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  • Welcome to the new site. Here's a thread about the update where you can post your feedback, ask questions or spot those nasty bugs!

Coronavirus

Asher Kelman

OPF Owner/Editor-in-Chief
Folk,

If you re-read my words on chloroquine, it was merely to help anyone with access to it so that they would have the drug the moment their doctor agrees. Obviously the
doctor knows all your conditions and can read the Merck pharmacopeia and the Mayo Clinic list of precautions and instructions!

None of your physicians would allow you to harm yourself with a drug contraindicated by your medical condition.

As I clearly stated, I am just providing knowledge and general advice. I advised getting the drug but not taking it.

Unlike respirators, likely as not, the drug can be ramped up in production by simple agreement between just India, China and the UK. We have unlimited giant jets for transport of raw materials.

Besides, countries like the USA, France and the U.K. have strategic drug reserves that could be released. I assure you if the Chinese, Israeli and now French studies are confirmed, then drugs of one sort or other can likely tame this pandemic and shortages of hospital intensive care capabilities with trained personnel and mechanical ventilators will be eased.

My early ideas on chloroquine are now being shown to be on the right general track. But one shouldn’t take the drug without consulting your physician.

Again, I am just a retired virologist and Physician and only have access to results that are published. The experts have access to unpublished work of their colleagues.

So newer drugs, some inexpensive with different side-effects will be shortly available and a choice for physicians according to toxic profile, availability and efficacy.

Right now, strict isolation, social distancing if mobile, protective gear and perhaps Choroquine at hand is likely the best advice.

If you feel it’s immoral to buy Choroquine in advance, don’t!

I believe it’s in adequate supply and getting 30 pills constitutes mere budget dust in the entire availability picture. But certainly if you are elderly or have an immune suppressed condition, your use of Choroquine is well-deserved and fully justified.

If enough folk were on effective prophylaxis, (and Choroquine, for just one drug example),prevents cell to cell spread, at least in tissue culture), then the pandemic will be slowed down to be manageable.

Let’s see what France now does!
 

Asher Kelman

OPF Owner/Editor-in-Chief
Can we all please go back to common sense?

There is no vaccine and there won't be any this year.

Not for us, but if the current Seattle and other studies give immune antibodies, I assure you the government leaders will get it if they do wish, under the guise of “National Security”. For them, vaccines will likely be approved as early as by the end of April.


There is also little chance of a treatment for the masses.

That was true, Jérôme!

Hardly true today!

Israel has already approved a slew of drugs, some inexpensive. The very top of the list is chloroquine!

NIH has already started first responder prophylaxis studies.

With the exciting news from France, (if confirmed in several more studies), the results will be reviewed carefully by international teams of experts and suddenly tons of the drug, (whatever it turns out to be), will be available one way or another.

I am cautiously optimistic!

Asher
 

Asher Kelman

OPF Owner/Editor-in-Chief
A quick DEEPL translation:
At the Insitut Hospital-Universitaire in Marseille, Professor Raoult announces that the first trials of chloroquine are spectacular. This drug is already being used against malaria.

Professor Didier Raoult, Director of the IHU in Marseille
Professor Didier Raoult, Director of the IHU in Marseille © Maxppp - Valérie Vrel
In an 18-minute video recorded in front of his students in Marseille, Professor Raoult does not hide his satisfaction. In concrete terms, 24 coronavirus patients agreed to take Plaquenil, one of the commercial names for chloroquine. Only six days later, only 25% still carry the virus. While 90% of those who did not receive this treatment are still positive.

The students applaud the professor as he presented these results. "It's spectacular," the IHU director tells them. The average viral load with this virus is normally 20 days. And all the people who die from corona still have the virus. Not having it anymore changes the prognosis."

An inexpensive medication

This clinical trial has received approval from the health authorities to be conducted at IHU in Marseille, one of the reference centres for the coronavirus. The advantage of this drug if its efficacy is confirmed is that it is already known. To fight against malaria. And what's more, it is cheap.

Thanks you Nicolas!

Thanks you France!


.......but it still needs much more work with many more people and look for toxicities. Asher
 

Asher Kelman

OPF Owner/Editor-in-Chief
Why we need to be braver to protect first responders!

From Medscape:

Colleagues and others are mourning the coronavirus-related death earlier this week of Italian physician Roberto Stella, 67, leader of the medical association in Italy's northern Varese region, who continued to treat patients even after protective gear ran out.


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Stella, president of the Medical Guild of Varese, died of respiratory failure after contracting SARS-CoV-2 Tuesday in a Como hospital, according to news reports.

A colleague of Stella's at a health service training academy in the region, Alessandro Colombo, was quoted by the Italian news service ANSA as saying that Stella told him a few days ago, "We have run out of masks. But we don't stop. We are careful and we go on."


Colombo continued, "Such a man belongs to everyone, because he gave himself to everyone. He was more than a hero; he was a man who knew how to cry. Who was moved in the face of beauty and truth. He wanted to change. Change yourself and help people do it. A master."

ABC News reported that Stella was a general practitioner in Busto Arsizio, a city about 20 miles from Milan.

According to the BBC, as of Thursday Italy has recorded at least 1016 coronavirus deaths, amid 15,113 infections. Currently on a nationwide lockdown, Italy is second-hardest-hit by COVID-19 after China.

Lack of Protective Gear


Silvestro Scotti, head of Italy's National Federation of Doctors and General Practitioners, told CNN, "He was the example of the capability and hard work of family doctors. His death represents the outcry of all colleagues who still today are not equipped with the proper individual protection needed."

Physician and colleague Simon Gregory tweeted, "I am so sorry. Roberto was a dear friend and colleague and I am privileged to have known him. As Alessandro Colombo's (comment) shows, he carried on serving patients when PPE (personal protective equipment) ran out. Such courage and compassion."


Jane Townson, CEO of the UK Homecare Association, tweeted, "Our deepest sympathy to the family, friends and colleagues of Dr Roberto Stella and to all in Italy struggling with illness and loss. We are indebted to those who work tirelessly in the health and care systems across all nations to support us all."
 

Asher Kelman

OPF Owner/Editor-in-Chief
It is sad to have such losses. We urgently need a world expert conference with authority to direct a world response. Trump called this a “Chinese Virus” that shows such ignorance. We are one humanity!

Asher
 

Asher Kelman

OPF Owner/Editor-in-Chief
How to Run Your Life Safely until we know better:

Each country has its own guidelines, but these are perhaps the strictest and worth reading as they are detailed enough to deal with most social family needs, logical and preserve the minimum pulse of normality.

I will continue to search for indications, proof and availability of updated safe prevention and treatment with drugs.

Asher
 

Asher Kelman

OPF Owner/Editor-in-Chief
To get a sense of reality from France, (fter Italy in post # 66 above), a week ago the first line workers in the hospital were 100% negative, now they are 40% positive.

COVID-19: Advice From a French Doctor on the Frontline
Véronique Duqueroy
March 16, 2020
COVID-19 cases in France are rising but is the country heading for infections on the scale seen in Italy?
What measures have already been taken in hospitals? Are they enough? What advice can infectious disease specialists give to healthcare professionals?


3605732-Davido.jpg

Dr Benjamin Davido


Dr Benjamin Davido is an infectious disease specialist at Raymond-Poincaré hospital in Garches, on the outskirts of Paris. He is the lead referral for COVID-19 and clinical lead for their ‘Plan Blanc’


He spoke to Medscape’s French Edition.


Q&A
What is the situation in your hospital?

Since the beginning of [last] week, we have had a worrying and very significant increase in the number of cases. Currently, we receive one phone call for a screening request every 2 minutes, and one request to evaluate a patient suspected of having, or already tested positive for, COVID-19 every 10 minutes (and try to find a bed). We have had to assign two doctors full time to handle this.

In addition, today [13th March], outpatient screening of caregivers suspected of having the disease revealed that 40% tested positive for SARS-CoV-2. There is now a worrying degree of infection that shows the virus is circulating outside but also inside the hospital. This figure is all the more worrying because, 10 days ago, we were close to 0%. The increase did not happen by chance.

When we had only 40 cases in France, we relied on level 1 Health Referral Centres (établissements de santé de référence; HRCs), such as Bichat or Pitié-Salpêtrière hospitals in Paris, to absorb the flow of patients. Now we have more than 3000 infected individuals, it is obvious that the dozen level 1 HRCs across the country are no longer enough. Consequently, second line centres, like our hospital, are taking their turn, just in time.



We have had to adapt and put in place dedicated COVID-19 units. We have, as of today [13th March] a total of 11 beds, with a planned increase to 20 beds next week. Centres no longer have the time nor the space to receive and respond to the demand for screening. Fifteen days ago, the screening of suspected patients had to be done in the hospital with containment measures. Today, it is no longer possible as these places are taken by confirmed cases. Screening is therefore performed in the emergency department. This is stage 3 crisis management, although this has not yet been officially announced, which underlines the pressure from the flow of patients arriving in hospitals.


Are there annexes for screening?

Some hospitals have installed tents for urgent services, but you still need to have the capacity, to have the space and enough caregivers. And these tents only allow outpatient diagnoses, they don’t allow for patients considered fragile or severe cases requiring hospitalisation in a dedicated isolation facility.
 

Asher Kelman

OPF Owner/Editor-in-Chief
Is France heading for a situation like Italy?

It is certain that the curves of the Italian and French epidemics can be superimposed; they are just separated in time by around 10 days. One difference between the two countries is that Italy has a particular set-up in which healthcare is organised separately by region, which may have led to a delay in the organisation of care.

Italy also organised the situation by geographic area; thinking, for example, that only the north of the country was affected, which was, in hindsight, probably a mistake. But in the same way, in France, in mid-February, we thought only in terms of clusters or people returning from at-risk zones, 10 km outside of which patients were not considered suspect, only for, the next day, those areas to become clusters.

Today, in France, we no longer talk of zones or foci of COVID-19, and we no longer take into account travel. On the contrary, we consider the severity of the illness, and it is the presence of unexplained pneumonia that makes us suspect a COVID-19 diagnosis, especially if it is serious straight away (in resuscitation, for example).


We are now in the middle of a major public health problem. We have stayed at stage 2 in terms of the health alert, in that we screen people with relevant symptoms, even if they are minor. But as we no longer include history of travel, and the relevant symptoms are flu-like, such as having a fever, a runny nose, or coughing, and that, chronologically, it is the peak of the flu epidemic, we have an enormous influx of patients who may have flu or seasonal viral infection (mainly rhinovirus). These are consistent with the new coronavirus and, as such, we cannot, for benign cases, make a clinical distinction between them. It becomes therefore impossible to screen everyone. In any case, we don’t have enough kits. We are at the stage of counting the number of cotton swabs to take samples…


Did France act too late to prevent shortages?

Yes. Personally, for 10 days, I and my colleagues have struggled with the healthcare teams to urgently set up a hospitalisation and screening structure to make the diagnoses, as some seemed doubtful due to the lack of anticipation by our local bodies. I don’t blame them, because bodies at the ministerial level have not given us the funds for taking the samples, as the laboratories themselves do not yet have the testing machines.

On the other hand, what should have been anticipated is the current situation where we find ourselves with questions over the supply of masks. There are general practitioners who cannot see patients in their office due to a lack of surgical masks (FFP2s [masks] only have demonstrated effectiveness in resuscitation and when obtaining the sample), while we are in a period of seasonal flu and colds…and coronavirus. There is also a lack of hydroalcoholic gels. For lack of a better option, it is necessary to rely on hand-washing, which is a backwards step in terms of hygiene practices. That’s why, there should be, from tomorrow, a national plan that fits with the pandemic, as declared by the WHO. Care, as set out in the current plan, is not tenable in the long-term because in the short-term we will no longer have the capacity to accept and regulate the flow of hospitalised patients, or even to screen them.

How did you set up your dedicated COVID-19 unit?

We opened our unit around 15 days ago in response to a call from level 1 HRCs. As with any new epidemic, there was a lot of apprehension at the outset, especially among caregivers and nurses. We anticipated that before opening the service. It’s what we saw with HIV in the 90s and with highly resistant bacteria in the 2010s. It’s a normal reaction. Once we had explained the issues and above all that we are capable of effectively protecting ourselves against transmission of the illness (in hospital) by using FFP2 masks in particular, everyone took part with extraordinary energy.

Is transmission really controlled in your unit?


Yes, in the hospital it is. Contaminated caregivers have been probably, in the main, in the community or hadn’t take sufficient precautions at the start of the epidemic by not wearing a mask when the patient had signs consistent with the illness (especially cough). Personally, I think I have more risk of catching the virus on public transport than in the hospital. We are working on a cohort of patients to determine the risk factors for infection specific to caregivers, to know precisely how much of a role is played by contamination outside the hospital, in meetings, or the non-application of precautions (wearing a mask or using hydroalcoholic gel).

It is certain that, in our infectious diseases service, there is a bias because we are used to protecting ourselves, so the risk is obviously and thankfully residual. What is dangerous is, for example, a patient hospitalised in orthopaedics for a hip fracture who coughs; we aren’t necessarily going to think about COVID-19, and in orthopaedics the policy outside theatre is to not wear a mask.
 

Asher Kelman

OPF Owner/Editor-in-Chief
How anxious are you?

I am personally not afraid of being infected. I am, on the other hand, very preoccupied by the thought that the numbers are increasing exponentially; we are at the beginning of the epidemic, so that’s normal. But the question is: will we have the physical means (masks, hydroalcoholic gel…) and the people (who could work non-stop days, nights, the weekends…?) at a constant level and without additional help? If the epidemic lasts for 3 months, I think it will be very difficult.
Current health policy is to keep the epidemic at alert stage 2, flattening the curve to not saturate the health system, which may make the epidemic last longer. Hospitals in France have been in crisis for years; in January, healthcare professionals protested against the lack of healthcare personnel and to explain that the austerity policy, which would see hospital beds close and push outpatient care, was not viable. Today, we are reopening hospital beds and requisitioning them to hospitalise suspected coronavirus patients.

This morning, the regional health agencies asked us to cancel all scheduled non-urgent hospital admissions.

Doctors in Italy have had to make difficult ethical choices due to the lack of equipment (respirators, beds, etc). Will this happen in France?

We have discussed it among infectious disease specialists, and we think that it’s a question which will sadly arise when we have no more room for resuscitation, which is currently not the case. But COVID-19 patients with severe disease stay in hospital for a long time (around 3 to 6 weeks) so if the epidemic lasts, it may indeed happen. But this decision algorithm is sadly not rare in medicine. We decide not to resuscitate a patient when we know it will not save them. What is new is that this is a kind of illness for which we are not used to taking this type of decision.

In Italy, several doctors report that patients under 40 years old, without comorbidities, could also present with serious forms of COVID-19. Are we seeing the same thing in France?
Currently, a third of hospitalised patients in resuscitation in France don’t have risk factors, including some under 40 years of age. We don’t know why yet. There is probably a genetic factor to the illness. One hypothesis is that it causes an immune reconstitution inflammatory syndrome, which we see sometimes in infectious diseases like tuberculosis and HIV.

How do you explain there being fewer severe paediatric cases? Could children, in a second outbreak of the epidemic, be more susceptible?

There are currently two hypotheses. We know that children are exposed to a number of different coronaviruses; they could have therefore developed an immunity against this virus, and don’t develop the severe clinical form. The second hypothesis is that COVID-19 cannot attach itself to the respiratory epithelium in children. This immature epithelium has few if any receptors.


One could reasonably think that in the case of a second outbreak that children could still be protected. We know that the virus mutates relatively little, so the risk is probably small, even if it cannot be confirmed at this stage. We saw in Japan patients re-infected with coronavirus but it seems that there is nevertheless a partial immunity, contrary to what was said initially.

You will take part in a clinical trial in France for the treatment of COVID-19. Can you tell us more?

It is a large-scale clinical trial [with 3200 European patients, including 800 from France] conducted at Bichat hospital by Dr Yazdan Yazdanpanah, which will attempt to answer many questions. It will consist of four arms, testing the following treatments:
  • Remdesivir [GS-5734, Gilead], an antiviral that has already been tested on MERS-CoV. The first version was tested on SARS in 2003, but we have little data for SARS-CoV-2 because the illness has only been around for several months. The in vitro results were interesting; it could be effective against SARS-CoV-2.
  • Lopinavir/ritonavir [Kaletra, AbbVie]. It’s an old retroviral used against HIV. It’s a protease inhibitor which is said to be effective against sequences similar between SARS-CoV-2 and HIV. It could reduce the viral load. But the recent data showed, in vitro, that HIV, which is meant to be resistant to lopinavir, was paradoxically more sensitive than SARS-CoV2, calling into question its clinical effectiveness.
  • A combination of interferon beta and lopinavir/ritonavir.
  • A control arm of standard of care, with oxygen therapy, etc.
 

Asher Kelman

OPF Owner/Editor-in-Chief
What message would you give to your colleagues?

When we are in stage 3, we should not see it as a nuisance. We will be able to take decisions that will allow general practitioners to be involved and manage outpatients, as these are mainly non-severe cases (80% of cases). And to properly care for these patients, it will be absolutely necessary to follow hygiene rules (masks, hand washing…) and monitor them well; in other words, see them again at 7 and 14 days to ensure that they don’t have complications of the illness.


No conflicts of interest or funding declared.


COVID-19 : quelle est la réalité du terrain ? Témoignage du Dr Benjamnin Davido, médecin infectiologue referent

Adapted from Medscape's French Edition.
 

Asher Kelman

OPF Owner/Editor-in-Chief
This French doctor's in depth report provides a realistic picture of the facts of life for this virus, spreading at a log rate of approx up too x1000 in a month where the people are not immune.

The terrible situation is that the pandemic will continue until it peaks in each country in 2-4 months or 14 months if we “social distance” as recommended.

This means all States will have to give their struggling citizens a basic monthly allowance and airlines will need massive support.

Online education will become a new norm.

Sports, meetings and on campus colleges is not possible until we have prophylactic drugs or else or herd immunity one way or another. So we are looking at at least 2 years of disruption.

Early drug discovery could change this!

I do hope this information is useful.

Asher
 

Asher Kelman

OPF Owner/Editor-in-Chief
Question:

Are my notes, reports and opinions on the Pandemic helpful, of interest or mostly an invasion and annoying!

Let me know!

Asher
 

Asher Kelman

OPF Owner/Editor-in-Chief
Well thanks Robert!

I am thinking more and more that either Choroquine or another antiviral is needed to protect first line responders and induce an artificial herd immunity.

In the USA, we may have missed our opportunity to stop the entire continent being infected. Not following China’s and Korea’s management leads is close to criminal neglect!

We can’t even test patients on every respirator never mind the general population.

But notice an entire group of sports players got tested within 5 hours of a contact coming down with the disease!

Asher
 

Jerome Marot

Well-known member
Antivirals and chloroquine have been tested in China and South Korea, publications can be found. While there is some effect, it is not the magical cure we need.

Something else: https://jamanetwork.com/journals/jama/fullarticle/2762028

That publication details the particular of a young lady who had no symptoms at all, yet infected at least 5 persons over a period of 18 days. Some of the infected people died. This is evidence that people can transmit the disease without experiencing symptoms.

People at elevated risk of pneumonia should avoid social contacts, even with people without symptoms. All others should refrain from social contacts as far as possible. While I have no elevated risk myself except for age, and am feeling presently fine, I decided to work at home, limit outside activities to the essential and the ones with ample distance from others, etc.
 

Asher Kelman

OPF Owner/Editor-in-Chief
Antivirals and chloroquine have been tested in China and South Korea, publications can be found. While there is some effect, it is not the magical cure we need.

Not the magic cure? For those in the Intensive Care Unit, that get better and don’t die, it’s magic for sure.

Of course it has zero effect on an epidemic as it is not used, for that purpose, YET!

I believe that it could be used to prevent person to person spread!

avoid social contacts, even with people without symptoms. All others should refrain from social contacts as far as possible. While I have no elevated risk myself except for age, and am feeling presently fine, I decided to work at home, limit outside activities to the essential and the ones with ample distance from others, etc.
Perfectly well said!
 

James Lemon

Well-known member
More about stealth transmission by by asymptomatic carriers:

All good advice considering that it takes about 6 days to show signs of infection.

That six day period is how the virus is being spread rapidly people don’t know that they have it until it’s too late.

I have practised social distancing for some 35 years and have rarely been sick. Having a compromised immune system is something that I have had to protect myself from . In doing so I have developed some odd behaviour when out in public. Lots of little things that would not occur to most.

I like to get lots of sunlight and spend a great deal of time outside. Hospitals are a place that I avoid visiting at all costs. Having a sophisticated air return system in my home is a big plus too.. I think.

I am currently away from home on business having to stay in unfamiliar places. I see that many businesses are taking precautions .
 
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Asher Kelman

OPF Owner/Editor-in-Chief
Interesting approach by the British. They are keeping schools open with the idea that infection can spread amongst the young, thus increasing herd immunity.

It could be justified by good math. I wish they would publish the scientific thought behind this idea.

Asher
 

nicolas claris

OPF Co-founder/Administrator
Interesting approach by the British. They are keeping schools open with the idea that infection can spread amongst the young, thus increasing herd immunity.

It could be justified by good math. I wish they would publish the scientific thought behind this idea.

Asher
Foolish, if kids cannot, apparently, be infected, they can spread the virus to their elders!
Herd immunity is nonsense with COVID-19.
 

Jerome Marot

Well-known member
The Boris Johnson Guide To Handling A Pandemic

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Published one hour ago: Boris Johnson confirms all schools in the UK will close 'until further notice' as coronavirus crisis deepens
"The power of holding two contradictory beliefs in one's mind simultaneously, and accepting both of them… To tell deliberate lies while genuinely believing in them, to forget any fact that has become inconvenient, and then, when it becomes necessary again, to draw it back from oblivion for just as long as it is needed, to deny the existence of objective reality and all the while to take account of the reality which one denies—all this is indispensably necessary." (George Orwell).
 
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Asher Kelman

OPF Owner/Editor-in-Chief
Foolish, if kids cannot, apparently, be infected, they can spread the virus to their elders!
Herd immunity is nonsense with COVID-19.
Good to hear that Boris is at last listening to the aghast protests of hundreds of U.K. scientists. So school will be closed!

Nicolas,

Children are infected, Nicolas but they don’t seem to get pneumonia. But they will be still bringing the virus home to their very susceptible parents and grandparents.

Herd immunity is indeed very critical to prevent the virus returning each year!

In 12-18 months vaccination will start and with 80-90% immunized could substantially protect us.

But the British upper classes have always had, (“in loco Deus”), colonialistis attitudes to the general populations under their authority.

Like an army General saying, “Din’t worry, at most, we could lose only 75,000 men in the first landing on the beach. I can accept that!”

Asher
 

Asher Kelman

OPF Owner/Editor-in-Chief
First dog dies after catching COVID-19 from its owner.


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Stock picture: Pomeranian
The Pomeranian died but we don’t know if it was because of the virus!

Asher
 

Doug Kerr

Well-known member
I had not yet seen the COVID-19 statistics from Pomerania. Have we heard yet with the Prime Minister there has to say?

Best regards,

Doug
 
Question:

Are my notes, reports and opinions on the Pandemic helpful, of interest or mostly an invasion and annoying!

Let me know!

Asher

Definitely informed and interesting, Asher. Examples include mention of chloroquine, which I didn't know much about, and your support of the herd immunity principle that is welcome. I've got a couple of additional comments that you might find interesting.

First, the science relevant to this virus is in its infancy. We both know that early epidemiological studies of most topics often show low replicability (i.e., due to retrospective designs, with small and/or unrepresentative samples, and differences in controlled variables, etc.). Consequently, the 'scientific knowledge' that informs early political judgements must be considered tentative rather than unequivocal. It's no wonder, therefore, that policy development that is reactive to scientific information twists and turns rather than follows a linear trajectory.

Second, you're fully aware of the difference between prevention of disease and alleviation of symptoms. Chloroquine is an inexpensive and accessible medication credited with both prevention and alleviation of viral illness. A clinical trial is also underway that examines Vitamin C for purposes of alleviation of CoronaVirus symptoms. I mention this because, after nearly for years of taking 1000mg of high absorption gellform Vitamin C, neither my wife nor I experienced cold or flue symptoms more severe than a day's worth of sniffles. Our experience of flue differs hugely from the usual symptomatology exhibited during this period by family members, friends and colleagues. Now this obviously isn't scientifically credible evidence. However, neither does it allow me to discount the possibility that massive Vitamin C dosages might alleviate symptoms associated with the new Pandemic.

Cheers, Mike
 

Dr Klaus Schmitt

Well-known member
Interesting approach by the British. They are keeping schools open with the idea that infection can spread amongst the young, thus increasing herd immunity.

It could be justified by good math. I wish they would publish the scientific thought behind this idea.

Asher

It is only "clever" insofar as the statistics will look much better, as the overall mortality rate will show much lower, as the younger have a much lower letality rate!!
And a clever politician will use that showing how great his "leadership" works!
 
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