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Follow up to Letter from Front Line Doctor post and more

After posting the letter from an ER doc who eloquently expressed the danger, concerns, and most importantly, call for action I realized that some explanation for the lay person is necessary.

Intubation is the placement of a breathing tube into the windpipe for a person in respiratory failure. During the procedure the doctor and all providers in the immediate area are in a very high risk situation because the droplets filled with billions of virus can become aerosolized. I previously explained the difference between spread by droplet vs aerosol. Droplets fall to the floor and surfaces where virus can be infectious for hours. But when aerosolized, the virus remains suspended in the air for hours and anyone entering the area can become infected by simply breathing the air.

During intubation the doctor has his/her face inches from the patients mouth and nose. During this procedure droplets can become aerosolized. Even wearing a perfectly fitting N95 mask, goggles, gown, gloves the doctor (and those assisting) is/are not completely protected.

I received a warning letter from an ENT surgeon at Stanford, warning colleagues about cases of ENT and Neuro-surgery (endoscopic surgery through the nose) where despite FULL PPE, all practitioners in the operating room became infected and  surgeons have died. The ENT surgeon warned that PPE with N-95 mask was not fully protective and recommended PAPRs be used (Powered, Air Purifying Respirators.) Here is what the surgeon reported he received from his international colleagues:

“All 14 people who came in and out of the OR during that case became infected. He saw this repeat with other endoscopic cases

He has also shared that a significant number of doctors who died in China were ENTs and Ophthalmologists, possibly due to the high viral shedding from the nasal cavity. This has now been confirmed in the media as well.[i]

[i] https://www.bloomberg.com/news/articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese-doctors-say?fbclid=IwAR2ds9OWRxQuMHAuy5Gb7ltqUGMZNSojVNtFmq3zzcSLb_bO9aGYr7URxaI”

All 14 people who entered and left the operating room during the surgery became infected despite wearing PPE!!!!!!!!!!

“we have additionally heard from Iran that at least 20 ENTs are currently hospitalized with COVID-19, with 20 more in isolation at home.” 

Although SARs had a higher mortality rate, IT WAS NOT AS CONTAGIOUS.

This demonstrates how contagious this virus can be, and that was early on in China and Iran, before it mutated. Mutations can make the virus more contagious and more lethal. There has already been a SECOND STRAIN IDENTIFIED.

In my career I have performed more than 10,000 intubations. Many under emergency circumstances. Donning full PPE correctly takes time and when in a hurry the N95 mask may not be perfectly fitted. (WATCH THE VIDEO BELOW)

Although I have intubated people with sepsis and TB under emergency conditions, I have never been exposed to the level of danger that doctors and other providers around the world are now experiencing. The PPE (personal protection equipment) is already running short in hot zones. Many hospitals are a few days away from running out. MANY PROVDERS are reusing PPE that is not meant to be reused.

AS more doctors, nurses, and techs become infected (which is inevitable) there will be less personnel to care for patients so MORTALITY RATES WILL INCREASE.

This has not been factored into the epidemiologic models and projections.

Temporary emergency hospital tents are great, but useless without personnel. There is a limited # of ICU and ER doctors, nurses and techs. And they all need PPE.

That is why flattening the curve is so important.

That is why folks who ignore the behavioral guidelines are reckless and endangering others in the community and in hospitals.

We need to hear this every day from Doctors like FAUCI.

Misinformation from uninformed and anti-science politicians is tragically harmful.


Ventilators are useless without doctors, nurses and respiratory therapists to manage them. So production of ventilators is futile unless PPE are prioritized, WHICH HAS NOT YET HAPPENED. Shortages abound and the executive branch has not coordinated the private sector in addressing production and distribution. Instead leaving it up to the MARKET!

This has been described as a WAR, but we are not mobilizing the way we did during WW2. Mobilization requires central coordination, not bidding wars between states and hospitals for PPE, bleach and other sanitizers.

Here is the link to AN instructional video on donning PPE. Watch how long it takes and the steps required to achieve proper fit and seal for the N95 mask. Now imagine doing that while a patient is blue/hypoxic, or in cardiac and/OR respiratory arrest.



Later I will post practical precautions for groceries, mail, gas stations etc. A separate page on this website will document that.

I will also create a COVID 19 page with cut and pasted excerpts from documents as well as links to informative documents, videos and websites.


I do not wish to create or contribute to panic, if you follow the recommendations of shelter in place and social distancing and follow good hygiene you and everyone around you will be MUCH SAFER. I merely want to emphasize why flattening the curve and following recommendations are so important. The more people comply, the shorter will be the time when we can prudently start to return incrementally to normal activity.

Testing still remains inadequate with backlogs of 10 days in hot zones. So the information we are getting on # of cases is almost 2 weeks behind what is out there and even if we had 45 minute turn around, the testing kits are being rationed. So we are just seeing the tip of the iceberg. And that will be the UNFORTUNATE situation for a while.

Although we have seen TOO LITTLE TOO LATE, we can still flatten the curve by following recommended practices. We can still save lives, prevent disability and suffering, and get to a point where we can return to a more “normal” life. The longer we wait for every state to institute necessary measures (Florida is an example of inadequate measures) the longer will be our restrictions.

Remember, you can boost your immune system by getting adequate restorative sleep, rest, exercise, sunshine, stress reduction and eating an anti-inflammatory diet. Avoid alcohol (which impairs your immune system) and quit smoking. You can help prepare your body to mitigate a cytokine storm by increasing in your cell membranes, the omega 3 marine fats (EPA and DHA) which are the precursors for RESOLVINS that help regulate the inflammatory response. The inflammatory response is protective but when out of control it can be lethal in the ICU or on your way to the hospital. Your body’s defense systems can be optimized by eating an anti-inflammatory diet rich in nutrients that support immunity and regulate inflammation. A healthy diet can only be beneficial. All of these measures can be practiced while sheltering in place and practicing social distancing.


Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

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On March 10 a panel discussion/conference of Infectious Disease and PANDEMIC experts convened at UCSF (University of California San Francisco). Here are the panelists.

  • Panelists
    • Joe DeRisi:  UCSF’s top infectious disease researcher.  Co-president of ChanZuckerberg BioHub (a JV involving UCSF / Berkeley / Stanford).  Co-inventor of the chip used in SARS epidemic.
    • Emily Crawford:  COVID task force director.  Focused on diagnostics
    • Cristina Tato:   Rapid Response Director.  Immunologist.
    • Patrick Ayescue:   Leading outbreak response and surveillance.  Epidemiologist.
    • Chaz Langelier:   UCSF Infectious Disease doctor

Unless bracketed, these are direct quotes of the panelists. This was forwarded to me by a physician friend whose colleague prepared it. The “I” refers to that colleague.

University of California, San Francisco BioHub Panel on COVID-19

March 10, 2020

  • Top takeaways 
    • At this point, we are past containment.  Containment is basically futile.  Our containment efforts won’t reduce the number who get infected in the US.  
    • Now we’re just trying to slow the spread, to help healthcare providers deal with the demand peak.  In other words, the goal of containment is to “flatten the curve”, to lower the peak of the surge of demand that will hit healthcare providers.  And to buy time, in hopes a drug can be developed. 
    • How many in the community already have the virus?  No one knows.
    • We are moving from containment to care.  
    • We in the US are currently where at where Italy was a week ago.  We see nothing to say we will be substantially different.
    • 40-70% of the US population will be infected over the next 12-18 months.  After that level you can start to get herd immunity.  Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.
    • [We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die.  The panelists did not disagree with our estimate.  This compares to seasonal flu’s average of 50K Americans per year.  Assume 50% of US population, that’s 160M people infected.  With 1% mortality rate that’s 1.6M Americans die over the next 12-18 months.]  
      • The fatality rate is in the range of 10X flu.
      • This assumes no drug is found effective and made available.
    • The death rate varies hugely by age.  Over age 80 the mortality rate could be 10-15%.  [See chart by age Signe found online, attached at bottom.]
    • Don’t know whether COVID-19 is seasonal but if is and subsides over the summer, it is likely to roar back in fall as the 1918 flu did
    • I can only tell you two things definitively.  Definitively it’s going to get worse before it gets better.  And we’ll be dealing with this for the next year at least.  Our lives are going to look different for the next year.


  • What should we do now?  What are you doing for your family?
    • Appears one can be infectious before being symptomatic.  We don’t know how infectious before symptomatic, but know that highest level of virus prevalence coincides with symptoms.  We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).
    • How long does the virus last?
      • On surfaces, best guess is 4-20 hours depending on surface type (maybe a few days) but still no consensus on this
      • The virus is very susceptible to common anti-bacterial cleaning agents:  bleach, hydrogen peroxide, alcohol-based.
    • Avoid concerts, movies, crowded places.
    • We have cancelled business travel.
    • Do the basic hygiene, eg hand washing and avoiding touching face.
    • Stockpile your critical prescription medications.  Many pharma supply chains run through China.  Pharma companies usually hold 2-3 months of raw materials, so may run out given the disruption in China’s manufacturing.
    • Pneumonia shot might be helpful.  Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
    • Get a flu shot next fall.  Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
    • We would say “Anyone over 60 stay at home unless it’s critical”.  CDC toyed with idea of saying anyone over 60 not travel on commercial airlines.
    • We at UCSF are moving our “at-risk” parents back from nursing homes, etc. to their own homes.  Then are not letting them out of the house.  The other members of the family are washing hands the moment they come in.
    • Three routes of infection
      • Hand to mouth / face
      • Aerosol transmission
      • Fecal oral route



  • What if someone is sick?
    • If someone gets sick, have them stay home and socially isolate.  There is very little you can do at a hospital that you couldn’t do at home.  Most cases are mild.  But if they are old or have lung or cardio-vascular problems, read on.
    • If someone gets quite sick who is old (70+) or with lung or cardio-vascular problems, take them to the ER.
    • There is no accepted treatment for COVID-19.  The hospital will give supportive care (eg IV fluids, oxygen) to help you stay alive while your body fights the disease.  ie to prevent sepsis.
    • If someone gets sick who is high risk (eg is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use” of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China.  Need to find a doc there in order to ask to enroll.  Remdesivir is an anti-viral from Gilead that showed effectiveness against MERS in primates and is being tried against COVID-19.  If the trials succeed it might be available for next winter as production scales up far faster for drugs than for vaccines.  [MoreI found online.]
    • Why is the fatality rate much higher for older adults?
      • Your immune system declines past age 50
      • Fatality rate tracks closely with “co-morbidity”, ie the presence of other conditions that compromise the patient’s health, especially respiratory or cardio-vascular illness.  These conditions are higher in older adults.
      • Risk of pneumonia is higher in older adults.


  • What about testing to know if someone has COVID-19? 
    • Bottom line, there is not enough testing capacity to be broadly useful.  Here’s why.
    • Currently, there is no way to determine what a person has other than a PCR test.  No other test can yet distinguish “COVID-19 from flu or from the other dozen respiratory bugs that are circulating”.
    • A Polymerase Chain Reaction (PCR) test can detect COVID-19’s RNA.  However they still don’t have confidence in the test’s specificity, ie they don’t know the rate of false negatives.
    • The PCR test requires kits with reagents and requires clinical labs to process the kits.
    • While the kits are becoming available, the lab capacity is not growing.
    • The leading clinical lab firms, Quest and Labcorp have capacity to process 1000 kits per day.  For the nation.
    • Expanding processing capacity takes “time, space, and equipment.”  And certification.   ie it won’t happen soon.
    • UCSF and UC Berkeley have donated their research labs to process kits.  But each has capacity to process only 20-40 kits per day.  And are not clinically certified.
    • Novel test methods are on the horizon, but not here now and won’t be at any scale to be useful for the present danger.


  • How well is society preparing for the impact?
    • Local hospitals are adding capacity as we speak.  UCSF’s Parnassus campus has erected “triage tents” in a parking lot.  They have converted a ward to “negative pressure” which is needed to contain the virus.  They are considering re-opening the shuttered Mt Zion facility.
    • If COVID-19 affected children then we would be seeing mass departures of families from cities.  But thankfully now we know that kids are not affected.
    • School closures are one the biggest societal impacts.  We need to be thoughtful before we close schools, especially elementary schools because of the knock-on effects.  If elementary kids are not in school then some hospital staff can’t come to work, which decreases hospital capacity at a time of surging demand for hospital services.
    • Public Health systems are prepared to deal with short-term outbreaks that last for weeks, like an outbreak of meningitis.  They do not have the capacity to sustain for outbreaks that last for months.  Other solutions will have to be found.
    • What will we do to handle behavior changes that can last for months?
      • Many employees will need to make accommodations for elderly parents and those with underlying conditions and immune-suppressed.
      • Kids home due to school closures
    • [Dr. DeRisi had to leave the meeting for a call with the governor’s office.  When he returned we asked what the call covered.]  The epidemiological models the state is using to track and trigger action.  The state is planning at what point they will take certain actions.  ie what will trigger an order to cease any gatherings of over 1000 people.


  • Where do you find reliable news?
    • The John Hopkins Center for Health Security site.   Which posts daily updates.  The site says you can sign up to receive a daily newsletter on COVID-19 by email.  [I tried and the page times out due to high demand.  After three more tries I was successful in registering for the newsletter.]
    • The New York Times is good on scientific accuracy.



  • Observations on China
    • Unlike during SARS, China’s scientists are publishing openly and accurately on COVID-19.
    • While China’s early reports on incidence were clearly low, that seems to trace to their data management systems being overwhelmed, not to any bad intent.
    • Wuhan has 4.3 beds per thousand while US has 2.8 beds per thousand.  Wuhan built 2 additional hospitals in 2 weeks.  Even so, most patients were sent to gymnasiums to sleep on cots.
    • Early on no one had info on COVID-19.  So China reacted in a way unique modern history, except in wartime.


  • Every few years there seems another:  SARS, Ebola, MERS, H1N1, COVID-19.  Growing strains of antibiotic resistant bacteria.  Are we in the twilight of a century of medicine’s great triumph over infectious disease?
    • “We’ve been in a back and forth battle against viruses for a million years.”
    • But it would sure help if every country would shut down their wet markets.
    • As with many things, the worst impact of COVID-19 will likely be in the countries with the least resources, eg Africa.  See article on Wired magazine on sequencing of virus from Cambodia.

So that is the synopsis provided by my friend’s colleague.

Unfortunately, the Trump administration has been dangerously incompetent in addressing-mitigating the public health and economic impact. Trump STILL HAS NOT DECLARED THIS A NATIONAL EMERGENCY!

Whitehouse spokespeople have stated Trump does not want to declare this an emergency because it would contradict his earlier statements that COVID19 is not a serious problem (he tweeted and stated it is less serious than the flu). If declared a NATIONAL EMERGENCY it would free up large amounts of money and resources for public health, FEMA, and economic assistance, yet it has not been done. INSTEAD, TRUMP is waiting for his son-in-law (who has no scientific training) to research COVID19 and make recommendations for national policy!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!


This post and all posts are for informational, educational purposes and should not be taken as medical advice. Consult your health care practitioner for medical advise.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob



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Depression, Food, Sunshine, Gut Microbiome

A family member was admitted to a psychiatric hospital this year with a major depressive episode. For the sake of anonymity lets call her Margie. I investigated the hospital and found that the medical director, chief nursing officer and CEO had excellent credentials. I asked Margie about her food choices, opportunity for exercise and time outdoors. All of these were deplorable. The only opportunity to spend time outdoors was to go outside with the smoking group for 20 minutes twice per day (cigarette breaks). There was no exercise program or exercise opportunity other than walking the halls and walking up and down the stairs with the smoking group going to/from a smoking session. The only green leafy vegetable available was iceberg lettuce (minimal nutritional value). Food options included high sugar and high starch content items, with very few vegetables and fresh fruits. Sugar and refined carbohydrates contribute to inflammation and gut dysbiosis, both of which contribute to psychiatric illness.

Margie had insomnia and depression. These two problems travel together and feed on each other. The lack of outdoor light in the morning and presence of artificial light in the evening all contribute to disruption of  circadian rhythm, worsening depression and insomnia. Lack of exercise also contributes to both.

Here is an excerpt of a letter I sent to her treating psychiatrist with copies to the CEO, medical director and chief nursing officer.

I do have concerns about the lack of availability at XXXXXXXXX Hospital of two essential components to mental health, specifically nutritional support and exercise.

So far the dietician has not yet consulted with XXXXX. I called the dietary department to discuss my concerns that she has been served primarily nutritionally deplete starch and sugar laden foods with a minimum of vegetables, fruit, healthy fat and protein. I was told that the only green leafy vegetable available is lettuce and when I inquired about other vegetables the response was very limited. Bob in the dietary department was great and very receptive to my concerns but seems somewhat limited in the availability of appropriate nutrient dense food at XXXXXXXX.

In addition, Maria tells me that XXXXXXX has no exercise program or exercise facility for patients. The importance of exercise and nutrition has been discussed extensively in the psychiatry literature.

Enclosed are a few review articles and abstracts relevant to nutrition and exercise for in-patient psychiatry. I hope you find these useful and would consider making efforts along the lines of the author’s recommendations in these studies and review articles.

I found the review by Dr LaChance and Dr. Ramsey “Antidepressant foods: An evidence-based nutrient profiling system for depression” to be most informative. You are probably aware that Dr. Ramsey has presented many lectures at the annual meeting of the American Psychiatric Association. The authors of the other studies enclosed have also been well represented at that meeting.

Despite requesting a response from the Medical Director, Chief Nursing Officer, and CEO, I never received any communication in response to my concerns.

The concept of “NUTRITIONAL PSYCHIATRY” has received much attention in the psychiatry literature. This article was published in the World Journal of Psychiatry. Antidepressant foods: An evidence-based nutrient profiling system for depression.

The article discusses nutrients that are “related to the prevention and treatment of depressive disorders”

Here is a summary:

Twelve Antidepressant Nutrients relate to the prevention and treatment of depressive disorders: Folate, iron, long-chain omega-3 fatty acids (EPA and DHA), magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc.

The highest scoring foods were bivalves such as oysters and mussels, various seafoods, and organ meats for animal foods. The highest scoring plant foods were leafy greens, lettuces, peppers, and cruciferous vegetables.

This description aligns with the anti-inflammatory diet that I recommend to patients.

This dietary approach provides essential nutrients for brain health but also provides for healthy diversity in the gut microbiome,.

The relationship between psychiatric illness and the gut microbiome has been extensively reviewed in the medical literature.

Source of image:

Frontiers in Integrative Neuroscience, 11 September 2018 | https://doi.org/10.3389/fnint.2018.00033

This complicated picture depicts the interaction between food, gut microbiome, immune system, inflammation, endocrine system (stress response mediated by the hypothalamic pituitary adrenal axis), nervous system, neuro-transmitters including serotonin (the target of many ante-depressant medications). BBB is the blood brain barrier. ENS is the enteric nervous system. SCFAs are short chain fatty acids, very important for health, produced by “good” gut bacteria by using dietary fiber. SCFAs serve several useful purposes including nourishment for the cells that line the gut, protection of the tight junctions between those cells (prevent leaky gut), direct anti-inflammatory actions and more. Leaky gut leads to an increase in pro-inflammatory substances crossing the gut barrier and entering the body (instead of staying in the gut and leaving with stool) with a cascade of undesirable consequences. LPS (lipopolysaccharides) are bacterial wall toxins that stimulate the immune system and create inflammation. This inflammatory response is a major contributor to death in the setting of systemic infections (sepsis).

If you are interested in understanding this picture you can read the entire article here.

It is clear from this picture that the authors recommend beans and whole grains. I advise  against the consumption of grains and legumes in favor of colorful vegetables which provide for 5-7 times the amount of fiber per calorie compared to grains. Many reasons to avoid grains and legumes discussed on the website many times.

Fiber-rich diets are the main fermentable sources for SCFAs which contribute to the attenuation of systemic inflammation by inducing regulatory T cells. (Lucas et al., 2018) and through multiple other mechanisms.

SCFAs are one of many metabolites produced by gut bacteria that contribute to the prevention of depression

The mechanisms of action include direct communication to the brain through the vagus nerve, absorption of SCFAs into the blood where it can reach the brain and have beneficial effects, dampening of the inflammatory immune response, protecting the gut lining as mentioned above. These are depicted below.


SCFAs and depression

Image Source : Microb Cell 2019 Oct 7,; 6(10): 451-481, PMID 31646148

Exercise protects against depression and is useful as therapy for depression.

In her discussion of depression as a brain inflammatory disorder Psychiatrist Emily Dean describes well some of these interactions.

This is not the first time I have observed  very limited access to nutritious foods, exercise and sunlight in the setting of a psychiatric hospital. Unfortunately, it will likely not be the last despite multiple studies and articles in the medical literature pointing to the importance of these three ingredients for general and psychiatric health.

To prevent and treat depression and other psychiatric illnesses, nutrition, exercise, sunshine are all important. Lack of these basic treatment modalities hampers recovery and health.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose.

Doctor Bob






A growing body of evidence suggests that masks for everyone might be a beneficial strategy. In the US that strategy has been rejected in order to encourage conserving PPE for health care providers.  In Czech Republic, where national leaders have successfully waged a masks4all campaign (in combination with quarantine), COVID19 GROWTH seems to have stabilized. I previously discussed droplet vs. aerosol spread. The WHO and CDC have officially labeled COVID19 as droplet spread.

Droplets fall to the floor and surfaces, they do not linger in the air. Disease transmission can occur by touching a contaminated surface and then touching your face. Droplets coughed or sneezed into your face (even from a distance) will transmit disease. Singing, yelling, or loud talking can probably do the same. Face to face conversation without cough or sneeze can transmit COVID19.

Aerosol represents smaller particles that linger in air for hours making a confined space infectious for hours and allowing for disease transmission just by breathing the air, a more contagious situation.

Certain medical procedures such as intubation produce aerosol, increasing risk for health care providers.

On March 10, 60 members of a choir rehearsed in the state of Washington. None were symptomatic. They did not share music and distanced themselves. 45 members became ill, 28 tested + for COVID19, 2 died. It is likely all 45 who are symptomatic have COVID19 (there is a 37% false negative rate for nasal swab PCR test, 28/45=62%, very close to expected # of positives if all 45 have the virus.)


Those without symptoms should be tested, they are likely carriers.

If they all had been wearing masks transmission rates would probably have been lower.

As described in a previous post, an advisory letter from Stanford ENT Surgery Dept., warned about highly contagious circumstances in the OR during ENT surgery. In one case all 14 personnel who entered and left the OR contracted COVID19 despite wearing PPE including N95 Masks. Multiple reports of deaths among ENT and eye surgeons who work close to the nose have been reported from other countries.

These examples and many more suggest that there is a continuum between droplet and aerosolization and both may be present. Although not completely protective, masks would decrease the viral load associated with an exposure. A lower load of virus would be less likely to overwhelm the immune system. COVID 19 is also called SARS-COV-2.droplets vs aerosol.png

The virus enters human cells by attaching to a specific protein on the cell surface. These proteins (ACE2) are in high concentrations in the NOSE.entry at nose with high ACE recpetors.png


virus lock and key.png

There is no discrete safety with a distance of 6 feet. That degree of separation is just a guideline. A forceful cough or sneeze might project droplets much further.

Baerosol and droplet projection.png

Based on these considerations MASKS4ALL might help contain this virus AND flatten the curve with greater efficiency.


Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob


COVID-19: The Problem of a high False Negative test rate and single testing

I received notes taken from a ZOOM session with Dr. Wen Hong Zang, chair of the Society of Infectious Diseases, China Medical Association. About 7000 attendees, mostly US listeners, including Stanford Health Care, Santa Clara County hospitals, and NYC hospitals.

First the most salient points, then comparison to US approach, then the full notes from the COVID CRITICAL CARE GROUP.

  • Key to mitigating spread in Shanghai was doing diagnostic COVID test on every suspected case. (anyone with symptoms)
  • Tests are done within 4 hours in China, or frozen at -20C, otherwise there is increased false negative.
  • False negative rate of COVID PCR even with two serial swabs was 10-30%!  Next Generation Sequencing for COVID was used as the gold standard.
  • Molecular diagnostics was needed, and even two negative PCRs, for suspected cases on CT – they sent Next Gen Sequencing, a PCR to National Lab, a 3rd local PCR, and local PCR in another swab location (e.g. anal) (e.g. sent all 4) before they would rule out COVID. Thus SIX TESTS: SAMPLING DIFFERENT LOCATIONS, using DIFFERENT LABS, multiple METHODS and multiple SITES WERE REQUIRED to absolutely identify all positives.
  • All patients with positive COVID PCR were admitted to a designated COVID hospital regardless of their level of illness. (ACHIEVING GUARANTEED ISOLATION FROM FAMILY/COMMUNITY) 
  • Cases went down to zero or near zero by late-Feb, and there is now a small second wave from imported cases.

Compare this with the US situation.

  • Testing is usually done once (Missing many positives because of high FN rate)
  • Testing is NOT done on all symptomatic people, in most areas criteria for testing include symptoms AND exposure to a known case (BUT WITH LOW TESTING RATES THE SECOND CRITERIA WILL NOT BE MET FOR MANY who have actually been EXPOSURED)
  •  Only very sick patients are hospitalized, so mildly symptomatic are sent home where their families/communites will be exposed, enhancing spread of the virus, hampering containment.
  •  Our guidelines are to stay home for mild symptoms so we are testing even fewer patients and exposing more households to symptomatic patients.
  • Test turnaround at Quest and Labcorp is as high as 10 days in some areas.
  •  LabCorp and Quest are not accepting specimens in some locations because of the tremendous backlog. (therefore turn around time > 10 days (indefinite) when a sample is refused)
  • With delays in testing, and long turn around times, the false negative rate increases (viral decay in sample over time) thereby sending more positive cases back to family/community and under-reporting positives.
  •  US is not routinely employing CT scan, which can be positive in the face of a negative PCR.

With very stringent widespread multiple testing for everyone with symptoms, utilization of chest CT scan, and hospitalization of all positives, China achieved near zero growth within 2 months with subsequent small second wave from imported cases.

The US approach thus far has clearly been TOO LITTLE, TOO LATE, and appears destined to fail unless significant changes are immediately instituted.

Based on the experience in China, in order to achieve adequate control, we need:

  1. Intensive widespread testing (multiple tests for every symptomatic person)
  2. If CT scan is positive, even if two PCRs are negative, further repeat testing is required to discover all positives.
  3. rapid turn-around and frozen samples for remote testing
  4. complete isolation of all positives, away from family/community.
  5.  we cannot send symptomatic patients home or let them remain in the community unless they repeatedly test negative.
  6. Aggressive use of CT scan for evaluation.

Here is the full set of notes I received.

From Physician anesthesia group on FB…

Posted in Covid Critical Care Group & to be shared : 

Predicted number of cases in Shanghai with exponential growth was calculated to be nearly one million by March 1, but social distancing avoided this. (editorial Bob Hansen MD: Along with stringent testing of all symptomatic individuals, multiple testing, CT scan part of workup, isolation of all positives in hospital)

Cases went down to zero or near zero by late-Feb, and there is now a small second wave from imported cases.

Key to mitigating spread in Shanghai was doing *diagnostic COVID test on every suspected case* .

All patients with positve COVID PCR were *admitted to a designated* *COVID* *hospital* *regardless* *of their level of illness.* 

Coinfection was very common with other respiratory bacteria and common cold viruses, and >50% patients were positive for a co-infection with a respiratory organism.

False negative rate of COVID PCR even with two serial swabs was 10-30%!  Next Generation Sequencing for COVID was used as the gold standard.

RSV, Mycoplasma and Parainfluenza virus also caused similar bilateral CT findings to COVID.  Molecular diagnostics was needed, and even two negative PCRs, for suspected cases on CT – they sent Next Gen Sequencing, a PCR to National Lab, a 3rd local PCR, and local PCR in another swab location (e.g. anal) (e.g. sent all 4) before they would r/o COVID.

Mean incubation was 6.4 days, and patients were quarantined mean 5.5 days from symptom onset, with this approach the “curve” was 1 month in duration.

Hydroxychloroquine is in a multicentre RCT in China and will be published “very soon”.

LDH and D-Dimer was associated with development of ARDS.

He felt there is a narrow window between positive CT findings and deterioration to ARDS, where corticosteroids have been helpful and further studies are required to investigate this.

Approxiatemately 5% of patients will need ICU level care, and mortality depends on availability of ICU.

How to protect medical personnel* – China protocol:

1) Standardized process in terms of patient care areas and flow.

2) PPE – double-layer gloves, double-layer shoe covers, isolation gown, masks, googles, etc.  “The most important is to cover the head”

3) Positive pressure masks – for aerosol generating procedures.


Time window until infection and test positive? 3d by PCR, and 7d by Serological.

Who did you test?  They abandoned risk factor criteria quickly and just tested anyone with symptoms.

What is the best test?  PCR is better than Antibody test for sensitivity.  But the Antibody test is helpful, as PCR can have false negative by week 3.  Antibody test is helpful to see the overall population prevalence in terms of patients with mild or no symptoms.

Does viral RNA degradation of samples happen?  Tests are done within 4 hours in China, or frozen at -20C otherwise there is increased false negative.

What is risk for pregnant women?  These cases were mild, and no severe/intubated cases were seen so far in Shanghai (no Wuhan data presented).

What is the underlying medical conditions that are high risk?  Heart disease do the worst – the virus causes myocarditis as well.

 What percentage of patients have antibodies?  Every recovered patient tested have found to have antibodies on testing but it is unclear if these are actually protective.

What is the dosage for hydroxychloroquine? 400mg bid x1d, 400mg po qd.  They did not treat with azithromycin due to hepatotoxicity observed.

 What is the risk to health care workers? There were none of his colleagues who went to Wuhan to help that became infected with COVID, and this is attributed to PPE.

What is the outcome of COVID survivors?  Lung fibrosis is definitely less than SARS and most patients had a good long-term outcome.


Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob





From an immunologist at Johns Hopkins University. Maybe this will make just one person stop saying “it’s been around forever, it’s just the flu.” It hasn’t and it’s not. Read why.

Feeling confused as to why Coronavirus is a bigger deal than Seasonal flu? Here it is in a nutshell. I hope this helps. Feel free to share this to others who don’t understand…
It has to do with RNA sequencing…. I.e. genetics.
Seasonal flu is an “all human virus”. The DNA/RNA chains that make up the virus are recognized by the human immune system. This means that your body has some immunity to it before it comes around each year… you get immunity two ways…through exposure to a virus, or by getting a flu shot.
Novel viruses, come from animals…. the WHO tracks novel viruses in animals, (sometimes for years watching for mutations). Usually these viruses only transfer from animal to animal (pigs in the case of H1N1) (birds in the case of the Spanish flu). But once, one of these animal viruses mutates, and starts to transfer from animals to humans… then it’s a problem, Why? Because we have no natural or acquired immunity.. the RNA sequencing of the genes inside the virus isn’t human, and the human immune system doesn’t recognize it so, we can’t fight it off.
Now…. sometimes, the mutation only allows transfer from animal to human, for years it’s only transmission is from an infected animal to a human before it finally mutates so that it can now transfer human to human… once that happens. We have a new contagion phase. And depending on the fashion of this new mutation, that’s what decides how contagious, or how deadly it’s going to be..
H1N1 was deadly….but it did not mutate in a way that was as deadly as the Spanish flu. It’s RNA was slower to mutate and it attacked its host differently, too.
Fast forward.
Now, here comes this Coronavirus… it existed in animals only, for nobody knows how long…but one day, at an animal market, in Wuhan China, in December 2019, it mutated and made the jump from animal to people. At first, only animals could give it to a person… But here is the scary part…. in just TWO WEEKS it mutated again and gained the ability to jump from human to human. Scientists call this quick ability, “slippery”
This Coronavirus, not being in any form a “human” virus (whereas we would all have some natural or acquired immunity). Took off like a rocket. And this was because, Humans have no known immunity…doctors have no known medicines for it.
And it just so happens that this particular mutated animal virus, changed itself in such a way the way that it causes great damage to human lungs..
That’s why Coronavirus is different from seasonal flu, or H1N1 or any other type of influenza…. this one is slippery AF. And it’s a lung eater…And, it’s already mutated AGAIN, so that we now have two strains to deal with, strain s, and strain L….which makes it twice as hard to develop a vaccine.
We really have no tools in our shed, with this. History has shown that fast and immediate closings of public places has helped in the past pandemics. Philadelphia and Baltimore were reluctant to close events in 1918 and they were the hardest hit in the US during the Spanish Flu.
Factoid: Henry VIII stayed in his room and allowed no one near him, till the Black Plague passed…(honestly…I understand him so much better now). Just like us, he had no tools in his shed, except social isolation…
And let me end by saying…. right now it’s hitting older folks harder… but this genome is so slippery…if it mutates again (and it will). Who is to say, what it will do next.
Be smart folks… acting like you’re unafraid is so not sexy right now.
#flattenthecurve. Stay home folks… and share this to those that just are not catching on.

This is Dr. Bob speaking now.

Since this immunologist provided this explanation it has gotten worse. 20% of COVID deaths are in the 20-64 year old age group.

I have been in contact with physicians and nurses with boots on the ground in many states. They work in ICUs and ERs. The back-log for testing is 10 days in many areas. Quest and LabCorp cannot handle the volume and in some places they are not accepting new swabs for testing. Our data are therefore behind by a few weeks so reports that CDC provides are looking at the past, not the present. South KOREA,  a much smaller country has done more tests than in the US and by virtue of immediate effective action (early social distancing, stay-at-home, widespread testing, public health teams tracking down contacts and placing them in quarantine, etc) they have flattened the curve.

Fortunately a company has developed a rapid test with turn-around time of 45 minutes. FDA approved it. Production expected to hit the market soon. Hopefully it can be in use soon which will give more accurate information.

In the US some anti-science governors have still not instituted minimally effective measures to flatten the curve. (example Florida)

Spring break college students who went to Florida to party were eventually sent home (after great pressure on the governor by critics) and have delivered the virus to their family and friends at home. Remote body temperature monitoring data showed high rates of fever in Florida during spring break.

But today, as of 12 noon,  Florida did not show RED so the spring break dissolution and social distancing may be having an effect.

Stay at home and practice social distancing. Tips from two Stanford doctors/researchers provided in previous post.


Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

CIVID-19 Groceries, Mail, Cleaning, Practical Information.

Ultraviolet Light Kills Viruses and Bacteria and it is “free”.


But we do not know whether exposing clothing and other articles to outdoor light will kill COVID-19. So washing machine + Dryer is the best advice unless you have a medically approved UV sanitizing device. Soap and hot/warm water works.


Viruses are not really “alive” in the sense that bacteria, parasites, algae are alive but they can cause great harm. For the rest of this discussion “alive” and “dead” in reference to harmful viruses will refer to “probably infectious/viable” and “not probably infectious/viable”.

A Stanford professor and viral researcher posted how he goes about grocery shopping and engaging in other tasks. His comments are worth considering.

You can find them here.

These are some of his salient points.

A recently published paper in the NEJM studied viable virus duration on various surfaces.

Copper – no viable COVID-19 after 4 hours
Cardboard – no viable COVID-19 after 24 hours
Stainless steel – no viable COVID-19 after 48 hours
Plastic – no viable COVID-19 after 72 hours
Not tested – glass, rubber, clothing, carpeting, tile, wood, stone, paper, and foods. No documented food transmission, cooked or uncooked, has been reported to my knowledge.

From Dr. Utz:

It is important to understand several things about these numbers:
–    The virus decay over time is “exponential”. 
o    This means that half of the virus on stainless steel is dead after 5.6 hours, and half of virus on plastic is dead after 6.8hours.
o    So for stainless steel at 24 hours, only about 5% is still alive. For plastic at 24 hours only about 10% is still alive. That’s not much. With hand washing and not touching eyes, ears or nose, my personal interpretation for typical exposure out in the community is that there is not much to worry about.
–    The studies were done under very controlled conditions – room temperature and 40% humidity.
–    There is no way to know what happens in fridges and freezers. 
–    It is thought that warmer weather and sunlight make it harder for viruses like this to survive.
–    The data on cardboard was “noisy”, that is was more variable, and should be interpreted with caution.

Here is Professor Utz’s practical tips.

–    Assume public surfaces could be contaminated. Wipe down surfaces, like door handles, gas pumps, and keyboards. Use Purell, wash hands frequently, and don’t touch your eyes, nose or mouth unless you have washed your hands. Gloves are really not needed in the community. Healthcare workers on the front lines need gloves way more than any of us. Our risks are extremely low if we follow the guidance.
–    Assume the virus can be aerosolized (the length of time in air is still being studied and is very hard to estimate given all of the variables in the community). Minimizing time in closed spaces with others in the public, and staying 6 feet apart is good practice and reduces this risk greatly. Personally, I only used an N95 mask once last week in a massively overcrowded grocery store. The mask I used was from my garage that I have used for years when sanding my decks. Again, healthcare workers on the front lines need masks way more than any of us. Moreover, unless properly trained, the masks don’t work and can even increase your risk if in a high-risk environment like a hospital ICU (but not uncrowded places like stores – these are low risk places). The same with gloves – most people don’t know how to properly put them on and take them off, potentially increasing the risk of getting the virus to aerosolize. MGH sent out an email this morning about this topic. They described how to use masks if on the front lines, and how to clean them in the event there is a shortage (a worrisome message). The take home point is that we don’t need masks, but our caregivers and first responders do. Donate unused masks if asked. The MGH video is here: https://www.youtube.com/watch?v=IfTVPCDami4&feature=emb_logo&mkt_tok=eyJpIjoiTVdabE1ERmhPVFV5TURFdyIsInQiOiJQQWNSZFJaTjBRNHYzWk01cUphbmEzRVNScXVtWG1FMmZsUEZQWUtJT25NTEs2RmdBVzEyS3ZHdTlVS1h5VFNETzFpalo1U0h3V1wvOWxRQjdNVElSVUpFNFMrZE1MdU5MdVhYYTFoemhydW9rK2FJb3ROWnlaaFdCUFpYOGJ0cFQifQ%3D%3D
–    There have not been any documented cases of food transmission. We should assume for now that we should be washing fresh food as usual, and preparing food hygienically.
–    Based on available data, I personally am doing the following (again, this is not a recommendation, just a description of my approach):
o    At grocery stores. I try to get in and out as quickly as I can. I used to go to our local store almost daily, but now go every 4-5 days to buy for several households. This means going in with a list of only what is needed. I keep my 6 foot distancing. I don’t wear gloves or mask. I go alone and if I had kids I’d not bring them in the store (yes, I still am seeing this happen – parents should STOP). If the store is crowded, I come back when it is not crowded. I pay with a credit card and not cash. After shopping I take the cart out to the car and then load into my own canvas bags myself. (Note some stores in our area are now banning customers bringing in their own bags). I bring the groceries home and unload them on the porch (that is, I don’t bring the bags in the house and I don’t place them on my kitchen floor like I used to do). I deliver to some at risk relatives and friends and just leave the bags on the front porch and text them to grab them. When I am done unpacking groceries, I leave the bags out in the sun and consider them OK to use again when I shop again 4-5 days later.
o    At restaurants. I am now starting to get take out again regularly. The restaurants clearly need the business. I distance myself, pay with a credit card, carry to my car, unload like I do for groceries, and I transfer food to plates (ie I don’t eat from containers). 
o    Delivery. Many people are using delivery services which is one way to cut exposure at grocery stores and restaurants completely, and to provide income to drivers. 
o    When returning home from work or these rare outings.
§    We have always had a “no shoe rule” in our home because we work in hospitals and have no idea what is on the floor. 
§    For those who do wear shoes in the house – based on the data in the NEJM paper, it sees unlikely that enough virus would land on the floor, then get transmitted to shoes, then somehow make it to the mouth, eyes or nose and cause an infection. Since carpeting has not been tested in studies yet, there is no way to know for sure. 
§    For days where we are in the clinics or in a crowded grocery store only, we change clothes and shower when we get home out of an abundance of caution. How long the virus can remain in clothing, and whether it is transmissible, is not known and is hard to study. Follow the CDC guidelines:  https://www.cdc.gov/coronavirus/2019-ncov/prepare/cleaning-disinfection.html.
§    We wash hands regularly, and particularly after unloading new purchases. And before, during and after preparing and eating food.
§    We wipe down cell phones, and we use speaker phone wherever possible so we don’t get the cell phone close to our face.
§    And to end with some levity, we don’t bite our nails, apply cosmetics while pumping gas (I observed this last week, I kid you not), pick our noses, or pick other people’s noses.

Some information on disinfectants from Michael Lin PhD-MD:

• Hand sanitizer is just 60-70% ethanol with moisturizers.
• The ethanol you want to use is 95% non-denatured ethanol
– 95% denatured ethanol has toxic additives to prevent drinking (will have a health hazard logo).
– 100%/dehydrated/absolute/anhydrous ethanol has benzene, also toxic, from the purification process.
• Isopropanol can be substituted for ethanol, but just takes longer to evaporate
– 60-70% isopropanol is just as effective as 60-70% ethanol as a disinfectant.
– 99-100% isopropanol (rubbing alcohol) can be purchased by the consumer as a cleaning and disinfecting agent.
• The moisturizer can be aloe vera gel (available in drugstores) or glycerol (a common lab reagent, and an ingredient in moisturizers and makeup).
Lin Lab recipe: Mix two parts 95% non-denatured ethanol or 99-100% isopropanol with 1 part aloe vera gel or 90-100% glycerol. That’s it!

Hygiene recommendations from Dr. Lin:

• Don’t shake hands and stay 6 ft away from people outside your household – these are easy.
• But ”wash your hands often” and “don’t touch your face” are confusing without context – how often is often? Why can’t I touch my face? Should I ask someone to scratch my itchy nose for me? Shouldn’t I also worry about what I’m touching, not just my hands? If so, what cleaning solutions should I use?
• I’ll provide some details. I treat hands and objects similarly, and I am pretty strict:
– To protect yourself, sanitize your hands right before eating and right after touching things touched by others.
– To protect others, use clean hands to touch others’ things or when handling things to others.
– Sanitize objects you get, and only give out sanitized objects. For example, I have hand sanitizer open and ready to clean my credit card right after I get them back from cashiers, before I put it back in my wallet.
– Outside your house, sanitize smooth surfaces you will touch directly with your hands (e.g. tables and chair edges, wherever you put your phone and computer).
– I keep track of whether hands/objects are clean. As long as they have not encountered unknown/dirty things after their last cleaning, they don’t need to be recleaned. This is why I suggest immediate sanitation of hands after touching unknown/dirty things, so you can resume using your clean things without worry.
– You can open doors with your body or foot, and use paper towels to handle faucets or knobs.
– Create clean zones – your house, your office (if you’re allowed to work), your car.
– Sanitization can be done by soap and water (hands) or hand sanitizer (hands or objects) or Windex (objects).
– “Disinfectants” like bleach or quaternary amines are for large areas for which soap (due to the need to rinse) or alcohol (due to fumes, expense) are not practical. If you can use soap or alcohol, you don’t need them.
– Finally, if your hands are clean, you can touch your face! But remember to sanitize them before you touch other people’s stuff.

Because this information is practical I have created a separate page on this website to include it’s contents.


Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob



CDC recommending hospital staff use bandanas when masks run out. Hospitals are asking the public to sew masks. Here is a physician responding:

Please don’t tell me that in the richest country in the world in the 21st century, I’m supposed to work in a fictionalized Soviet-era disaster zone and fashion my own face mask out of cloth because other Americans hoard supplies for personal use and so-called leaders sit around in meetings hearing themselves talk. I ran to a bedside the other day to intubate a crashing, likely COVID, patient. Two respiratory therapists and two nurses were already at the bedside. That’s 5 N95s masks, 5 gowns, 5 face shields and 10 gloves for one patient at one time. I saw probably 15-20 patients that shift, if we are going to start rationing supplies, what percentage should I wear precautions for?

Make no mistake, the CDC is loosening these guidelines because our country is not prepared. Loosening guidelines increases healthcare workers’ risk but the decision is done to allow us to keep working, not to keep us safe. It is done for the public benefit – so I can continue to work no matter the personal cost to me or my family (and my healthcare family). Sending healthcare workers to the front line asking them to cover their face with a bandana is akin to sending a soldier to the front line in a t-shirt and flip flops.

I don’t want talk. I don’t want assurances. I want action. I want boxes of N95s piling up, donated from the people who hoarded them. I want non-clinical administrators in the hospital lining up in the ER asking if they can stock shelves to make sure that when I need to rush into a room, the drawer of PPE equipment I open isn’t empty. I want them showing up in the ER asking “how can I help” instead of offering shallow “plans” conceived by someone who has spent far too long in an ivory tower and not long enough in the trenches. Maybe they should actually step foot in the trenches.

I want billion-dollar companies like 3M halting all production of any product that isn’t PPE to focus on PPE manufacturing. I want a company like Amazon, with its logistics mastery (it can drop a package to your door less than 24 hours after ordering it), halting its 2-day delivery of 12 reams of toilet paper to whoever is willing to pay the most in order to help get the available PPE supply distributed fast and efficiently in a manner that gets the necessary materials to my brothers and sisters in arms who need them.

I want Proctor and Gamble, and the makers of other soaps and detergents, stepping up too. We need detergent to clean scrubs, hospital linens and gowns. We need disinfecting wipes to clean desk and computer surfaces. What about plastics manufacturers? Plastic gowns aren’t some high-tech device, they are long shirts/smocks…made out of plastic. Get on it. Face shields are just clear plastic. Nitrile gloves? Yeah, they are pretty much just gloves…made from something that isn’t apparently Latex. Let’s go. Money talks in this country. Executive millionaires, why don’t you spend a few bucks to buy back some of these masks from the hoarders, and drop them off at the nearest hospital.

I love biotechnology and research but we need to divert viral culture media for COVID testing and research. We need biotechnology manufacturing ready and able to ramp up if and when treatments or vaccines are developed. Our Botox supply isn’t critical, but our antibiotic supply is. We need to be able to make more plastic ET tubes, not more silicon breast implants.

Let’s see all that. Then we can all talk about how we played our part in this fight. Netflix and chill is not enough while my family, friends and colleagues are out there fighting. Our country won two world wars because the entire country mobilized. We out-produced and we out-manufactured while our soldiers out-fought the enemy. We need to do that again because make no mistake, we are at war, healthcare workers are your soldiers, and the war has just begun.

Thank you my fellow healthcare workers for working on the front line.
I pray for you and your safety.
Copy & Paste!



COVID-19 Potential Treatments and Israeli Webinar

I highly recommend this webinar from Israel. The medical leaders there really have their act together. Possible treatments on horizon discussed around 20 minute mark.


The early part discusses some basics everyone can/should understand.

Some key points.

COVID 19 is an RNA virus. After entering the cell it must use it’s own enzymes to replicate and this is one place an anti-viral might work. (Block replication). DNA viruses can use the host cell’s own DNA replication enzymes/machinery.

Blocking entry into the cell is also a possibility (Chloroquine and Hydroxychloroquine) These drugs (that treat malaria) may be useful in that regard based on small studies in-vitro and in-vivo. I have several papers in my files on both relative to COVID-19 if anyone is interested.

Because RNA viruses mutate quickly, vaccine production is more difficult as compared to DNA viruses (darn!)

Singapore got things under control very quickly because they had a plan ready to go (after experiencing previous virus outbreaks). For example, they had already built a 400 bed hospital with 250 negative pressure rooms just to be used for a SARs type situation. (Large facility for a very small country). They had travel restrictions, stay at home, rapid testing, etc., all immediately in place. Public health teams were immediately dispatched to investigate all contacts and institute isolation and quarantine. Japan seems to have done very similar quick containment. The Japanese culture is also conducive to social distancing and compliance with public health recommendations (they follow rules/recommendations, including the teenagers and young adults,  unlike Americans).

Back to the Israeli Webinar.

So blocking viral entry into the cell and blocking viral replication seem to be the best targets for potential drugs. The Protease Inhibitors used to treat HIV are much less likely to be useful according to the virologist (Susan Weiss) on the webinar. I have already read a paper and editorial in NEJM demonstrating no benefit.

The fatality rate in Germany is about 1/4 that of Italy. These societies are very different. Italian households often include multiple generations, Germany less so.

The virus has hit Northern Italy (colder) much harder than Southern Italy (warmer) and we know that many viruses are temperature sensitive relative to replication/survival/epidemiology.

Also observed has been less viral activity in the Southern as compared to Northern hemispheres.

Israel has been tracking data from multiple perspectives. # cases went from 30 to 300 in one week (double every 2 days approximately, which I have discussed appears to be the case in US). They project 600 cases in 4-5 days (as of the Webinar), 4,000 cases in 2 weeks, and as many as 20,000 cases at peak which they anticipate will be late April or early May.

Israel is working on technologies for remote monitoring of isolated positive patients who are mildly symptomatic and has already converted a building into that kind of facility (US take a hint)

The webinar is an hour long and well worth the time.

I applaud the governor of California for taking decisive action for state wide stay-at-home and essential services open only. This should prevent the degree of crisis seen in the Lombardi region of Italy.

Finally, another note on improving and maintaining your immune status.

Immunity and Morality in COVID-10

There are two general aspects. We must do everything we can to support our immune system and at the same time follow an anti-inflammatory lifestyle so our immune system does not over-react to an infection producing a cytokine storm.

People who develop COVID-19 related pneumonia and progress to multi-organ failure and death follow a path led by excessive inflammation. The immune system produces various inflammatory chemicals and cascading events that are not resolved in time to save the host. The host’s own immune system response causes friendly fire damage and death. What keeps the immune system in check?

Resolvins are produced by humans to contain excessive inflammation. They are produced from the marine omega 3 fats (EPA and DHA) which are widely deficient in modern diets. That is one advantage of the anti-inflammatory diet.

The dietary approach on this website provides for a more healthy intake of  anti-inflammatory omega 3 fats relative to pro-inflammatory omega 6 fats. The latter are consumed in great quantities in the standard American diet.

But that is just one aspect of the diet that can contribute to your body being more able to handle an infection.

With regards to maintaining a properly functioning immune system a few simple lifestyle habits are essential,

  1.  Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2.  Get plenty of sleep (without adequate sleep your immune system does not work well )
  3.  You must follow good sleep habits
  4.  Exercise, especially out of doors in a green space, supports the immune system
  5.  Get some sunshine and make sure you have adequate Vitamin D levels.
  6.  Eat an anti-inflammatory diet rich in micronutrients.
  7.  Practice stress reduction like meditation and yoga which improves the immune system

Now would be a good time to address all of these areas to enable your body to withstand the stress of social isolation and COVID-19.

Hopefully, with warmer weather coming and most states taking the lead in stay-at-home policy (federal leadership still lacking tremendously) if independent-minded American culture can overcome our innate distaste for following rules we may see a rapid turn-around and ability to resume modest amounts of economic and social activity. But this will take very aggressive behavior changes (especially among the young) and a united-we-stand approach.

More to come so stay tuned. I will stay on top of this crisis and provide filtered and up to date information.


Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob