 1985, because of: – ease of transmission in close proximity (= sprayborne droplets per Chapin) – cases of lack of infection with shared air.

Measles outbreak in a pediatric practice: airborne transmission in an office setting

Wells thought that measles was airborne (and now we know he was correct, though he died 2 decades before this was accepted). Wells has some initial success showing that UV lights installed in the ceiling of classrooms greatly reduced measles infection.

Air Disinfection in Day Schools

However, subsequent attempts to replicate these findings produced mixed results. In retrospect, in schools where UV prevented measles transmission, children were together indoors only in the school, not elsewhere. In other schools, children shared other spaces (e.g. buses).

Wells established the scientific basis of airborne infection But he was working in a period of intense hostility in public health and infectious diseases towards airborne transmission, ushered by the success of the 1910 paradigm shift of Chapin after 2 millenia of belief in miasmas.

General skepticism against airborne tr. is illustrated by 1951 quote of Langmuir (first and longtime director of epidemiology at the CDC). “It remains to be proved that airborne infection is an important mode of spread of naturally occurring disease.”

Langmuir worked preventing disease transmission among US military in World War II. Substantial resources were dedicated to the effort, generating knowledge “which would have taken decades to accumulate under peacetime conditions” and established leaders for decades.

Langmuir et al. studied airborne transmission, but MISINTERPRETED the results of their own studies: Distance reduced transmission, therefore it was droplets. Ignoring that distance reduces airborne transmission by dilution.

Airborne Disease: Including Chemical and Biological Warfare

Systematic way to understand and classify the shared-room airborne transmission risk of indoor spaces

However, Langmuir’s work renewed interest in airborne infection, as he concluded that WEAPONS of airborne disease could be created, which became a topic of intense interest during the cold war.

Despite stubborn resistance to the idea that airborne transmission had relevance for natural diseases, Wells, Robert Riley, and Cretyl Mills succeeded in demonstrating airborne transmission of tuberculosis (TB) in 1962 through extensive efforts.

Robert Riley

They routed air from TB hospital ward to 150 guinea pigs for two years. About three guinea pigs/month were infected No guinea pigs were infected in the control group where the only difference was that the air was irradiated with germicidal ultraviolet light, killing the TB bacterium.

Because of this, TB was the first important natural disease to be accepted as airborne in modern times It was shown that pulmonary TB can ONLY infect if bacterium-containing aerosols reach the alveoli, for which they need to be smaller than 5 microns.

Here is when we think that the ERROR of “5 micron particles fall to the ground in 1-2 m” originated: Only TB and bioweapons were important, someone at the CDC confused the size that goes to alveoli with size that falls to ground. This was repeated until 2020.

The fascinating story of how @katierandall,@linseymarr et al. figured out the cause of the 5 micron error was told in this article in @WIRED by @MeganMolteni. Reads like a spy novel, one of the best of the pandemic!

In a paper we characterize the years after the demonstration of TB as “Reluctant acceptance of as little airborne transmission as possible (1962–2020).” Airborne disease was not impossible, but required an extremely high (undeniable) standard of proof.

Unfortunately, standards of evidence were very different for different routes of transmission. Many diseases accepted as “droplet” without any substantive proof—let alone extensive and time-consuming experiments. Only the hypothesis of Chapin, ease of infection in close proximity = droplets.

Remember, large droplet transmission has NEVER been demonstrated DIRECTLY for ANY disease in the entire history of medicine (Paper from Prof. Yuguo Li, lone airborne specialist in @WHO IPC Committee).

An example of the resistance to airborne, an obvious case of long-distance airborne transmission of smallpox in [occured in] Germany in 1970. SP airborne transmission debated for centuries, only definitely accepted in the complete absence of community transmission.

An infected person arrived from in Germany from Pakistan, where there were no cases at all. Only possible explanation was transmission through air. In latter tests, smoke from index case room went to rooms of secondary cases.

The recent outbreak of smallpox in Meschede, West Germany

An airborne outbreak of smallpox in a German hospital and its significance with respect to other recent outbreaks in Europe

The case report shows the prevailing bias against airborne in Public Health: “The only remaining route of transmission considered reasonable was airborne spread of a virus-containing aerosol, **a possibility against which all of the investigators were initially prejudiced**”

Measles and chickenpox were similar, described as droplet diseases till mid-1980s, and only accepted when superspreading events with long-distance transmission made airborne undeniable.

Measles Outbreak in a Pediatric Practice: Airborne Transmission in an Office Setting 

Interestingly the WHO IPC commitee members stated that COVID could not be airborne as it was much less transmissible than measles. Otherwise they would have recognized it quickly Except… it took their profession 70 years to recognize it

Note that it is always the same error, going back to Chapin. Assuming that ease of transmission in close proximity (and decreasing transmission with distance) is proof of large droplets, and that airborne is very unlikely. For TB, measles, chickenpox… and COVID-19.

SARS-1 in 2003 brought renewed attention to airborne transmission Superspreading was clearly observed. Airborne spread was implicated in several outbreaks in hospitals, and also in large Amoy Gardens outbreak in Hong Kong.

The same dynamic played out for SARS-1, observed ease of infection in close proximity was considered evidence of droplet transmission. Airborne transmission was considered unlikely, and only accepted if evidence was undeniable.

From IPC member: Airborne transmission and precautions: facts and myths

During last several decades, until the COVID-19 pandemic, with available antibiotics, vaccines, and no major respiratory pandemics, studies further probing the details of droplet vs. airborne transmission had NOT been a major public health priority.

High standards of ventilation and filtration in modern hospitals mean that airborne risks have been substantially mitigated in these settings, where many key infection control scientists work.

Adherents of droplet transmission were in control of all key public health institutions. Scientists proposing airborne transmission were typically ignored (as we saw later for COVID-19, and explaining persistence of errors).

How did we get here: what are droplets and aerosols and how far do they go? A historical perspective on the transmission of respiratory infectious diseases

Orthodoxy, illusio, and playing the scientific game: a Bourdieusian analysis of infection control science in the COVID-19 pandemic

This schematic qualitatively captures the situation before COVID-19 appeared:

Importantly, substantial scientific evidence had accumulated (BEFORE COVID) of airborne transmission of the flu, as reviewed in this paper in @ScienceMagazine (led by @ChiaWang8 and @kprather88).

But the evidence of airborne transmission of the flu had been ignored, and @WHO and@CDCgov pages on the flu ONLY mention droplets and surfaces.

WHO Influenza (Seasonal)

CDC Influenza (Flu)

Airborne transmission is well accepted in veterinary medicine, including several coronaviruses and flu viruses, and sometimes over many kilometers (facilitated by large animal concentrations). Every veterinarian I’ve talked to is dismayed about COVID

Finally we get to the COVID-19 pandemic. It is so massive and disruptive that every researcher that can contribute in some way gets to work doing so. It includes lots of aerosol researchers (e.g. yours truly), with fast collaboration with medical researchers, virologists etc.

Some early scientific and public health reports out of China state that COVID-19 has airborne transmission:.

Despite a lack of direct evidence in favor of droplet or fomite transmission of COVID, by Mar 2020, @WHO concluded that ease of transmission in close proximity proved that COVID-19 was transmitted by those mechanisms, continuing Chapin’s 1910 error

The same errors described for other diseases are repeated for COVID-19 and the bar is moved higher. Unlike TB, animal transmission is not enough. Unlike measles, superspreading and long-distance transmission is not enough.

What were the historical reasons for the resistance to recognizing airborne transmission during the COVID-19 pandemic?

However, accumulating evidence in favor of airborne, and critical LACK of evidence for droplets or surfaces tilts the balance. Airborne transmission is (reluctantly and slowly) accepted.

E.g. one summary of evidence for #COVIDisAirborne: TEN SCIENTIFIC REASONS IN SUPPORT OF AIRBORNE TRANSMISSION OF SARS-CoV-2

@WHO commissioned some reviews on the modes of transmission of COVID-19. The one on airborne included no airborne experts, and has been rejected by the reviewers: SARS-CoV-2 and the role of airborne transmission: a systematic review [version 2; peer review: 1 approved with reservations, 2 not approved]

Shockingly, no review has appeared (to my knowledge) on the evidence in favor of large droplet transmission, despite @WHO being so sure for a long time that it was dominant.

A @WHO-sponsored review has been written on “close contact transmission” equals “close proximity,” but that is a measurement of distance, NOT a mechanism of transmission! Still carrying the error of Chapin, confusing close proximity w/ spray droplets

That @WHO-sponsored review on close prox. transmission has also NOT been accepted for publ., and remains in limbo after over a year Even though THEY GET TO CHOOSE REVIEWERS! Read the comments that we posted on both articles:

SARS-CoV-2 and the role of close contact in transmission: a systematic review [version 2; peer review: 1 approved with reservations, 1 not approved]

SARS-CoV-2 and the role of airborne transmission: a systematic review [version 2; peer review: 1 approved with reservations, 2 not approved]

“Aerosol-generating medical procedures” were the only accepted cause of airborne transmission for over a year (e.g. by @WHO). They originated from low-quality research in SARS-1. Research has show that real AGPs are talking, singing…

@WHO has finally accepted airborne transmission, including the fact that transmission in close proximity includes short-range airborne transmissionut only in Dec. 2021, after we pushed them a lot.

But both @WHO and @CDCgov communicate poorly about this, not explaining it to the public, and avoiding the word “airborne” (which is the clearest for the public) as much as they can, e.g. no mention of airborne COVID in @WHO’s extensive Twitter feed and especially no clear description of the control measures. As @kprather88 keeps saying, it is totally doable to majorly reduce transmission, once we accept it and get serious about it. But it is a really inconvenient truth for those in power…

My pinned tweet has a good summary of those protection measures against transmission (also in many other sources such as @CleanAirCrewOrg, or the @CDCgov web pages if you actually read them in detail):

So where does that leave us in mid-2022: – PH institutions such as @CDCgov have given up on explaining or preventing transmission. Too inconvenient for those in power. Scientifically, the cat is out of bag. Tons of evidence of airborne, some medical and public health people understand it.

Measures to improve ventilation are favored (e.g. by the @WhiteHouse) since they don’t face resistance from public, but they are inconsistently applied. Carbon dioxide meters are resisted by institutions, because they make poor ventilation obvious.

Not sure how this will evolve. But as it becomes scientifically clearer, it will be harder to justify lack of action. As we know from climate change (follow https://twitter.com/i/lists/1053067173961326594…), the scientific evidence can be overwhelming & those in power still resist inconvenient actions.

This is the final (hopeful) paragraph of this historical paper. Wells lamented in 1945 the ignorance of airborne transmission in public health. Let’s hope that ends with COVID-19 (& fight to make it reality – we need to be activists).

I didn’t do this alone. I got involved in COVID-19 transmission research in early 2020, and was shocked and confused by the stubborn and impatient resistance we faced.

E.g. Conly’s (@WHO IPC Chair) rudeness on our Apr. 2020 call with @WHO]

I’ve been lucky to work with the Morawska/@Don_Milton group of 36 scientists & with many others

@Don_Milton made me curious about history, mentioning Chapin and his impact. I was perplexed an “ancient” researcher could influence @WHO advisors today so much and started reading.

As we investigated many aspects of transmission, I kept an eye on the history. The paper on the 5 micron error with @katierandall and @linseymarr made me learn a lot, and also see more clearly the pendulum of history.

Contributors to the paper include @linseymarr, @katierandall, @EThomasEwing, @zeynep, @trishgreenhalgh, Raymond Tellier, Julian Tang, Yuguo Li, Lidia Morawska, @jmcrookston, @DFisman, @Orla_Hegarty Stephanie Dancer, Philo Bluyssen, Giorgio Buonanno,, @Marcel_Loomans, @WBahnfleth.
@pkubioaerosol
, Chandra Shekhar, @WargockiPawel Arsen Kritov Melikov, and @kprather88. The authors contributed majorly to the paper. If there are any remaining mistakes, they are mine.

As always, if you think that something is incorrect, or if you have a paper that contradicts (or further supports) anything I am saying here or in the paper, please send it my way.

Monkeypox – A Sinister Side?

This was initally written as a Twitter thread, but it is worth expounding on further, and also requires a greater understanding of the role of Russian actions in the global economy and global security.

12/30/2020 FireEye, a cybersecurity company, discovered that Russia had hacked into both business and government systems using a Trojan horse in a SolarWinds software update. “Among those who use SolarWinds software are the Centers for Disease Control and Prevention, the State Department, the Justice Department, parts of the Pentagon and a number of utility companies.” Of course, these activities predated this for a very long time, which has been a part of the division in the US today.

If this isn’t bad enough, Russia has a history of hacking into power grids to shut them down, including a successful attack bringing down the power for 230,000 people in 2015, which should serve as a warning of potential future attacks. It’s also worth noting that this recent attack was by Sandworm, a part of the Russian GRU, more formally known as the Main Directorate of the General Staff of the Armed Forces of the Russian Federation. This is the same group behind the US cyberattack discovered in 2020.

Energy is a vulnerability for a number of countries given that Russia is the third largest exporter of crude oil and the second largest producer of natural gas. The EU gets 38% of their natural gas from Russia. This can pose a particularly large problem this winter. If Russia has achieved a method to either disrupt energy though cutting off supply or directly disabling power, that could lead to some deadly consequences in the colder months.

More current Russian actions and statements also suggest that Russia is taking a threatening stance toward countries supporting Ukraine through military aid or economic sanctions against Russia.

2/23/2022 The Russian Foreign Ministry states “There should be no doubt – sanctions will be met with a strong response, not necessarily symmetrical, but measured and sensitive for the US side.”

3/5/2022 Putin described the sanctions placed on Russia in response to the Ukraine invasion as “declaring war.”

The monkeypox pandemic is thought to have started at a pride festival in the Canary Islands. This may not seem significant, but Putin has taken a very anti-LGBT stance, signing a “Gay Propaganda” law on June 11, 2013, which has led to further hostility toward minority groups. The pride festival then becomes an ideal vehicle to use the LGBT community both as a scapegoat for a pandemic but also as a means to spread it primarily to the West (most countries of the European Union as well as the U.K., Norway, Iceland, Switzerland, the United States, Canada, Australia, and New Zealand). The timing of this during the war in Ukraine is notable, potentially as a diversion from the war crimes committed by Russia.

This table was created on 6/27/2022. It is the WHO list of countries with unusual cases of monkeypox this year (those that don’t have endemic disease). It is also notable how many of these countries belong to NATO (yellow) and the highest case counts are all among NATO countries. Finland and Sweden applied to join on 5/18. A few others are a part of the NATO Partnership for Peace (blue). What remains looks like spillover cases.

6/22/2022 Putin has pushed for more trade through BRICS (Brazil, Russia, India, China, South Africa) countries, all notably free of monkeypox cases. He states “At the same time more and more politically motivated sanctions are continuously introduced, mechanisms of exerting pressure on competitors are further strengthened. There is intentional destruction of cooperation ties; transport and logistics chains are destroyed. And all this is contrary to common sense and basic economic logic, it undermines business interests on a global scale, negatively affecting the wellbeing of people, in effect, of all countries.

As a result, the problems in the world economy become recurrent. What we see is an economic slowdown, growing unemployment, shortages in raw materials and components. Problems with ensuring global food security are getting worse; prices for grain crops and other basic agricultural products are being inflated…Together with BRICS partners, we are developing reliable alternative mechanisms for international settlements.”

Of course, the question remains as to why someone would intentionally launch a monkeypox attack, since that could easily spread to one’s own country. That would take some very unstable thinking, or would it?

What could be the purpose of such an attack? That takes a little more history. The USSR had a massive bioweapons program called Biopreparat. The deputy director defected to the US in 1992. His book has a great deal of information about their program.

“In the 1970s, smallpox was considered so important to our biological arsenal that the Soviet military command issued an order to maintain an annual stockpile of twenty tons.” Smallpox vaccines “must be administered before the first symptoms appear. The smallpox weapons we developed sharply reduced this comfort period. When we exposed monkeys to an aerosol of the highly virulent India-1, they contracted smallpox within one to five days.”

“In December 1987, three months after I arrived in Moscow, Kalinin presented me with my first big assignment: I was to supervise plans to create a new smallpox weapon…Considering that outsiders might be suspicious if they saw hundreds of people with the distinctive marks of flesh smallpox inoculations on their arms years after the Soviet Union had discontinued all immunization, we decided, after some deliberation, to issue a directive that workers be inoculated on their buttocks.”

“We calculated that the production line in the newly constructed Building 15 at Koltsovo was capable of manufacturing between eighty and one hundred tons of smallpox a year. Parallel to this, a group of arrogant young scientists at Vector were developing genetically altered strains of smallpox.”

To put tons of virus into context, “Fewer than five viral particles of smallpox were sufficient to infect 50 percent of the animals exposed to aerosols in our testing labs.” Nobody knows where all the manufactured smallpox went after the breakup of the USSR. Think of train tanker cars full.

In 2003, I arranged for the hospital I worked at to be one of 15 study sites across the US around vesicular pustular rashes for the CDC, which eventually led to an algorithm to assess smallpox risk. The concern was misdiagnosis leading to delays causing potential further spread.

The most puzzling piece is that the first case was on 5/6/2022 . On 5/20/2022 there were only 93 known cases outside of Africa, but Russia had already been vaccinating healthcare workers with smallpox vaccine, even with no monkeypox cases in the country. Mass vaccination programs require a lead time to ramp up. How did they know what was developing and how did they implement this so quickly? Why would researchers at VECTOR publish a study in 2019 titled “We should be prepared to smallpox re-emergence“?

Smallpox vaccination leaves a scar about the size of a nickel on the arm or leg after using a two-pronged needle dipped in vaccine and pressed into the skin 15 times.

Russia has one of the highest vaccine hesitancy rates in the world. This is also very evident in the lack of uptake of the Sputnik V vaccine that was developed by Russia.

How does one hide that they are vaccinating their population against a disease that isn’t present in the wild? One might combine it as an oral vaccine against both smallpox and Hep B, but tell the population that they are only getting Hep B vaccine as to stop rumors that this is being done. If one has been surreptitiously vaccinating their population against smallpox, then releasing monkeypox or smallpox as a biological weapon makes sense in a very weird, twisted way if one is willing to suppress the press and dissention.

Putin has stated “Above all, we should acknowledge that the collapse of the Soviet Union was a major geopolitical disaster of the century. As for the Russian nation, it became a genuine drama. Tens of millions of our co-citizens and co-patriots found themselves outside Russian territory. Moreover, the epidemic of disintegration infected Russia itself.” It’s pretty clear his goal is to rebuild the Soviet Union. One way to accomplish that goal would be to undermine the abilities of his perceived enemies through traditional warfare, economic warfare, or biological warfare. Russia has been known to pose a smallpox threat to the world for a long time.

https://www.law.uh.edu/healthlaw/perspectives/Bioethics/990803Smallpox.html

https://www.paho.org/english/DD/PIN/Number12_article1_3.htm

A monkeypox attack would be an ideal way to delay early detection of a smallpox attack, allowing further spread of this horrible, eradicated disease with a mortality rate of 30%. Who knows what that could be if it were weaponized.

BA.5 in Italy

Italy had raised alarm bells in my head on 2/28/20. I went back and read what I wrote and am honestly surprised at just how accurate it turned out to be. We also didn’t seem to pay attention to warnings like this:

We are getting another warning from Italy now. BA.5 is more likely to cause more severe acute disease like we saw in waves prior to omicron.

“The cases of pneumonia caused by the SarsCoV2 virus that require assisted ventilation return to increase in Italy and the most recent of the Omicron sub-variants, BA.5, is responsible: this was told to ANSA by the national president of the Emergency Health Service 118, Mario Balzanelli. ‘We are starting to see things we no longer saw: while previous versions of Omicron spared the lower airways, we are now starting to see pneumonia caused by Omicron BA.5, which is able to reach the pulmonary alveoli…Viral forms of pneumonia requiring assisted ventilation’ are observed.”

We are on the threshold of a big tipping point from which I suspect the healthcare system will not recover. This substrain appears to evade immunity, and in combination with more severe disease, means much higher inpatient and ICU bed demands.

It almost seems poetic that we have the worst superspreader event happening right now since the start of the pandemic. People aren’t wearing masks and are travelling all over the country over Independence Day weekend. People flexing their independence and not taking into account their impact on others around them is going to deal a very painful blow.

Pediatric Hepatitis

I have noticed some odd patterns in the US state data that stood out. In particular, I recall Ohio having a much higher proportion of pediatric hospitalizations than any other state. That left me wondering if other states that have reported pediatric hepatitis have had a higher proportion of pediatric hospitalizations as well, especially in comparison to states that have reported that they are not investigating any at this time. The statements for each state with hepatitis counts are taken from this website for TODAY, dated May 6, 2022.

I didn’t know exactly what I would find but my hunch was correct. I’m comparing states with pediatric hepatitis to those without. This can be done with the data itself, but I wanted to see if there was any visual differences that were obvious. It is quite clear that those states with a higher percentage of pediatric hospitalizations had a larger chance of having pediatric hepatitis.

The next piece I was going to add was a stringency index to see what kind of correlation there was with hospitalizations, but then I realized that I only had that data for nations, not US states.

Given my priority is prevention, the obvious piece was to look at how the lack of masks might be a part of the problem so I recreated all of the graphs with self-reported mask use rates and estimates of the use seen by others. The mask use is reflected on the right hand scale. Normally I would label these more carefully but I really wanted to get this information out, with the hopes of maybe influencing some policy as the BA.2 surge ramps up.

One thing to note is the consistently wide difference between self-reported mask use and what the same people perceived as use by others. Self-reporting is a known common problem in survey data in that people often want to make themselves look better in the data. This phenomena is known as social desirability bias. What is important to realize is that the true estimate is likely much closer to what is reported as percentages of the use by others (the yellow line).

Recall that the omicron BA.1 surge started around the end of November, which corresponds well with the rise in the pediatric proportion of hospitalizations in most states (again, except Ohio). That lends some support to hepatitis being associated with the omicron strains, although clearly it’s impossible to prove causation and may only be a temporal association. Given that pediatric hospitalizations were higher during this period though, it would seem to suggest that COVID, particularly omicron, is playing a causal role in the disease pathway.

Just a quick aside about Ohio. I’ve been watching pediatric hospitalizations there and have a very strong suspicion of what may be behind it. It could very well be due to a surface chemist by the name of Douglas Frank. He started a Facebook group at the beginning of the pandemic called “Dr. Frank Models” where he was going on about his expertise in modeling pandemics and predicting only about 1500 deaths in the US. Anyone that tried to counter his arguments were booted from his group, so it became an echo chamber of conspiracy theories as well as anti-mask and anti-vax propaganda. The group went through a couple of name changes and eventually was removed from Facebook. He claims that Facebook took it down, but I suspect that he and his admins did so because the evidence against his claims became so damning. It had grown to over 50,000 members. He relished in the attention and was always self-promoting himself to try to get news interviews. He is adept at making things look like advanced science and mathematics, but he’s really just playing off the lack of education among many of his followers who wanted something good to believe about the pandemic.

I also suspect that since he was doing all of this self promotion and getting on local media in Ohio as well as being asked to speak on the pandemic, many people in the state got on board with his false philosophy and that is why Ohio is in such bad shape when it comes to children there.

After his group disappeared, he went on to start claiming to be an expert on election fraud and is the “scientist” that is in one of Mike Lindell’s (My Pillow Guy) crackpot “documentaries” claiming that he has evidence for election fraud using a “6th degree polynomial” that has been repeatedly debunked. He parades Christianity and patriotism as a means to continue fooling his followers. His platforms of choice are now Telegram, Rumble, and other dubious sites.

His specific words about the pandemic and links to rebuttals to his election fraud conspiracy are available online if you are curious.

So what is the take home message if in fact this hypothesis is right concerning hepatitis? It means we aren’t doing a good job at protecting our children, or pretty much a lot of people in American society. The cases of pediatric hepatitis also suggest that there are other chronic conditions that are likely to show up among those with a history of COVID infection in the future. Many have already been emerging.

Here are my recommendations:

  • Resume mask mandates in public spaces, particularly in schools, but also in workplaces.
  • Educate the public on the need for respirators, not just cloth masks. Even better, get these in the hands of the public using the Defense Production Act and make them freely available to those who might not be able to afford them. Have stockpiles of them available in the appropriate sizes for children in schools as well.
  • Improve ventialtion indoors by increasing the number of air changes per hour.
  • Add HEPA filtration systems to air handlers and make Corsi-Rosenthal boxes readily available in schools and workplaces to help reduce viral particles in the air since this disease is airborne. In addition, promote their use as a means to keep family members safe if one is currently infected.
  • Get the vaccine approved for those under age five.
  • Encourage vaccine manufacturers to get variant- and subvariant-specific vaccines in the pipeline when they are emerging, such as omicron BA.4 and BA.5 in South Africa.
  • Keep all of these measures in place until the END of the pandemic. The claims that we are in the “endemic phase” are simply false.

If we fail to take these measures, the health, social, and economic consequences will be worse for each that isn’t in place.

Finally, if anyone is interested in doing a multivariate analysis of the data for publication, I would be more than interested in coauthoring that with you.

States with Pediatric Hepatitis Cases and Counts (if available)

Alabama (9) The first report the CDC issued on the mysterious hepatitis focused on a cluster of nine cases spread across different parts of Alabama.

Arkansas (1) Arkansas Department of health is “investigating one potential case, but more investigation is necessary,” a statement to TODAY read.

California (7) The California Department of Public Health told TODAY in a statement on May 5 that it has “received reports of seven young children in California with severe hepatitis since October 2021. We do not know yet if adenovirus played a role in these rare illnesses or if these cases are connected.”

Colorado (4) After asking health providers in late April to start reporting cases of pediatric hepatitis with an unknown cause, the Colorado Department of Health told TODAY in a May 5 statement that it received one reported case that dated back to December 2021. The child was under 10 and tested negative for adenovirus at the time.

Delaware (1) One case is being investigated in Delaware, NBC News reported in late April.

Georgia (handful) The health department in Georgia said it was also investigating a “handful” of cases as of late April, according to NBC News.

Idaho (2) The Idaho Department of Health is currently investigating two cases pediatric acute hepatitis of unknown origin, it told TODAY in a statement.

Illinois (3) The Illinois Department of Health announced in late April that it is investigating “three suspected cases of severe hepatitis in children under ten years of age, potentially linked to a strain of adenovirus. Two of the cases are in suburban Chicago and one is in Western Illinois.”

Louisiana (1) In late April, NBC News reported one case was being investigated in Louisiana.

Michigan (2) Two patients in Michigan meet the CDC’s criteria for being investigated as possibly part of the outbreak, a spokesperson for the Michigan Department of Health and Human Services told TODAY.

Minnesota (3) The Minnesota Department of Health is investigating “several cases” of hepatitis in kids with an unknown cause, local NBC affiliate KARE 11 reported in late April.

New York (handful) New York health officials are investigating a “handful” of cases of hepatitis in kids with an unknown origin, NBC News reported in late April.

North Carolina (2) Two cases of the rare liver inflammation were reported in school-age children in North Carolina, local NBC affiliate WCNC reported in late April.

North Dakota (1) A child in Grand Forks County is recovering at home after being hospitalized with hepatitis with an unknown cause, the North Dakota Health Department announced Thursday.

Ohio (6) Doctors at Cincinnati Children’s Hospital in Ohio told NBC News that they had treated at least six cases in kids between 18 months and 10 years old, all of whom were from Ohio. One child needed a liver transplant.

Pennsylvania (multiple) The Pennsylvania health department is investigating “multiple cases for a possible connection” to the ongoing pediatric hepatitis outbreak of unknown origin but has not confirmed any, according to a statement to TODAY.

South Dakota (1) The South Dakota Department of Health is investigating a case in a child under 10 years old in Brown County, it announced Wednesday.

Texas (cases) University of Texas Health San Antonio has “seen cases of a mysterious and serious liver disease in otherwise healthy children” in South Texas, according to a statement.

The Texas Department of State Health Services told TODAY in a May 6 statement that the state has no confirmed cases of pediatric hepatitis associated with adenovirus 41. “We are aware that some local health departments are investigating cases of pediatric hepatitis to determine if they are associated with adenovirus type 41,” it said, adding that the investigations are ongoing.

Wisconsin (4) As of late April, the Wisconsin Department of Health is investigating at least four cases of unusual hepatitis in children, including one death and one liver transplant.

States with No Confirmed Cases – This may mean that cases are under investigation.

Florida — no confirmed cases

South Carolina — no confirmed cases

States with No Reported Cases (others not listed had not responded)

Maine — not investigating any cases

Mississippi — not investigating any cases

Montana — not investigating any cases

Nevada — no reported cases

Oklahoma — not investigating any cases

Rhode Island — no reported cases

South Carolina — no confirmed cases

Vermont — no reported cases

Virginia — no confirmed cases

Wyoming — not investigating any cases

1,000,000+ Americans

WHY?

Deadly Alignment

I posted this on Twitter on April 9th. I realized that I should have written it more clearly. I was simply trying to stress that we were about to see another steep climb in cases like we had seen with BA.1 in December.

I use the prior three weeks of data to calculate the first derivative of COVID cases. It provides a means to assess the rate of climb or decrease in cases, and also allows for some projection forward. I’ve used ten days as a cutoff to have a reasonably good estimate of the future. The second derivative is simply a measure of the rate at which the first derivative is going. When they are both positive, that’s a bad sign and why I expected cases to start rising very steeply around April 19th. This is the image on the right from above.

The data table showing the raw numbers for the first derivative is below. It should be pretty clear that this indicates that we are entering a rapid rate as expected. There is obviously some variation on a daily basis, partly because some states don’t report on weekends and others only once per week. This poses a major challenge for keeping tabs on what is happening day to day in each county, metro area, or state.

When that derivative is plotted against cases, it’s quite clear that we are starting a surge in the US that will continue to grow faster over the next ten days.

There are other events that have aligned that will amplify this problem significantly. Every 33 years, Easter (Christian), Passover (Jewish), and Ramadan (Islam) occur about the same time. I’ve previously written how religion plays a role in the spread of outbreaks and/or pandemics. In addition, spring break was occuring in a number of areas near this time frame. That means somewhat of a perfect storm to create an additional acceleration in cases in about 4-6 weeks.

If that wasn’t enough, U.S. District Judge Kathryn Kimball Mizelle struck down the mask mandate on public transportation on April 18th. This was a terrible decision that will impact the health and safety of a number of people, particularly those who must use public transportation, which are often people of color, children under five who cannot be vaccinated, and those with compromised immune systems. This decision is almost analogous to removing airbags requirements from vehicles since they don’t prevent all traffic deaths. That will drive cases up in May as well.

Yes, a number of people use the wrong kinds of masks and/or use them incorrectly. We should be providing respirators to the public and teaching them how they should be used.

The longer we fail to take intervention measures, the more sickness and death that will occur, and the longer we will drag the pandemic out and risk even more variants. One of the major messages that isn’t being communicated enough is that death is NOT the only adverse outcome. Most people have heard of long COVID, but it doesn’t seem to register with people that there are considerably increased risks of chronic diseases from an infection. We are putting a very unfair burden on the future health of children.

The US is failing at mitigation. There are simple solutions that everyone should be taking. Wear a respirator around others. Get vaccinated. Improve ventilation in buildings. Avoid indoor gatherings with others outside of your household. In short, care about others.

“This is the true joy in life, the being used for a purpose recognized by yourself as a mighty one; the being thoroughly worn out before you are thrown on the scrap heap; the being a force of nature instead of a feverish selfish little clod of ailments and grievances complaining that the world will not devote itself to making you happy.”

George Bernard Shaw (1856 – 1950)

Be a mighty one.

Two Views, April 14, 2022

The image on the top is the current CDC risk map. The one below is their old methodology. Both of them are available to view with current data. You can select the drop-down to get the first map (or zoom in) by selecting “COVID-19 Community Levels.” Use “Community Transmission” to get the old version. I’ll update this occasionally with the date that the images were pulled in the title.

What gives CDC? It really looks like you have sold out to business and economic interests. It’s going to take decades to make your agency trustworthy again. Your old adage had been “Be First, Be Right, Be Credible.” Was there so much belt tightening that it’s just “Be First” now?

If you want to protect yourself and those around you, get vaccinated (or boosted), improve ventilation, and wear a N-95 or comparable respirator.

Monitoring BA.2 in the US

Currently there is a technical problem with a platform I started using to automate moving graphs on this site but their support team is looking into it. In the meantime, I am going to manually post state case and variant charts. It’s my take that BA.2 is going to start another surge in the US in April. This might help individuals get an idea of when that could occur in their particular state.

My big fear is that a combination of the notion that the pandemic is over, inadequate testing and at home testing leading to insufficient data, and the lack of mask use by the public could combine to create another surge beyond what most people expect. Influenza has been climbing in the US, which started a few weeks later than usual, which closely correlates to the lifting of mask use across much of the US.

We are simply not collecting enough data or reporting it frequently enough to have a clear picture of what is really happening. Some states have moved to reporting case data weekly. During a time of exponential growth, a delay of a week can cause considerably more spread without the availability of data to make policy decisions. COVID cases are starting to climb in the US and that will become even more apparent as the weekend data becomes available this evening.

We are steaming full ahead through iceberg filled waters while in dense fog. I’m afraid that this won’t end well..

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

The International Rise of Omicron BA.2

It’s very disheartening to watch mask mandates and other controls be eased just as the US is moving into what likely will become a surge of BA.2. Some have made the argument that because it is so similar to BA.1, that should reduce risk. That may be true to some extent, but it is also likely that because of the messaging that seems to have grabbed hold of much of the US population that the pandemic is over, masks and distancing have been tossed aside. I suspect that will have a greater impact. In addition, the boosters that many have had were given months ago, so that protection is likely waning as well.

I will also add that what I say about each country is just my thinking which could admittedly be wrong. It’s difficult to really know without complete data as well as more information about other factors that could be influencing spread, but right now I’m mostly concerned about the role of BA.2.

The biggest surges are currently occurring in SE Asia and Europe. It would be helpful to have a visual of cases as they relate to both covariants and to vaccination. Unfortunately, no educational or government institution has done so publicly but I have pulled that data together to do so.

First, if you haven’t seen my work before, I’ll quickly describe the two graph types. Both have the number of new cases plotted on the left y-axis over time on the x-axis. This is known as an epidemic curve. The one with vaccines is the percentage of the population over time that has had one, two or three doses, is plotted on the right y-axis, and should be relatively easy to interpret.

The other plots the epidemic curve against the variants or covariants. Only the major ones get their own line, the rest are lumped together as “other.” These lines represent the samples that have been taken for genetic sequencing and provides and graphs the percentage of each sequenced sample as a percentage of all sequenced samples over time. That percentage is on the right y-axis.

One thing that I am seeing consistently is that both BA.1 and BA.2 seem to drive case climbs about two months after each particular subvariant starts becoming more dominant. I am generally excluding countries that don’t have variant or hospitalization data. The combination of both was my initial criteria for tracking a country more closely, but I have added a few that did not meet that for various reasons.

Africa

South Africa is a little puzzling although the wide, tapered base is likely some of the impact of BA.2 It is entirely possible that the high number of BA.1 cases provided some protection, but it is difficult to know.

Asia

India has been very puzzling all along. Given their population density, one would expect an even bigger catastrophe. I think that the first wave was mitigated by the hard control measures that were put into place. The second and third waves (delta and omicron) however fall at roughly the same time of the year and during the dry season. I have argued since before the pandemic that humidity plays a role of transmission of respiratory viruses. My argument is that in dry air, some of the aerosols have small enough droplets that desiccate, leaving the virus particle suspended, hence pushing transmission further to the airborne end of the transmission continuum and further from the droplet transmission end. Those two surges lend support to that.

What remains to be seen is the interaction between BA.1 and BA.2 I would argue that with both emerging at the same time and BA.2 becoming dominant quickly, that this might be the only surge that India sees with this particular subvariant.

Indonesia appears to be a little bit behind the US. There is an obvious surge from BA.1 which looks to be slowing. The question remains around what will happen there with BA.2. They would be wise to watch other countries that have gone through both.

Israel will also be interesting because of their high uptake of vaccine. Cases are just starting to climb there as well.

Japan also has relatively high vaccination rates. What I note in their epidemic curve is how much wider it is related to omicron. I’m attributing this to what I had said earlier about a two month lag for each variant. The initial climb is what is expected, but the widening at about the 70,000 case mark aligns well with a BA.2 surge while BA.1 was falling.

Malaysia shows a similar pattern to Japan, but BA.2 started climbing earlier, thus pushing that widening closer to the peak of when the BA.1 trend was heading downward.

Singapore further supports this two month argument. In this case though, the BA.2 surge started DURING the BA.1 surge, hence the entire curve is widened at the outset.

South Korea has been hit particularly hard after doing so well through the pandemic. That is a testament to just how easily the omicron variants are spread. Again, using the same two month assumption, I interpret this as the BA.2 surge starting just as the BA.1 surge was nearing its peak. The question is if BA.2 has peaked or if there is more climb ahead (or at least a slowed decline) since it is a much smaller percentage of sequenced cases so far.

Europe

With the rationale I’ve laid out in the Asia section, I think it will be very easy to see the same patterns in European countries and in Oceania. I’m only going to post images for countries with the worst spread right now and will only comment on anything exceptional.

Austria

Belgium

Czechia

Denmark surge on surge on surge?

Estonia

Finland has a very clear delta wave followed by BA.1 and BA.2 widening it.

France

Germany

Greece is particularly interesting because there is a bulge in the BA.1 wave that seems to coincide with a brief uptick in delta percentage rates.

Iceland doesn’t report variant data anymore, but the waveform of the epidemic curve since the beginning of the year suggests that they have had both their BA.1 and BA.2 wave, with BA.2 starting just as BA.1 was starting to recede.

Ireland

Italy might look like an exception to the pattern, but given that there wasn’t a curve to the proportion of BA.1 but shot up suddenly, this may be due to insufficient testing.

Latvia

Liechtenstein

Lithuania

Luxembourg

Malta doesn’t have BA.2 data, but I bet it started about the start of the year.

Netherlands

Portugal

Russia isn’t have a rapid climb currently but I’m assuming people would want to know because of the war. Expect cases to climb with BA.2 shortly.