Category Archives: COVID19

Vaccination risks vs. infection risks, COVID 19

A recently published study from Israel compared vaccinated vs unvaccinated people who developed COVID 19. The study was huge. It evaluated the absolute risk of various events following vaccination vs no vaccination with COVID-19 infection. The absolute risk numbers are presented as # of events per 100,000 people. The data clearly shows safety of the vaccine and a large difference between vaccination vs no vaccination/infection. The study matched vaccinated individuals with unvaccinated individuals (before the vaccine was available) for various risk factors and followed the two groups for 42 days. Events were recorded during the 42-day study period.

Here is a summary of the findings. The vaccine was the mRNA vaccine (Pfizer).

“We used a data set involving more than 2.4 million vaccinated persons from an integrated health care organization to evaluate the safety profile of the BNT162b2 mRNA Covid-19 vaccine. The main potential adverse events identified included an excess risk of lymphadenopathy (78.4 events per 100,000 persons), herpes zoster infection (15.8 events), appendicitis (5.0 events), and myocarditis (2.7 events).

To place these risks in context, we also examined data on more than 240,000 infected persons to estimate the effects of a documented SARS-CoV-2 infection on the incidence of the same adverse events. SARS-CoV-2 infection was not estimated to have a meaningful effect on the incidence of lymphadenopathy, herpes zoster infection, or appendicitis, but it was estimated to result in a substantial excess risk of myocarditis (11.0 events per 100,000 persons). SARS-CoV-2 infection was also estimated to substantially increase the risk of several adverse events for which vaccination was not found to increase the risk, including an estimated excess risk of arrhythmia (166.1 events per 100,000 persons), acute kidney injury (125.4 events), pulmonary embolism (61.7 events), deep-vein thrombosis (43.0 events), myocardial infarction (25.1 events), pericarditis (10.9 events), and intracranial hemorrhage (7.6 events).

Another particularly notable class of adverse events that has been reported in the context of Covid-19 vaccines is thromboembolic events. These adverse events, which primarily affect young women, have been linked with the ChAdOx1 nCoV-1932 and Ad26.COV2.S (Johnson & Johnson–Janssen) Covid-19 vaccines,33 both of which are adenoviral vector vaccines. However, we did not find an association between the BNT162b2 (mRNA) vaccine and various thromboembolic events in this study.”

We already know that vaccination substantially decreases the risk of severe illness, hospitalization and death. The media has reported on potential, rare complications of the vaccine.  Those reports have frightened some people primarily because when the media report them in a sensational way, they do not compare the risk of the same events with infection. This study demonstrates that the rare complications of vaccination pale in comparison to the risk of the same complications with infection. This study also identifies several serious complications of infection that do not occur as a result of vaccination.

Read the article.

And here is a graphic display of the results:

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)
  11. If you are over age 12 and eligible for vaccination, consider protecting yourself and your neighbor with vaccination.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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

Nutrition and Lifestyle vs Pandemic

Earlier this year I gave 2 presentations on this topic at the (virtual) annual meeting of Physicians and Ancestral Health, a physician organization dedicated to incorporating evolutionary biology and lifestyle recommendations into the practice of medicine. Here is the first slide:

And here are some very important references:

Please note that this lecture was given before the delta variant arrived so the data applies to the pre-delta period.

MI= Myocardial Infarction (heart attack with loss of muscle), PE=Pulmonary Embolus, DVT= Blood Clots in legs, SIRS= Systemic Inflammatory Response Syndrome

I will skip several of the slides and get to the nutritional immunology and other lifestyle factors.

This slide shows many lifestyle factors that interact with the immune system. The “12% metabolic health” refers to a study demonstrating that only 12% of American adults are metabolically healthy, which will be explained later. Dysbiosis refers to an imbalance in gut bacteria favoring inflammation and immune compromise. The rest should be self explanatory but discussed in detail later in this series.

Here is the very busy slide that summarizes nutritional immunology:

w3/w6 refers to the omega 3 to omega 6 ratio in the diet, ROS= Reactive oxygen species (oxidative stress), CH: carbohydrates; GALT: gut-associated lymphoid
tissue; GPRs: G-protein-coupled receptors; FA: fatty acids; GI/GL: glycemic index/load; RAR/RXR:
retinoic acid receptor/retinoid X receptor; SCFA: short-chain fatty acids; TF: transcription factors; VDR:
vitamin D receptor.

Key points in this slide:

  1. Omega 3 fats from fatty fish fight inflammation, excess omega 6 fats from refined “vegetable oils” (corn, soy, cotton seed, sunflower seed, safflower, etc.) contribute to inflammation and blood clots, contributing to cytokine storm and bradykinin storm.
  2. Vitamin D interferes with the virus at multiple points.
  3. Adequate iron (Fe) from meat and seafood is essential for immune function (Iron from plant sources is much less bioavailable compared to meat and seafood.)
  4. Adequate complete protein (not available from vegan diets) is essential for immune function.
  5. Zinc and selenium (both found in seafood and meat) are essential for multiple protective pathways in the immune system (enhancing response to infection and mitigating excessive inflammatory response as cofactors for antioxidant enzymes)
  6. Sugar and high glycemic foods cause inflammation, high blood sugars suppress the immune system
  7. Dietary fiber supports a healthy gut microbiome which in turn suppresses inflammation and provides the gut lining with SFAs (gut epithelium requires SFAs for energy and function, gut barrier function needs SFAs)
  8. Phenolic compounds in colorful vegetables and berries modulate multiple essential immune pathways that can inhibit viral replication.
  9. Carotenoids, phenolics support several vital immune pathways.
  10. Omega 3 fats are the building blocks of chemicals that help resolve inflammation and mitigate against cytokine storm and bradykinin storm.
  11. Multiple vitamins and phenolics support our internal anti-oxidant system.
  12. To get a balanced protein intake we should eat “nose to tail”. Include connective tissue (home made bone broth is a great source) and organ meats (from grass fed/finished ruminants) in addition to muscle meat.

Here is another busy slide that presents more detail, note the reference at the bottom of the slide to read more.

Sorry for the small print but you can see the blow up on line by going here.

http://A Review of Micronutrients and the Immune System-Working …

So does the “Standard American Diet” meet these nutritional needs to support a healthy immune system?

The % above represent the % of American adults with intakes BELOW the EAR (Estimated Average Requirement) for various vitamins and minerals. But note the definition of EAR:

“nutrient intake value that is estimated to meet the requirement of half the healthy individuals to avoid symptoms of a clinical or subclinical deficiency” (NOT OPTIMAL LEVELS for immune function)


Note also that this study did not consider omega-3s, phytonutrients, flavonoids, polyphenols, fiber, etc., all of which are essential to a robust immune response to any virus including SARS CoV-2.

With regards to omega 3 vs omega 6 fats:

Omega 3 fats (EPA and DHA) found in seafood fights inflammation, blood clots. DHA and EPA are the building blocks of SPMs which help RESOLVE INFLAMMATION (MITIGATE CYTOKINE STORM)

We will return to this topic in my next post. We are just scratching the surface of a complex system.

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)
  11. If you are over age 12 and eligible for vaccination, consider protecting yourself and your neighbor with vaccination.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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

An important reason to get vaccinated, respect for the safety of others.

I just read an article by an immunocompromised physician published in JAMA (Journal of the American Medical Association). In this article, Dr. Lindsay Ryan, an ER physician who takes immunosuppressive medication to treat her auto-immune disease, describes her thoughts on folks who refuse to be vaccinated against COVID-19. She acknowledges the many possible reasons one might choose to avoid vaccination, many related to lack of scientific information and confusion by false information so widely spread on the internet. At the heart of her discussion lays a fundamental conflict, individual freedom vs responsibility to protect our neighbor. Dr. Ryan has been vaccinated but her immunosuppressant medication has significantly blunted her response to vaccination, leaving her unprotected by the vaccine. Therefore in her job as an ER physician she is constantly at risk for infection from an asymptomatic or symptomatic patient with any infectious disease including COVID-19. Beyond that, living a “normal life” will remain elusive for her as so many individuals continue to refuse vaccination based on a “freedom of choice” decision which places their own freedom over the interests of one’s neighbor. Many Americans are immuno-compromised. There are many medications that render the immune system less effective to various degrees. There are many conditions that compromise immune systems and render vaccination less effective. By definition, all patients who have received an organ transplant are immunocompromised. All such individuals are at increased risk of death or disability from COVID-19 exposure. The single most effective way to help protect these individuals is for everyone eligible to become vaccinated.

You can learn more about organ transplants by perusing organ transplant data for the USA. Your neighbor, the person you pass in the aisle of the grocery store, the person who is sitting in the restaurant at a table next to you, could be a transplant recipient or on an immunosuppressive drug for auto-immune disease.

According to the National Institutes of Health, up to 23.5 million Americans (more than seven percent of the population) suffer from an autoimmune disease—and the prevalence is rising.

Alternatively, they may be immunosuppressed because of chemotherapy for cancer.

How many people in the United States have cancer? More than 16.9 million Americans (8.1 million males and 8.8 million females) with a history of cancer were alive on January 1, 2019; this number is projected to reach more than 22.1 million by January 1, 2030 based on the growth and aging of the population alone.

If you choose to avoid vaccination as a form of personal freedom expression, is that choice a charitable or responsible choice? Does it balance personal freedom against responsibility for the health and safety of our neighbor? Are not immuno-compromised individuals entitled to “life, liberty and pursuit of happiness” and freedom from unnecessary risk exposure because of their neighbor’s personal choices?

We have laws against driving under the influence. Such laws seek a balance between personal freedom and responsibility towards one’s neighbor. As a society we have accepted restrictions on personal behavior that places others at risk and we have instituted laws to enforce such restrictions.

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)
  11. If you are over age 12 and eligible for vaccination, consider protecting yourself and your neighbor with vaccination.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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 UPDATE: Masks, social distancing much more important than cleaning surfaces.

Today’s update from the Johns Hopkins Center for Health Security:

An editorial published in Nature discusses the need to shift focus away from surface decontamination as a mechanism to reduce SARS-CoV-2 transmission risk. Multiple studies have found that transmission of SARS-CoV-2 via contaminated surfaces, or fomites, is relatively rare compared to respiratory transmission via droplets or aerosols. Despite the evidence supporting respiratory exposure as the overwhelming driver of community transmission, numerous public health entities, including the WHO and US CDC, continue to emphasize the importance of surface decontamination, which can cause confusion among the public regarding transmission risk and appropriate protective measures. Notably, surface decontamination efforts, while highly visible and easy to recognize, are costly and likely not effective means of reducing transmission risk. The editorial calls for increased focus on improving ventilation and air filtration capacity to reduce respiratory exposure. Additionally, proper physical distancing and face mask use remain key tools in mitigating exposure and transmission risk for individuals.

The key to reducing the risk of symptomatic infection, especially moderate to severe illness and death appears to be vaccination.

While vaccination clearly reduces the risk of severe illness and death, we do not yet know whether or how much vaccination reduces the risk of carrying and transmitting the virus. So even after vaccination, an asymptomatic or minimally symptomatic person can still transmit the disease to others.

50-60% of viral transmission appears to be from asymptomatic individuals. So wearing a mask, social distancing, and avoiding unventilated crowded indoor spaces remains extremely important.

DOUBLE MASKING IS MORE EFFECTIVE THAN SINGLE MASKS.

A TRIPLE LAYER MASK OF TIGHTLY WOVEN FABRIC IS MORE EFFECTIVE THAN a SINGLE OR DOUBLE LAYER MASK.

N95 MASKS ARE MOST EFFECTIVE BUT THEY MUST FIT THE FACE WITH A TIGHT, SNUG FIT. 

TO IMRPOVE THE BARRIER FUNCTION OF MASKS WEAR A SNUG FABRIC MASK OVER A SURGICAL MASK OR OVER AN N-95. THIS WILL PROTECT BOTH THE WEARER AND THOSE AROUND THE WEARER. The fabric mask over a surgical or N-95 mask provides two mechanisms of protection. It adds an extra layer and it provides for a tighter fit of the underlying mask.

Doctors and nurses in hospitals and clinics often wear a surgical mask over an N-95. 

Face shields do not protect you or those around you from infection. Face shields and goggles (more so) likely decrease the risk of infection transmitted from aerosols that hit your eyes but do nothing for the most important mechanism of spread, breathing aerosols or droplets into your nose. Aerosols spread around a face shield into your nose. 

Think about smelling the pleasant odors of food cooking in a kitchen. Face shields will not block those aerosolized food vapors from entering your nose, but tightly fitting masks will do it to some degree.

SARS-CoV-2 virus is at least 10 times more lethal than an “average” case of influenza. Newer circulating variants have mutations that have probably increased the mortality rate.

SARS-CoV-2 is at least 10 times more easily transmitted compared to most respiratory viruses. Newer circulating variants have definitely increased ease of transmission by at least 30%. As a result, herd immunity will likely require 85-90% vaccination of a given population.

10 times 10 equals 100 TIMES MORE SERIOUS.

In addition, compared to other respiratory viruses, this virus will more frequently cause long lasting or even permanent damage and disability involving one or more organs (heart, lung, kidney, brain). Long-COVID can occur following minimally symptomatic illness and even after asymptomatic illness.

This virus is unique in that TRANSMISSION OCCURS MOST FREQUENTLY FROM ASSYMPTOMATIC INDIVIDUALS.

This occurs for two reasons.

1. Unlike most other respiratory viruses, there is a long time from the onset of when a person becomes infectious to when they become symptomatic. (an average of 5 days)

2. Some individuals never develop symptoms but are still highly infectious for up to 2 weeks.

Restaurants, bars, churches, meeting rooms, cafeterias, parties in closed spaces are situations for SUPERSPREADER EVENTS. An this includes SUPER BOWL PARTIES.

Studies in hospitals show that transmission to health care workers occurs most frequently in the cafeteria and in meeting rooms, not at the bedside where providers are wearing PPE.

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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

Autoimmunity: Another reason why VACCINE is safer than INFECTION.

There is growing evidence that self-attacking ‘autoantibodies’ could be the key to understanding some of the worst cases of COVID-19.

This might explain why lung damage and other organ damage sometimes continues to worsen AFTER the body seems to have cleared the SARS-CoV-2 virus. And it could explain why some individuals fail to mount an adequate immune response early in the disease.

With respect to the later, in September 2020 researchers at the Rockefeller University reported that > 10% of 987 patients with severe COVID-19 infection had antibodies that blocked type 1 interferon molecules, an essential part of the innate immune system.

Other researchers have screened patients with varying severity of COVID-19 and found higher prevalence of autoantibodies against the immune system in infected individuals compared to uninfected controls.

Yet another study found that some infected individuals had autoantibodies against proteins in their blood vessels, heart and brain.

Many patients with severe COVID suffer from life threatening blood clots. Phospholipids play a major role in controlling blood clotting. 52% of 172 people hospitalzied with COVID 19 were found to have anti-phospholipid antibodies.

Annexin A2 is a human protein that protects the integrity of small blood vessels in the lung. Researchers have found a significantly higher average level of anti-annexin A2 antibodies in people who died of COVID-19 compared to patients with less severe illness.

So far it is unclear whether the virus caused these antibodies or whether these unlucky individuals had higher than normal amounts of auto-antibodies prior to infection.

A paper published in the immunology literature just yesterday might shed some light on this issue as well as on the topic of LONG COVID.

We sought to determine whether immune reactivity occurs between anti-SARS-CoV-2 protein antibodies and human tissue antigens, and whether molecular mimicry between COVID-19 viral proteins and human tissues could be the cause.

In other words, they tested antibodies against the SARS-CoV-2 virus to see whether they reacted against various kinds of human tissue. Here is what they found.

We found that SARS-CoV-2 antibodies had reactions with 28 out of 55 tissue antigens, representing a diversity of tissue groups that included barrier proteins, gastrointestinal, thyroid and neural tissues, and more.

This extensive immune cross-reactivity between SARS-CoV-2 antibodies and different antigen groups may play a role in the multi-system disease process of COVID-19, influence the severity of the disease, precipitate the onset of autoimmunity in susceptible subgroups, and potentially exacerbate autoimmunity in subjects that have pre-existing autoimmune diseases.

You can read the full study here: https://www.frontiersin.org/articles/10.3389/fimmu.2020.617089/full

Cross reactivity between antibodies against COVID-19 virus and human tissue was found for every major organ system in the human body.

The concept of “molecular mimicry” has been well described in auto-immunity for many years. This occurs when a portion of a foreign protein (on for example a virus or bacterium) is identical to a portion of a protein found in human tissue. When the immune system responds to invasion by a virus or bacteria it creates antibodies to various proteins on the invader. But in so doing the anti-bodies can react against human tissue that shares a small common string of amino acids (referred to as an epitope).

A famous example of molecular mimicry occurs with Rheumatic Heart Disease in which antibodies against the bacteria responsible for Strep Throat cross react with heart tissue causing destruction of heart valve tissue and a resultant leaky heart valve. In this situation cross reaction can also occur with tissue in joints resulting in arthritis, another hallmark of rheumatic fever. These were serious complications of Strep Throat before Penicillin became widely available.

So far we know that sicker COVID-19 patients demonstrate antibodies against multiple types of human tissue.

We also know that antibodies that react against various portions of the virus can also react against human tissue.

Finally we know that multi-organ failure is an inflammatory response wherein the immune system, rather than the virus, causes organ failure.

It would be a reasonable conclusion that auto-immunity can acutely contribute to cytokine and bradykinin storm.

It would also be a reasonable conclusion that auto-immunity contributes to LONG COVID.

So why would that make an mRNA vaccine safer?

The mRNA vaccine results in antibodies against one part of the virus (one epitope, the spike protein).

But infection results in antibodies against MULTIPLE PARTS OF THE VIRUS (multiple epitopes). Because multiple antigens or epitopes are involved in the immune response to infection, it increases the probability that cross reaction with multiple human tissues can result.

From an autoimmune perspective, the mRNA vaccine is much safer.

Obviously, given the fact that over 400,000 deaths have resulted in the US from this infection and no deaths have been attributed to the vaccine, the vaccine appears to be much safer than infection. Both the Pfizer and Moderna vaccine have decreased the risk of symptomatic infection by 95%. Severe symptomatic infection can lead to death. Even asymptomatic infection can cause LONG COVID. The risk-benefit analysis overwhelmingly favors the vaccine.

For a deeper dive into auto-immunity and COVID-19 here are a few more references:

High frequency of cerebrospinal fluid autoantibodies in COVID-19 patients with neurological symptoms

Autoantibodies against type I IFNs in patients with life-threatening COVID-

Diverse functional autoantibodies in patients with COVID-19

Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19

 Association between anti-interferon-alpha autoantibodies and COVID-19 in systemic lupus erythematosus

Autoantibodies related to systemic autoimmune rheumatic diseases in severely ill patients with COVID-19

 IgM autoantibodies recognizing ACE2 are associated with severe COVID-19

Is the association between IgG anti‐cardiolipin autoantibodies and COVID‐19 severity related to the lung injury or to the SARS‐CoV‐2 infection?

Do cross-reactive antibodies cause neuropathology in COVID-19?

Immunoserologic detection and diagnostic relevance of cross-reactive autoantibodies in coronavirus disease 2019 patients

Anticardiolipin IgG Autoantibody Level Is an Independent Risk Factor for COVID‐19 Severity

Rheumatic manifestations of COVID-19: a systematic review and meta-analysis

The immunology of multisystem inflammatory syndrome in children with COVID-19

Clinical, Serological, and Histopathological Similarities Between Severe COVID-19 and Acute Exacerbation of Connective Tissue Disease-Associated 

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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

Vitamin D for All, the time is right

On Dec 7, 2020 a group of more than 100 scientists signed a letter recommending that governmental agencies and major medical organizations endorse their recommendation for universal Vitamin D supplementation at adequate doses in order to decrease the risk of COVID-19 infection and death.

https://vitamindforall.org/letter.html

The letter cites multiple converging sources of data from several studies that should no longer be ignored.

To all governments, public health officials, doctors, and healthcare workers,
[Residents of the USA: Text “VitaminDforAll” to 50409 to send this to your state’s governor.]
Research shows low vitamin D levels almost certainly promote COVID-19 infections, hospitalizations, and deaths. Given its safety, we call for immediate widespread increased vitamin D intakes .
Vitamin D modulates thousands of genes and many aspects of immune function, both innate and adaptive. The scientific evidence shows that:
● Higher vitamin D blood levels are associated with lower rates of SARS-CoV-2 infection.
● Higher D levels are associated with lower risk of a severe case (hospitalization, ICU, or death).
● Intervention studies (including RCTs) indicate that vitamin D can be a very effective treatment.
● Many papers reveal several biological mechanisms by which vitamin D influences COVID-19.
● Causal inference modelling, Hill’s criteria, the intervention studies & the biological mechanisms indicate that vitamin D’s influence on COVID-19 is very likely causal , not just correlation.

I have previously discussed the relationship between low Vitamin D levels and COVID-19 infection.

https://practical-evolutionary-health.com/2020/05/02/covid-19-link-to-vitamin-d-status-should-doctors-prescribe-sunshine/

Since that post several more studies have been published strengthening the evidence that low levels of Vitamin D are not only ASSOCIATED with increased risk of infection, severe illness and death from COVID-19, but that this relationship is CAUSATIVE.

80% of patients requiring ICU care for COVID-19 infection have low vitamin D levels (25-OH Vitamin D levels less than 30 ng/ml)

“The data strongly suggests that vitamin D is the safest, easiest, and most important anti-pandemic measure the world is failing to prioritize,” says Karl Pfleger, Ph.D., biotech investor, former Google data scientist, and one of the organizers of VitaminDforAll.org.

More than 80 percent of COVID-19 patients are deficient in Vitamin D, studies show.

But how much vitamin D should an adult take and in what form?

As discussed in the letter, 3875 IU (97 micrograms) of Vitamin D3 daily is required for 97.5% of adults to reach a level of 20 ng/ml. 6200 IU (155 mcg) are required for 97.5% of adults to reach a level of 30 ng/ml. These doses far exceed the RDA (minimum daily requirement) necessary to prevent rickets.

On a sunny day, not too far from the equator, adult humans are capable of generating 10,000 units of vitamin D per day from the interaction of sunlight with skin. Human studies have demonstrated NO TOXICITY with daily supplementation of 10,000 units Vitamin D3 per day. Because of the risks of skin cancer, common use of sun block, distance from the equator, and a decrease in the ability of humans to make vitamin D from sunlight as we age, too many people have chronically low levels.

Vitamin D is a fat soluble vitamin. On a given daily dose it takes about 3 months to reach a steady state (stable tissue levels).

The point of that open letter and similar letters which have been published in major medical journals is the following. There exists today enough data to support universal supplementation with safe doses of Vitamin D3, well above the RDA, in order to decrease the risk of COVID-19 infection, risk of severe illness, and risk of death with the infection. Any further delay, waiting for more data is senseless. The risk benefit calculation based on present data is a “no-brainer”.

My wife and I have been supplementing with 4000 IU per day. Fauci is reported to be taking 6000 IU per day. We take it with food in order to maximize absorption. Our levels have been measured. Our levels are >30 ng/ml, <40 ng/ml on this dose. These are protective levels.

The amount of supplementation necessary to achieve these levels varies from person to person, season to season, and varies with distance from the equator. Some individuals will require less, some more to achieve levels above 30 ng/ml. But adults can safely take the daily amount recommended in VitaminDforall, http://HTML version.

The suggested protocol for those not already receiving the recommended intake is 10,000 IU (250mcg) daily for 2-3 weeks (or until achieving 30ng/ml if undergoing testing), followed by taking 2000-4000 IU daily thereafter.

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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

UK variant, Ro and herd immunity

The new SARS-CoV-2 variant first appearing in southern England has a transmission advantage of 0.4 to 0.7 points higher in reproduction number, also known as R0, compared to the initial strain, British researchers found.

From the study itself:

There is a consensus among all analyses that the VOC has a substantial
transmission advantage, with the estimated difference in reproduction numbers between VOC and non-VOC ranging between 0.4 and 0.7, and the ratio of reproduction numbers varying between 1.4 and 1.8.

The researchers published their findings on the school’s website. VOC means “variant of concern”.

In other words, this new variant has an Ro which is 1.4 to 1.8 times higher than the previously circulating predominant strain.

CDC has concluded that based on genetic studies (discussed in a previous post) and reactivity to antibodies found in the blood of vaccinated individuals it appears unlikely to impact COVID-19 vaccine effectiveness. This conclusion has been reached by multiple immunologists who did those studies. (See https://practical-evolutionary-health.com/2020/12/31/new-uk-sars-cov-2-variant-we-see-no-evidence-that-the-reported-mutations-would-substantially-increase-reinfection-risk-or-decrease-vaccine-efficacy/)

So what is the reproduction number? Ro is the average number of individuals infected by one person. A Ro of 2 means that every infected person on average infects 2 other people.

When a critical proportion of a population becomes immune, called the herd immunity threshold (HIT), the disease no longer spreads exponentially in the population. The disease reaches an endemic steady state. It neither grows nor declines exponentially.

From Wikipedia:

This threshold can be calculated from the effective reproduction number Re, which is obtained by taking the product of the basic reproduction numberR0, the average number of new infections caused by each case in an entirely susceptible population that is homogeneous, or well-mixed, meaning each individual can come into contact with every other susceptible individual in the population,[and S, the proportion of the population who are susceptible to infection, and setting this product to be equal to 1:

Ro X S = 1

S can be rewritten as (1 − p), where p is the proportion of the population that is immune so that p + S equals one. Then, the equation can be rearranged to place p by itself as follows:

Ro x (1-p) = 1, 1-p = 1/Ro, so {\displaystyle p_{c}=1-{\frac {1}{R_{0}}}.}

When the effective reproduction number Re of a contagious disease is reduced to and sustained below 1 new individual per infection, the number of cases occurring in the population gradually decreases until the disease has been eliminated.

An assumption in these calculations is that populations are homogeneous, or well-mixed, meaning that every individual comes into contact with every other individual, when in reality populations are better described as social networks as individuals tend to cluster together, remaining in relatively close contact with a limited number of other individuals. In these networks, transmission only occurs between those who are geographically or physically close to one another. The shape and size of a network is likely to alter a disease’s HIT, making incidence either more or less common

But transmission is not just affected by the characteristics of the virus, it is also affected by the behavior of the population in which the virus is observed. So it is complicated. As stated by the authors of the transmission study.

We note that these estimates of transmission advantage apply to a period
where high levels of social distancing were in place in England; extrapolation to other
transmission contexts therefore requires caution.

So if social distancing is relaxed, fewer people wear masks, more people congregate, then this variant could have a much higher Ro.

Ro for measles is 12-18 rendering HIT at 92-95%

Ro for SARS CoV-1 (2002-2004 pandemic) was estimated at 2-5 rendering HIT 50-80%

Ro for SARS CoV-2 (COVID-19) has been estimated at 2.5-4 giving and HIT of 60-75%.

This is not the first variant to demonstrate increased transmission. A new variant emerged in February of 2020 called D614G which had a higher Ro compared to the previously circulating predominant strain. Such strains with higher transmission rates eventually become the predominant strain circulating in a population.

So just as more people suffer from pandemic fatigue and drop their guard we have a more easily transmitted virus. Now is not the time to loosen up on precautions.

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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

New UK SARS CoV-2 variant: “we see no evidence that the reported mutations would substantially increase reinfection risk or decrease vaccine efficacy.”

We must all be thankful for the immunologists who continue to stay on top of the pandemic. They have our backs.

Recent tweets posted by reliable experts who have evaluated the mutations in the B.1.1.7 strain.

We used our database of 579 COVID patient samples to evaluate immune evasion the UK variant (B.1.1.7). Overall takeaway is reassuring: we see no evidence that the reported mutations would substantially increase reinfection risk or decrease vaccine efficacy. (1/n)

Here is some data from the lab of Winn Haynes. @hayneswa

I would prefer this in a manuscript, but given the time of year and that I’m tired, I’ll just tweet the data regarding the UK #COVID19 variant: PRNT50 values from COVID patients for SARS2 WT WA1 vs a mutant that contains N501Y (among other spike mutations).

What does this mean?

In the words of Prof Akiko Iwasaki

As RT above, @TheMenacheryLab has shown functionally that the N501Y mutation in the RBD does not evade existing antibodies’ ability to block replication. (8/n)

Eric Topol:

The good news is that it is not anticipated the current vaccines, which rely on inducing neutralizing antibodies to the spike protein, will be affected by B.1.1.7 or N501Y

If you want to keep up on these issues I suggest you follow Akiko Iwasaki on twitter.

Prof. Akiko Iwasaki

@VirusesImmunity

Bottom line:

The vaccines should work for this new variant despite the mutations.

There is no evidence that the new strain is more lethal (time will tell).

It is probable that the new strain is more easily transmitted (greater affinity for the ACE2 receptor and recent epidemiologic data)

Masks, social distancing, hand washing will continue to work.

Improved ventilation (in-door settings) remains important.

If you want to visit and celebrate, DO IT OUTDOORS with masks and distancing.

Humans need social interaction, this can be done safely without ignoring hygiene recommendations. Socialize and exercise safely outside.

Super-spreader events (such as Whitehouse holiday parties) should be avoided.

Religious services should be held outdoors with precautions. Tents with distancing and masks work!

If you are sick isolate.

Remember, individuals are most infectious before symptoms develop and for the first 5 days after symptom onset. So even though you feel well, you could be a spreader.

Everyone is vulnerable.

Young previously healthy teens and adults are dying and suffering Long-Covid with significant chronic illness.

If you are obese, overweight, pre-diabetic, or have diabetes, now would be a good time to go low-carb with an anti-inflammatory diet. The benefits occur immediately even before or without weight loss.

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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.

Happy New Year

Doctor Bob

COVID 19 Immune Response, How does it fail?

Dr. Akiko Iwasaki, an immunologist at Yale, has led an amazing research team from the start of this pandemic, analyzing the immune response of patients sick with COVID 19. She has co-authored a review of the immune response to be published in the January edition of Scientific American.

Iwasaki A, Wong P.  The immune havoc of COVID-19.  Scientific American, January 2021, 35-41.

Here is the link.

http://The Immune Havoc of COVID-19 – Scientific American

Before reading that article, a good place for a lay person to start would be her 8 minute youtube video, Immunology 101.

After watching that video and reading the Scientific American article, if you want a deeper dive into some of her team’s research, watch this video (28 minutes).

The Scientific American article discusses many of the unique characteristics of SARS CoV-2 compared to two previous corona viruses SARS CoV-1 and MERS. SARS CoV-2 which causes the illness called COVID-19, evades the human immune system in many ways. Those who become seriously ill, requiring ICU care, seem to suffer a time lag in their immune response compared to those who suffer less severe illness. In addition, the T-cell response in sicker patients is subdued and inadequate to clear the virus. Finally, a hyper-inflammatory response is present in most who succumb to the illness. Dr. Iwasaki discusses how the Cytokine storm of COVID-19 differs significantly from that seen with other viral infections and likely includes a new phenomenon referred to as a Bradykinin Storm which involves another major component of the immune system. There may even be an auto-immune component to this disease in some or many patients.

Early in the pandemic, physicians did detect elevated cytokines in patients, but the amount of these proteins and the subsequent inflammatory state they evoked differed from that of a classic cytokine storm.

We observed high levels of IL-5 and IL-17,cytokines not classically associated with antiviral immune activity. Instead these cytokines initiate a seemingly misguided
response—one better suited for infections by parasites and fungi.
We have yet to understand whether this response causes damage
to tissue or just diverts resources the body needs to fight the virus.

In the second video linked above Dr. Iwasaki describes how men and women demonstrate different immune responses with a higher fatality rate observed among men.

Much has been learned but much remains to be discovered as this pandemic continues to unfold.

There are a few clear facts emerging from multiple studies and observations.

Masks and social distancing work. Masks protect both the wearer and those around the wearer.

Most transmission occurs by droplets and aerosol (emitted from the nose and mouth).

Six feet of distancing is helpful but does not guarantee protection. Cases of transmission in restaurants via air flow from HVAC units have been described in which the infected person transmitting disease is far removed from the people becoming infected. (aerosol spread). Droplets and aerosol studies have demonstrated that coughing and sneezing can project infectious particles up to 26 feet.

The most dangerous circumstances for transmission include indoor confined spaces, with multiple people interacting for long periods of time (restaurants, bars, meeting rooms, parties, social gatherings).

Ventilation and air turnover are important factors.

This virus is unique in that higher viral loads and transmissibility occur BEFORE ONSET OF SYMPTOMS, rendering this virus more dangerous than previous pandemics. This can occur in patients who later develop symptoms or in people who carry the virus without ever developing any symptoms.

Some estimate that as much as 50% of transmission occurs from people exhibiting no symptoms.

Finally, “herd immunity” for infectious disease has never been achieved by reaching a critical number of infected people. “Herd immunity” has only been achieved in the past with vaccination programs. Herd immunity does not mean that disease transmission ceases, it means that transmission rates are very low.

What is herd immunity?

When most of a population is immune to an infectious disease, this provides indirect protection—or herd immunity (also called herd protection)—to those who are not immune to the disease.

For example, if 80% of a population is immune to a virus, four out of every five people who encounter someone with the disease won’t get sick (and won’t spread the disease any further). In this way, the spread of infectious diseases is kept under control. Depending how contagious an infection is, usually 50% to 90% of a population needs immunity to achieve herd immunity.

Most experts estimate that vaccination of at least 70% of the population will be required to reach some degree of herd immunity for COVID-19.

Here is a 2 minute discussion of herd immunity from Johns Hopkins before the Pfizer-BioNtech and Moderna vaccines were given Emergency Use Authorization by the FDA.

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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

New COVID strain in UK: Is it more dangerous?

A new strain of the SARS-CoV-2 virus has been identified in an area of the UK. The media are reporting on this as a new, more easily transmitted or more virulent strain.

Hold on!

There are theoretical concerns that some of the many mutations identified in this virus might make it more contagious and/or cause more severe illness. But this has not been confirmed by clinical data. The case rate in this part of UK is accelerating, leading to more restrictive social measures, but it is not clear whether this is related to human behavior, virus mutations, or a combination of both.

Caution would be prudent.

Here is the link to the posted report.

Preliminary genomic characterisation of an emergent SARS-CoV-2 lineage in the UK defined by a novel set of spike mutations

This report appears on the website:

SARS-CoV-2 coronavirusnCoV-2019 Genomic Epidemiology

This strain is of concern for several reasons.

It presents an unusually high number of mutations.

One of these mutations increases the virus’s affinity to the human ACE2 receptor.

Another mutation has been linked to evasion from the human immune system.

This strain accounts for an increasing proportion of cases in parts of England.

The number of cases of this strain is growing, and the number of regions reporting this strain are growing.

This combination of facts should be a red flag and the authors of the post state:

The rapid growth of this lineage indicates the need for enhanced genomic and epidemiological surveillance worldwide and laboratory investigations of antigenicity and infectivity.

In other words, it needs to be studied and tracked to see if it is significantly more contagious and what impact it has on the pandemic (spread of spread, intensity of illness, morbidity-mortality).

The authors speculate on the possible causes for this large a number of mutations in a single strain. They suggest that the administration of antibody therapy to immune deficient-depressed chronically infected patients could create conditions of evolutionary pressure for rapid and diverse mutation. If that theory is correct, given that there is no data demonstrating reduced mortality rates with this form of treatment, we may be creating a problem with an unproven therapeutic intervention (iatrogenesis).

Convalescent plasma is often given when patient viral loads are high, and Kemp et al. (2020) report that intra-patient virus genetic diversity increased after plasma treatment was given.

Hmmmmmmmmmmmmmm!

Stay tuned for updates.

Also, please read my post from 12/18/20 on the Pfizer-BionTech vaccine. I have made a few minor corrections and clarifications since the original post.

Covid 19 Vaccine: Statistics, Safety, Efficacy, What is a Confidence Interval? | Practical Evolutionary Health (practical-evolutionary-health.com)

In the context of the COVID 19 pandemic I will close with the usual summary.

  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. 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
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

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