The CDC recently relaxed recommendations for masks. It was waiting for the results of two studies before doing this. The studies showed that:
1. Vaccinated people rarely transmit the virus
2. The vaccines are effective against variants.
Those two confirmed facts mean it is safe for vaccinated people to remove masks.
See:
India just went all in with Ivermectin.
Not quite.all in .. Maybe soon.
but the evidence base is growing by the day
the next protocol should be interesting.... in June
the current recommendation for ivermectin is expressed as "low evidence based treatment"
the trunk of the elephant is flexible but the rest of the body takes a while to move..
but at least it is moving and not moribund or corrupted like other national agencies..
The 60-Year-Old Scientific Screwup That Helped Covid Kill
All pandemic long, scientists brawled over how the virus spreads. Droplets! No, aerosols! At the heart of the fight was a teensy error with huge consequences.
https://www.wired.com/story/th…hat-helped-covid-kill/amp
Marr is an aerosol scientist at Virginia Tech and one of the few in the world who also studies infectious diseases. To her, the new coronavirus looked as if it could hang in the air, infecting anyone who breathed in enough of it. For people indoors, that posed a considerable risk. But the WHO didn’t seem to have caught on. Just days before, the organization had tweeted “FACT: #COVID19 is NOT airborne.” That’s why Marr was skipping her usual morning workout to join 35 other aerosol scientists. They were trying to warn the WHO it was making a big mistake.
Over Zoom, they laid out the case. They ticked through a growing list of superspreading events in restaurants, call centers, cruise ships, and a choir rehearsal, instances where people got sick even when they were across the room from a contagious person. The incidents contradicted the WHO’s main safety guidelines of keeping 3 to 6 feet of distance between people and frequent handwashing. If SARS-CoV-2 traveled only in large droplets that immediately fell to the ground, as the WHO was saying, then wouldn’t the distancing and the handwashing have prevented such outbreaks? Infectious air was the more likely culprit, they argued. But the WHO’s experts appeared to be unmoved. If they were going to call Covid-19 airborne, they wanted more direct evidence—proof, which could take months to gather, that the virus was abundant in the air. Meanwhile, thousands of people were falling ill every day.
On the video call, tensions rose. At one point, Lidia Morawska, a revered atmospheric physicist who had arranged the meeting, tried to explain how far infectious particles of different sizes could potentially travel. One of the WHO experts abruptly cut her off, telling her she was wrong, Marr recalls. His rudeness shocked her. “You just don’t argue with Lidia about physics,” she says.
Morawska had spent more than two decades advising a different branch of the WHO on the impacts of air pollution. When it came to flecks of soot and ash belched out by smokestacks and tailpipes, the organization readily accepted the physics she was describing—that particles of many sizes can hang aloft, travel far, and be inhaled. Now, though, the WHO’s advisers seemed to be saying those same laws didn’t apply to virus-laced respiratory particles. To them, the word airborne only applied to particles smaller than 5 microns. Trapped in their group-specific jargon, the two camps on Zoom literally couldn’t understand one another.
When the call ended, Marr sat back heavily, feeling an old frustration coiling tighter in her body. She itched to go for a run, to pound it out footfall by footfall into the pavement. “It felt like they had already made up their minds and they were just entertaining us,” she recalls. Marr was no stranger to being ignored by members of the medical establishment. Often seen as an epistemic trespasser, she was used to persevering through skepticism and outright rejection. This time, however, so much more than her ego was at stake. The beginning of a global pandemic was a terrible time to get into a fight over words. But she had an inkling that the verbal sparring was a symptom of a bigger problem—that outdated science was underpinning public health policy. She had to get through to them. But first, she had to crack the mystery of why their communication was failing so badly.
According to the medical canon, nearly all respiratory infections transmit through coughs or sneezes: Whenever a sick person hacks, bacteria and viruses spray out like bullets from a gun, quickly falling and sticking to any surface within a blast radius of 3 to 6 feet. If these droplets alight on a nose or mouth (or on a hand that then touches the face), they can cause an infection. Only a few diseases were thought to break this droplet rule. Measles and tuberculosis transmit a different way; they’re described as “airborne.” Those pathogens travel inside aerosols, microscopic particles that can stay suspended for hours and travel longer distances. They can spread when contagious people simply breathe.
The distinction between droplet and airborne transmission has enormous consequences. To combat droplets, a leading precaution is to wash hands frequently with soap and water. To fight infectious aerosols, the air itself is the enemy. In hospitals, that means expensive isolation wards and N95 masks for all medical staff.
The books Marr flipped through drew the line between droplets and aerosols at 5 microns. A micron is a unit of measurement equal to one-millionth of a meter. By this definition, any infectious particle smaller than 5 microns in diameter is an aerosol; anything bigger is a droplet. The more she looked, the more she found that number. The WHO and the US Centers for Disease Control and Prevention also listed 5 microns as the fulcrum on which the droplet-aerosol dichotomy toggled.
There was just one literally tiny problem: “The physics of it is all wrong,” Marr says. That much seemed obvious to her from everything she knew about how things move through air. Reality is far messier, with particles much larger than 5 microns staying afloat and behaving like aerosols, depending on heat, humidity, and airspeed. “I’d see the wrong number over and over again, and I just found that disturbing,” she says. The error meant that the medical community had a distorted picture of how people might get sick.
Epidemiologists have long observed that most respiratory bugs require close contact to spread. Yet in that small space, a lot can happen. A sick person might cough droplets onto your face, emit small aerosols that you inhale, or shake your hand, which you then use to rub your nose. Any one of those mechanisms might transmit the virus. “Technically, it’s very hard to separate them and see which one is causing the infection,” Marr says. For long-distance infections, only the smallest particles could be to blame. Up close, though, particles of all sizes were in play. Yet, for decades, droplets were seen as the main culprit.
Marr decided to collect some data of her own. Installing air samplers in places such as day cares and airplanes, she frequently found the flu virus where the textbooks said it shouldn’t be—hiding in the air, most often in particles small enough to stay aloft for hours. And there was enough of it to make people sick.
In 2011, this should have been major news. Instead, the major medical journals rejected her manuscript. Even as she ran new experiments that added evidence to the idea that influenza was infecting people via aerosols, only one niche publisher, The Journal of the Royal Society Interface, was consistently receptive to her work. In the siloed world of academia, aerosols had always been the domain of engineers and physicists, and pathogens purely a medical concern; Marr was one of the rare people who tried to straddle the divide. “I was definitely fringe,” she says.
Thinking it might help her overcome this resistance, she’d try from time to time to figure out where the flawed 5-micron figure had come from. But she always got stuck. The medical textbooks simply stated it as fact, without a citation, as if it were pulled from the air itself. Eventually she got tired of trying, her research and life moved on, and the 5-micron mystery faded into the background. Until, that is, December 2019, when a paper crossed her desk from the lab of Yuguo Li.
Story continues
Pfizer vaccines for USA teens criticized by Kenyan medical expert Kalebi and WHO head.
"
The US Centers for Disease Control and Prevention (CDC) has recommended expanded usage of Pfizer-BioNtech Covid-19 vaccine for 12- to 15-year-olds after the Food and Drug Administration granted emergency use authorisation. Kalebi said that vaccination of teenagers “makes no sense” when vulnerable groups and potential superspreaders across the world haven’t been inoculated.
“These are likely the breeding grounds for new super variants. It is a global village.
None of us is safe until all of us are safe,” he warned.
The World Health Organization (WHO) has also criticised the vaccination strategy of rich nations,
saying the world is witnessing “moral catastrophe”.
During a press briefing on Friday, WHO director-general Tedros Adhanom Ghebreyesus highlighted that vaccine supply in lower- and lower-middle-income countries has not been enough to vaccinate even their health care workers.
Moral catastrophe? What about ivermectin?
Who profits by vaccinating US teens?
Marr decided to collect some data of her own. Installing air samplers in places such as day cares and airplanes, she frequently found the flu virus where the textbooks said it shouldn’t be—hiding in the air, most often in particles small enough to stay aloft for hours. And there was enough of it to make people sick.
This has been done already a year ago in Germany and a few months later in China.
Only the FM/R/J/B mafia recommends to wear masks outdoors as a sign people are ready to follow their fascists orders.
CoV-19 spreads as aerosols nothing else and the funny surgical mask only say that people that mount them are idiots or do it just to be able to go to the gym...But certainly not to protect themselves!
The US Centers for Disease Control and Prevention (CDC) has recommended expanded usage of Pfizer-BioNtech Covid-19 vaccine for 12- to 15-year-olds after the Food and Drug Administration granted emergency use authorisation.
The Pfizer vaccine contains at least 30% unknown crap RNA. Do you really want to damage your kid with unknown RNA. How many criminal parents live in the USA, world wide??
Just to mention so far Zero = 0 death among people younger 30. May be the USA counts some marrow replacement cases as CoV-19 deaths...As hospitals get a bonus for such...
https://www.worldometers.info/coronavirus/country/zimbabwe/
Zimbabwe runs much better than Israel with no vaccines and only ivermectin!
But I'm sure JED will still want to sell them vaccines...
Also Slovakia and Portugal are on track with Ivermectin.
Portugal just has been awarded with the Football final of the European Champions League thanks to Ivermectin!
India:
Goa: https://www.firstpost.com/heal…need-to-know-9611751.html
Here the India FM/R criminals site that spreads all the FUD about Ivermectin with using 6 studies that are not related to what is discussed: https://indiacovidguidelines.org/ivermectin/
Philippines:
https://trialsitenews.com/phil…n-off-label-for-covid-19/
One more overview page: https://www.ivermectine.nu/en-gb
Saturday Night Live mocks Fauci and the CDC
https://reader.elsevier.com/re…inCreation=20210516123219
Still as usual: Pfizer's BNT162b2 performs worst against most mutations...
Among people who received two full doses of BNT162b2, themean fold decrease in neutralization relative to wild type was2.1-fold for B.1.1.7, 1.4-fold for B.1.1.298, and 2.0-fold forB.1.429 (Figures 4C andS4A); for those who received two fulldoses of mRNA-1273, the mean fold decrease in neutralizationrelative to wild type was 2.3-fold for B.1.1.7, 1.3-fold forB.1.1.298, and 2.0-fold for B.1.429 (Figures 4D andS4A). How-ever, neutralization of the Brazilian/Japanese P.2 variant, whoseRBD contains an E484K mutation, was significantly decreased(5.8-fold for BNT162b2, p < 0.001; 2.9-fold for mRNA-1273,p < 0.01) (Figures 4C–4D andS4A). This is in line with previousstudies suggesting that the E484K mutation can evade poly-clonal antibody responses (Greaney et al., 2021a;Jangra et al.,2021) and has been found in cases of SARS-CoV-2 reinfection(Paiva et al., 2020;Faria et al., 2021;Resende et al., 2021;Na-veca et al., 2021;Vasques Nonaka et al., 2021). Similarly,neutralizing antibody responses were also significantlydecreased for the Brazilian/Japanese P.1 strain (6.7-fold forBNT162b2, p < 0.0001; 4.5-fold for mRNA-1273, p < 0.001),
Absolute warning for RSA mutation:
Strikingly, neutralization of all three South African B.1.351strains was substantially decreased for both two-dose vaccines(v1: 34.5-fold for BNT162b2 and 27.7-fold for mRNA-1273; v2:41.2-fold for BNT162b2 and 20.8-fold for mRNA-1273; v3:42.4-fold for BNT162b2 and 19.2-fold for mRNA-1273; p <0.0001 for all comparisons) (Figures 4C–4D andS4A).
Power grabs under the guise of Covid!
European leaders seized more power during the pandemic. Few have 'exit plans' to hand it back
https://amp.cnn.com/cnn/2021/0…covid-intl-cmd/index.html
London and Paris(CNN)Hundreds of thousands of people have lost their lives across Europe due to Covid-19, and many more have suffered long-term ill health after contracting the disease. They're not the only casualties of the pandemic.
Democratic norms have also been seriously dented by a year of restrictions, and experts now fear power-hungry politicians could be reluctant to give up their near-total authority once the crisis is over.
In France, for instance, parliament approved a bill earlier this week that extends the country's state of emergency until late September. The bill allows President Emmanuel Macron to introduce a health pass, showing whether someone has been vaccinated against Covid-19 or not, as well as curfews across the nation.
The move was seen as controversial by some of Macron's liberal allies: after all, instructing your citizens to be home by a certain time and tracking their medical information is hardly consistent with France's liberal traditions.
Over the course of his presidency, Macron has been accused of drifting from the centrist liberal platform on which he was elected in 2017, most notably taking a harder line on Islam and immigration to compete with his top political rival, the far-right Marine Le Pen.
It wasn't long ago that the French president was extolling the values of democracy. Speaking to the US Congress in 2018, he paid tribute to the "sanctuary of democracy" he was addressing and reminded the world of the words "emblazoned on the flags of the French revolutionaries, 'Vivre libre ou mourir.' Live free or die." Ironic, given the president's apparent eagerness to boss his citizens around to stop the spread of a deadly virus.
Macron's loosening relationship with democracy doesn't stop at tracking who's been injected and forcing people indoors. Throughout the pandemic, the president has reduced the role that his parliament plays in scrutinizing his policy announcements.
"Parliament's role in France is more limited under the new state of health emergency than before," said Joelle Grogan, senior lecturer in UK public and EU law at the University of Middlesex. "There is no obligation for governments and administrations to send copies of orders they adopt to parliament."
Democracy Reporting International (DRI) recently published a comprehensive study on how governments across the European Union had responded in the context of democracy and the rule of law. France was listed as a country of "significant concern" for the extent to which its government has subverted legal norms.
France is not the only EU nation that has backslid on democracy.
In Austria, Slovenia, Belgium and Lithuania to name a few, there is serious concern that governments have misused existing laws to restrict the liberty of citizens. In fact, DRI listed only Spain out of the 27 EU member states as a country of "no concern" when it came to parliamentary or legal oversight of Covid measures.
The most egregious example probably comes from Hungary, where the government passed legislation that allowed it to rule by decree with no judicial review.
Courts in Cyprus and the Czech Republic claimed to have no jurisdiction over coronavirus measures. This significantly reduced moves to safeguard any attempted government overreach.
A central concern of DRI's report is that few European countries have a clear "exit plan" for ending states of emergency and returning to normal ways of governance.
This is a real concern in the case of France. Phillippe Marlière, professor of French and European politics at University College London, notes that in recent years, France has introduced numerous states of emergency in response to terror attacks. Many of the measures introduced at these times concerning personal liberty have remained in place.
I would bet that a lot of the illiberal measures that have come in under Covid, like the health pass and threats of curfews will remain in place or be seen again," he said. "Politicians are very good at taking authority but less good at handing it back."
There is particular concern among some that Macron, who is facing election next year, might see keeping a tight grip on power as advantageous.
"The French president has more power on paper than the American [resident. He can control the police, the army, all domestic policy, all foreign policy. He even appoints his own prime minister," said Marlière. "This, combined with someone seeking re-election who is already shifting to the right on issues like Islam with no real oversight is very concerning."
More worryingly, the DRI report also states that only five EU member states -- the Czech Republic, France, Lithuania, the Netherlands and Portugal -- have adequate exit strategies for a return to normal.
"It's far easier to govern by decree than to govern within limits, so it's obvious why leaders would want to hang onto powers," said Grogan, who also noted that undermining the rule of law has been a problem within the EU for some time.
In recent years, Hungary and Poland had both abused the rule of law to such an extent that article 7 of the EU's treaty, which, if approved by all member states, would restrict both nations' voting rights with the EU and restrict access to EU money, has been triggered against both.
The problem is that both Hungary and Poland are able to veto actions against the other, rendering the EU somewhat toothless. "What happens next is the big problem. We can talk about legal mechanisms and the laws. But ultimately we need political consensus," Grogan adds.
Last summer, Brussels tried to force Hungary and Poland to fall in line though a mechanism in the EU's long-term budget, but ultimately choked at the last minute and agreed a fudge in order to get the bloc's Covid recovery funds approved.
That was two member states. What happens when it's many more is a real unknown for the EU.
"Fundamentally, the EU is a legal structure. It exists to obligate mutual rights between states and citizens," said Grogan. "But it would be remiss to ignore the complexity beyond that. As Brexit proved it is a group of states deciding to be part of the club. Brexit showed us you can leave, but the problem is if someone doesn't accept the values and doesn't want to leave, it is legally impossible to remove a state."
Where this ends is anyone's guess. The EU is unlikely to fall apart, as many have predicted, but it is possible that Euroskeptics across the bloc can force changes that undermine the whole thing. And if you were looking for a way to destabilize the EU, making a mockery of the rule of law would be a good place to start.
"We're seeing, as usual with emergencies, a shift of power towards the executive with oversight from parliaments, judiciary and other bodies getting weaker," said Jakub Jaraczewski, research coordinator at DRI
The EU could work towards better legal oversight -- be it through the Commission, the Fundamental Rights Agency or even through the Court of Justice. But that would require political will from the leadership in member states for the central EU to take control of policy areas they prefer to keep close to their chests."
It's sometimes said that EU law is a complicated mess of narrow political interests dressed in a legal cloak. Those narrow political interests have had a greater impact on the bloc's direction of travel than the ideals that supposedly unite 27 vastly different nations.
For the best part of a decade, member states bickering over precisely what Europe should be and how it should respond to crises has been the hardest thing for the EU to navigate. The disregard for law, however, is a more fundamental headache than disagreements on migration or how money should be spent.
When politics returns to something resembling normal, Brussels might find itself with more than just Poland and Hungary on the naughty step. And if these recent delinquents decide that their newfound powers matter more to them than keeping their EU neighbors happy, there is very little that EU grandees can do to stop the fallout destabilizing the whole bloc.
Young Covid-19 patients under 10 may need short but intensive care’
https://www.koreabiomed.com/ne…icleView.html?idxno=11160
A joint group of researchers has found that children and adolescents infected by Covid-19 generally undergo shorter hospitalization than adults. Still, those aged nine or less are likelier to stay in intensive care units (ICU).
The joint research team of Kyung Hee University College of Medicine, Hanyang University Hospital for Rheumatic Diseases, and Korea University Guro Hospital discovered that the length of hospital stay (LOS) was shortest in patients aged between 10 and 19, recording an average of 22.4 days.
Those above 80 had to stay in hospital for 34.2 days, while patients in their 30s were hospitalized for 22.6 days.
Children with Covid-19 aged nine or less showed a similar LOS of 26.2 days to those in their 60s who received treatment for 26 days. Children aged 0 to 9 years also showed 90 percent hospital admission rates, even higher than the 87.2 percent recorded in the older populations aged between 60 and 69, the research team said.
The research results come as the education ministry moves to return to full-scale offline classes from the second semester.
According to the Korea Disease Control and Prevention Agency, 11.4 percent of 133,380 cumulative caseloads confirmed as of midnight Thursday were under 20 years of age.
Those aged 10-19 years showed the lowest hospitalization rate with 67.2 percent and the lowest ICU admission rate of 6.3 percent.
About 96 percent of Koreans over 70 had to stay in hospital for treatment, while children under 10 showed the highest ICU admission and hospitalization rate among patients under 50.
“As the possibility to develop severe infection of coronavirus in patients aged between 10 and 19 is the lowest, a mitigation policy is also required for middle and high school students. However, children with underlying diseases should not be exposed to high-risk infection environments,” researchers said in conclusion.
The study was based on a survey of 7,969 Koreans with Covid-19 infected between Jan. 1 and May 30 last year. It was published in the Journal of Korean Medical Science on May 12.
The union also criticized the CDC for other things, including its decision to stop tallying infections among those who have been vaccinated unless they result in hospitalization or death. That information is necessary “to understand whether vaccines prevent asymptomatic/mild infections, how long vaccine protection may last, and to understand how variants impact vaccine protection,” the union said.
Largest Nurses’ Union Condemns New CDC Guidance on Masks: “Not Based on Science”
https://slate.com/news-and-pol…ns-cdc-guidance-masks.amp
The country’s largest union of registered nurses is not happy with the Centers for Disease Control and Prevention. National Nurses United has condemned the CDC for its new guidance that says vaccinated people don’t have to wear masks in most settings and has called for a reversal. “This newest CDC guidance is not based on science, does not protect public health, and threatens the lives of patients, nurses, and other frontline workers across the country,” National Nurses United Executive Director Bonnie Castillo said in a statement. “Now is not the time to relax protective measures, and we are outraged that the CDC has done just that while we are still in the midst of the deadliest pandemic in a century.”
In addition to hurting nurses and other frontline workers, the new guidance will also disproportionately affect people of color, the union said. “There has been so much inequity in the vaccine rollout and racial inequity in who is a frontline worker put most at risk by this guidance. The impact of the CDC’s guidance update will be felt disproportionately by workers of color and their families and communities,” NNU President Zenei Triunfo-Cortez said.
Although vaccination is important, it is hardly the only thing necessary to control the spread of COVID-19. “This is a huge blow to our efforts at confronting this virus and the pandemic,” Castillo said. “The mask is another lifesaving layer of protection for workers.” Jean Ross, who is also a president of NNU said that “if the CDC had fully recognized the science on how this deadly virus is transmitted, this new guidance would never have been issued.” The union, which represents some 170,000 nurses across the United States, pointed out that more than 35,000 new COVID-19 infections are detected daily, more than 600 people die every day from the virus, and there is increasing concern about variants “that are more transmissible, deadlier, and may already be or may become vaccine resistant.”
The union also criticized the CDC for other things, including its decision to stop tallying infections among those who have been vaccinated unless they result in hospitalization or death. That information is necessary “to understand whether vaccines prevent asymptomatic/mild infections, how long vaccine protection may last, and to understand how variants impact vaccine protection,” the union said.
The criticism from the union comes shortly after the CDC on Thursday surprised Americans with new recommendations saying that vaccinated people could go maskless in most settings. It based its recommendation on studies that found few vaccinated people become infected and the vaccines appear to be effective against all variants that are present in the United States. The CDC said the new recommendations don’t apply to health care facilities, public transportation, and other types of facilities, including homeless shelters and prisons. On Saturday, the CDC said schools should still universally require masks through the end of the school year. All schools teaching students from kindergarten through grade 12 “should implement and layer prevention strategies and should prioritize universal and correct use of masks and physical distancing,” the CDC said.
The union also criticized the CDC for other things, including its decision to stop tallying infections among those who have been vaccinated unless they result in hospitalization or death.
If the union said this, they are confused. The CDC will continue to tally all infections, vaccinated, unvaccinated, light or severe. They will no longer do an intense investigation of breakthrough cases that result in a light illness not requiring hospitalization, but they will tally any case reported by a doctor or patient. They will -- of course! -- review any breakthrough case that results in hospitalization or death. Such cases are extremely rare.
It takes a lot of effort to do an intense review of a case, so this seems like a sensible policy to me. All breakthrough cases will still be categorized (coded for a computer search) and available for review. They will be reviewed by the AI tools that examine the database automatically. So, if a pattern emerges we will know. If a researcher anywhere in the world wants to take a closer look at the breakthrough cases, the data will all be there, ready to be examined.
The CDC VAERS database accepts any report from anyone, no matter how far fetched. Years ago a doctor submitted a report claiming that vaccination turned him into the Hulk comic book character. The report was uploaded and I gather it is still there.
Young Covid-19 patients under 10 may need short but intensive care’
From what I have read, children are as susceptible to infection as any age group. Fortunately, they seldom have a severe case.
Our neighbor's newborn baby got COVID-19, as did both parents. They had mild cases and they are all fine, thank goodness.
The US Centers for Disease Control and Prevention (CDC) has recommended expanded usage of Pfizer-BioNtech Covid-19 vaccine for 12- to 15-year-olds after the Food and Drug Administration granted emergency use authorisation. Kalebi said that vaccination of teenagers “makes no sense” when vulnerable groups and potential superspreaders across the world haven’t been inoculated.
I do not understand this. Children and 15-year-olds are as likely to spread the disease as anyone else. They are just as likely to be superspreaders as anyone. Maybe more likely, since their cases are often mild and they are out and about, and in schools. To achieve herd immunity, we must vaccinate 15-year-olds. Especially in Georgia where only half of adults say they will be vaccinated.
Vaccinating first-world 15-year-olds should not delay vaccinating people in the third world. Vaccine production is ramping up quickly. If it is not quick enough, first-world governments should get together to fund an emergency increase. The whole world needs to be vaccinated as quickly as possible.
Recurrence of Upper Extremity Deep Vein Thrombosis Secondary to COVID-19
Rutgers researchers report 1st instance of COVID-19 triggering recurrent blood clots in arms
https://www.mdpi.com/1999-4915/13/5/878/htm
Abstract
Infection with SARS-CoV-2 leading to COVID-19 induces hyperinflammatory and hypercoagulable states, resulting in arterial and venous thromboembolic events. Deep vein thrombosis (DVT) has been well reported in COVID-19 patients. While most DVTs occur in a lower extremity, involvement of the upper extremity is uncommon. In this report, we describe the first reported patient with an upper extremity DVT recurrence secondary to COVID-19 infection
Introduction
The COVID-19 pandemic, due to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has had worldwide consequences [1]. The clinical and pathological features of the infection are gradually becoming better understood [2]. While COVID-19 infects the respiratory tract and presents as pneumonia in most patients, others also suffer from severe neurological, cardiovascular, and/or gastrointestinal complications due to hyperinflammatory and hypercoagulable states [3,4,5,6]. Coagulation disorders have been noted in 23–49% of COVID-19 patients regardless of the use of heparin or low-molecular-weight heparin [7]. Arterial and venous thromboembolic events are more common than bleeding disorders, with the highest rates described in ICU settings [8,9,10,11,12]. COVID-19 hospitalized patients have had much higher DVT rates (31% in one New York study) than in hospitalized patients without COVID-19 (19%) [13].
Most DVTs occur in the lower extremities (LEDVT), due to increased gravitational stress and decreased endothelial fibrinolytic activity compared to upper extremity veins [14]. Only 4–10% of DVTs occur in the upper extremities (UEDVT), which may be primary (20%) or secondary (80%) [15,16,17]. Primary UEDVTs, identified as two events per 100,000 patients, are either idiopathic or due to effort-induced injuries or anatomical variation, like Paget–Schroetter syndrome or cervical rib [16,17,18,19]. Secondary UEDVTs may be caused by malignancy or, more commonly, by intravenous catheters or pacemaker wires, especially after their insertion [16,17,18,19,20].
Although UEDVT incidence is low, severe complications include pulmonary embolism, post-thrombotic syndrome, and death. Pulmonary embolism (PE) may occur in up to 30% of patients following a UEDVT and may be fatal [15,17]. The mortality rate in patients with UEDVT varies from 15–50%, chiefly related to underlying conditions including malignancy, infection, or organ failure [15,17]. Another disabling complication, post-thrombotic syndrome, presents as swelling, pain, and limb fatigue with exertion in 27–50% of UEDVT patients [17]. UEDVTs recur in 9% of patients, usually in the ipsilateral extremity, whereas LEDVT recurrence may reach 97% [16,21].
While both UEDVTs and LEDVTs secondary to COVID-19 infection have been reported [22,23], there is little information on COVID-19 as a risk factor for recurrent UEDVT and how to optimize management. We present the case of an 85-year-old patient, who to our knowledge, was the first to develop recurrent UEDVT as the presenting sign of an asymptomatic COVID-19 infection.
2. Materials and Methods
Written consent by the patient was obtained to receive medical records from the 2017 and 2020 hospitalizations for UEDVT.
3. Case Presentation
At age 81, the patient was diagnosed with his first episode of UEDVT in 2017. His past medical history is significant for long-standing hypertension, hypercholesterolemia, type 2 diabetes mellitus, and coronary artery disease post-myocardial infarction with residual severe ischemic cardiomyopathy. He has no prior personal or family history of clotting or bleeding disorders. He has a 15-pack-year tobacco smoking history, quitting at age 29, and denies illicit drug use. Until his cardiac symptoms worsened, he had an active lifestyle of bicycling and playing tennis weekly.
In November 2016, he underwent a biventricular pacemaker upgrade without significant post-procedure complications. Following the pacemaker manipulation, he was instructed to have limited upper extremity movement for 6 weeks, and then resumed playing tennis. While playing tennis, 42 days post-procedure, the patient noted new, left upper extremity swelling from the top of his wrist to his shoulder, which lasted for 4 days. Upon presentation to the ER, on physical exam he had 2+ nonpitting edema from the left hand to the upper arm with mild tenderness, but without phlegmasia or erythema. His right upper extremity had no edema but he had trace nonpitting edema around the ankles bilaterally with prominent venous pattern. He was not having acute distress or labored respiration on room air and his chest was clear to auscultation bilaterally. Portable chest X-ray revealed cardiomegaly with vascular congestion and interstitial densities. On admission, laboratory results (Table 1) were significant for normal PT, INR, and aPTT, but decreased platelet and white and red blood cell counts. Venous duplex ultrasound showed left axillary and brachial vein UEDVTs, but the left subclavian vein could not be adequately visualized due to the presence of a left-sided pacemaker. The UEDVT was considered secondary to subclavian vein trauma from the left-sided pacemaker placement 42 days previously.
Table 1. Significant laboratory values from the 2017 and 2020 hospital admissions.
Table
To treat this DVT, he received one dose of enoxaparin in the emergency department. On hospital admission day 2, his medical team continued his enoxaparin and home aspirin (325 mg daily) but stopped his home clopidogrel (75 mg daily). Interventional radiology consultation recommended anticoagulation treatment and monitoring of the symptoms, without the need for urgent thrombolysis or thrombectomy. He was transitioned to apixaban (5 mg BID) on hospital admission day three, which he then took for the next 8 months. He ultimately underwent a thrombectomy and angioplasty on 13 February 2017. Following the anticoagulation regimen, the patient’s left arm returned to normal and he did not experience any residual symptoms or complications. He remained physically active and continued playing tennis three times a week.
In November 2020, 4 years after his prior episode, the patient sought attention from his primary care physician for new, left arm swelling. He had noted the swelling for 7 days, without pain or erythema, shortness of breath, or chest pain. His home medications were significant for 81 mg of aspirin daily. Venous duplex ultrasonography showed left proximal and mid-brachial vein UEDVT. He was admitted to the hospital for further management. On physical exam, he had left forearm and hand edema that did not extend into his upper arm. Superficial veins were seen in the supraclavicular and infraclavicular region with normal left arm motor and sensation function. Right upper extremity and bilateral lower extremities were without edema. On admission, laboratory results (Table 1) showed slightly elevated PT, INR, and aPTT but decreased platelet and white and red blood cell counts. As part of routine hospital protocol for all admitted patients, he was tested for SARS CoV-2 by PCR of a nasopharyngeal PCR swab.
He was diagnosed with recurrent UEDVT, and a vascular surgery consultant recommended anticoagulation via heparin infusion and left arm elevation with ACETM bandage wrapping since the patient’s central veins were patent. He was admitted to the hospital and discharged the next day to receive apixaban, 10 mg BID for 1 week, followed by 5 mg BID lifelong treatment barring any bleeding episodes. His COVID-19 test was found to be positive after discharge from the hospital and he self-quarantined for 10 days. Aside from the UEDVT, the patient was asymptomatic for COVID-19. While his first UEDVT episode in 2017 was uncomplicated with no sequela, this recurrent UEDVT event was complicated by continued post-thrombotic syndrome, with limited ability to flex at the elbow, 5 months after the UEDVT recurrence.
4. Discussion
UEDVTs are uncommon, accounting for 4–10% of all venous thromboembolic events (VTE); 5–42% of UEDVTs occur in the axillary veins compared to the 4–13% in brachial veins [17]. According to a study by Joffe et al., insertion of a central venous catheter was associated with a 7-fold increase in the odds of developing a UEDVT [24]. The risk factors associated with UEDVT and LEDVT were not the same, providing a rationale for differential treatment and prophylaxis regimens. Of patients with pacemaker or internal cardiac defibrillator insertion who developed thrombosis, 59% of thrombotic events occurred within 3 months post-implantation [25]. Our patient’s left axillary and brachial vein UEDVT in 2017 occurred within 42 days after his left-sided pacemaker implantation. Prolonged stasis after pacemaker implantation and effort-induced tennis injury likely also contributed to the thrombotic process. Since the patient’s pacemaker provides a persistent risk factor for UEDVT [25], he would have benefited from long-term, oral anticoagulant treatment after the 8-month course of apixaban following his first UEDVT episode.
Only 2.4% of patients with a history of UEDVT, who account for 4–10% of all VTEs, have a recurring episode, predisposing them to future recurrences; recurrent UEDVT is an extremely uncommon event [16,17,26,27]. Furthermore, there have been no prior reports of UEDVT in an asymptomatic COVID-19 patient. Most patients develop a UEDVT recurrence in their ipsilateral arm, as did our patient [27]. The strongest risk factors for UEDVT recurrence include thrombophilia due to genetic mutations, including factor V Leiden, protein C, protein S deficiency, and hyperhomocysteinemia, as well as strenuous upper extremity muscle effort [27]. Our patient has not been tested for genetic mutations in his coagulation cascade but was an avid tennis player throughout his life, until age 83, 2 years prior to his recurrence, making mutation unlikely to be the etiology of UEDVT recurrence.
Of 115 UEDVT patients studied by Martinelli et al., after 6 months of oral anticoagulation therapy or 3 months of either subcutaneous heparin or antiplatelet agents, 34% had a residual vein thrombosis [27]. The authors further reported that the rates of developing UEDVT recurrence in patients with incomplete recanalization and those with complete recanalization were not significantly different [27]. One study demonstrated the rate of recanalization of thrombosed vein of the upper limb using a catheter-directed thrombolysis (CDT) or pharmacomechanical thrombolysis (PMT) using a phlebography or ultrasound immediately after and 1 year after the procedure [28]. The CDT group’s immediate success rate was 91.7% compared to 100% in the PMT group, while the 1-year vein patency rate was 91.7% in the CDT group versus 94.7% in the PMT group [28]. Since our patient underwent a thrombectomy and angioplasty of his UEDVT 1 month after his diagnosis, it is less likely that his UEDVT recurrence 4 years later was due to incomplete recanalization of the left axillary and brachial vein.
An important area of research has been the relationship between COVID-19 and thrombosis. The risk of thrombosis reflects Virchow triad of endothelial injury, stasis, and a hypercoagulable state [29]. Endothelial injury occurs when the virus invades endothelial cells via ACE2 receptors, activating the renin-angiotensin system, increasing angiotensin II levels [29]. This induces expression of tissue factor and plasminogen activator inhibitor 1, favoring coagulation [29,30]. Endothelial injury is enhanced by release of inflammatory cytokines, acute phase reactants, and complement pathway activation, as well as intravascular catheter insertion [29]. Finally, the COVID-19-induced hypercoagulable state, due to increased early thrombin burst, increased fibrin generation, greater clot strength, and reduced fibrinolysis, following elevated levels of prothrombotic factors like D-dimer, fibrinogen, factor VIII, and anionic phospholipids [29]. Because of the increased thrombosis risk, COVID-19 patients should have complete blood count (CBC), PT, aPTT, fibrinogen, and D-dimer assays obtained on hospital admission [29].
Although our patient did not have a D-dimer test, his laboratory values were significant for slightly elevated PT, INR, and aPTT during the UEDVT recurrence in 2020 (Table 1), despite their normal levels during the 2017 UEDVT event. The patient also had anemia, thrombocytopenia, and neutropenia during both UEDVT episodes. He has a history of thrombocytopenia since 2011. Further workup in 2017 revealed elevated immature platelet fraction indicating peripheral platelet destruction. We presume that the hypercoagulable state of COVID-19 led to an UEDVT recurrence despite thrombocytopenia.
The incidence of LEDVT in hospitalized COVID-19 patients also has been an area of increased concern. Among COVID-19 patients in Wuhan, China, the incidence of LEDVT was 35.2%, of whom 90% were admitted to the intensive care unit (ICU), indicating severity of illness as an important correlate [31]. In another Wuhan study, compared to non-LEDVT patients, LEDVT patients were more likely to be >65 years old and with lower oxygenation status, increased leg pain, and greater extent of stasis due to being bed-ridden and COVID-19 illness severity [32]. Among non-ICU COVID-19 patients in Rome, Italy, the incidence of LEDVT diagnosed by venous compression ultrasonography ~6 days after hospitalization was 11.9% [33]. This demonstrates that the hypercoagulable state induced by COVID-19 can occur despite thromboprophylaxis, with COVID-19 serving as an independent risk factor for DVT in hospitalized patients [32,33]. There was no significant difference among patients with DVT and those without, with regard to patient comorbidities, including obesity, hypertension, type 2 diabetes mellitus, and coronary artery disease, or demographic factors like age or sex [33]. Avruscio et al. found that DVTs occurred in 42.4% of hospitalized patients with COVID-19, with 25% of those DVTs occurring in the upper extremities. The risk of VTE was five times higher in patients with COVID-19 than those without [34]. All the COVID-19 patients received prophylactic or high-dose anti-coagulation. This patient did not receive the anti-coagulation expected for someone with his health history and COVID-19 infection, perhaps because he was otherwise asymptomatic.
LEDVTs recur ~20% of the time [35]. Risk factors for recurrence include smoking, age >65 years old, idiopathic initial LEDVT, discontinuation of anticoagulation therapy, and patient comorbidities, like diabetes mellitus, dyslipidemia, obesity, and malignancy [35,36]. Ipsilateral recurrence is associated with increased risk of post-thrombotic syndrome [36]. While the incidence of LEDVT recurrence secondary to COVID-19 is unknown, in one prospective Spanish study examining long-term (>90 days) outcomes in COVID-19 patients diagnosed with VTE, there were no VTE recurrences [37].
Only a few UEDVTs secondary to COVID-19 infection have been reported [21,22,34]. Patients with COVID-19 who have illness sufficiently severe to require continuous positive airway pressure therapy can have induction of UEDVT by compression of the superficial or deep veins of the upper extremities [21,22]. In another study determining the incidence of VTE in COVID-19 patients admitted to the medical wards versus the ICU, all 9 patients who had a UEDVT were admitted to the ICU [34]. Unlike those patients, our patient was found to be COVID-19 positive after seeking medical attention for his left arm swelling. That our patient did not need supplemental oxygen during his overnight hospital stay demonstrates that patients may have increased thrombosis risk regardless of COVID-19 illness severity. Furthermore, COVID-19 patients who are otherwise asymptomatic who present with VTE may represent a coagulation diathesis that differs from patients with increased disease severity requiring supplemental oxygenation or ICU level of care.
The current guidelines for UEDVT treatment parallel the initial treatment protocol for LEDVT, which includes unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) followed by 3 to 6 months of maintenance therapy [14]. Direct oral anticoagulants (DOAC) like rivaroxaban or apixaban, which were prescribed for this patient, can also be used for initial treatment [14]. While prophylaxis of LEDVT recurrence is usually highly effective, UEDVT recurrences are not easily prevented [14]. While there are no published recommendations for UEDVT secondary to COVID-19, for COVID-19 patients diagnosed with proximal DVT or PE a minimum of 3-month anticoagulation therapy has been recommended [35]. Moores et al. recommend the standard dose of anticoagulant thromboprophylaxis given parentally for acutely ill patients admitted to the hospital, and mechanical prophylaxis as well. For outpatient COVID-positive patients, the authors recommend apixaban, dabigatran, rivaroxaban or edoxaban therapy for at least 3 months [38]. In COVID-19 patients with recurrent VTE despite anticoagulation therapy, increasing the weight-adjusted LMWH dose by 25–30% appears beneficial [35]. Further investigation into specific treatment and prophylaxis protocols for UEDVT, as well as UEDVT secondary to COVID-19 infection, is needed.
5. Conclusions
We described the first case of recurrent UEDVT as the presentation of an otherwise asymptomatic SARS-CoV-2 infection. During these pandemic times, we recommend considering SARS-CoV-2 infection as the etiology of venous thromboembolic events whether in the presence or absence of characteristic COVID-19 symptoms. With insufficient knowledge of prophylactic strategies for UEDVT patients, further investigation is needed to determine optimal approaches for treating and preventing UEDVT recurrence during the COVID-19 pandemic and beyond.
From what I have read, children are as susceptible to infection as any age group. Fortunately, they seldom have a severe case.
From https://www.nature.com/articles/d41586-020-02973-3
Young children transmit less
Researchers suspect that one reason schools have not become COVID-19 hot spots is that children — especially those under the age of 12–14 — are less susceptible to infection than adults, according to a meta-analysis4 of prevalence studies. And once they are infected, young children, including those aged 0–5 years, are less likely to pass the virus on to others, says Haas. In an analysis5 of German schools, Haas’s team found that infections were less common in children aged 6–10 years than in older children and adults working at the schools.
Eric Clapton Blames ‘Propaganda’ for ‘Disastrous’ Covid Vaccine Experience
“My hands and feet were either frozen, numb or burning, and pretty much useless for two weeks,” guitarist writes of reaction to vaccine. “I feared I would never play again”
https://www.rollingstone.com/m…e-propaganda-1170264/amp/
Eric Clapton detailed his “disastrous” health experience after receiving the Covid-19 vaccine and blamed “the propaganda” for overstating the safety of the vaccine in a letter the guitarist shared with an architect/anti-lockdown activist.
Clapton previously shared his thoughts on the Covid-19 shutdown when he appeared on Van Morrison’s anti-lockdown song “Stand and Deliver” in December 2020; two months later, in February, Clapton received his first of two AstraZeneca vaccinations, he wrote in his letter to Robin Monotti Graziadei, who shared the letter on his Telegram with the guitarist’s permission. (Rolling Stone has confirmed the authenticity of the letter. A rep for Clapton did not immediately respond to a request for comment.
“I took the first jab of AZ and straight away had severe reactions which lasted ten days. I recovered eventually and was told it would be twelve weeks before the second one…,” Clapton wrote.
“About six weeks later I was offered and took the second AZ shot, but with a little more knowledge of the dangers. Needless to say the reactions were disastrous, my hands and feet were either frozen, numb or burning, and pretty much useless for two weeks, I feared I would never play again, (I suffer with peripheral neuropathy and should never have gone near the needle.) But the propaganda said the vaccine was safe for everyone…”
In the letter, Clapton also discussed discovering “heroes” like anti-lockdown U.K. politician Desmond Swayne as well as similarly-minded (and some would argue conspiratorial) YouTube channels.
“I continue to tread the path of passive rebellion and try to tow the line in order to be able to actively love my family, but it’s hard to bite my tongue with what I now know,” Clapton wrote.
“Then I was directed to Van [Morrison]; that’s when I found my voice, and even though I was singing his words, they echoed in my heart,” Clapton wrote. “I recorded ‘Stand and Deliver’ in 2020, and was immediately regaled with contempt and scorn.”
Last December, Clapton said in a statement that accompanied “Stand and Deliver,” “There are many of us who support Van and his endeavors to save live music; he is an inspiration. We must stand up and be counted because we need to find a way out of this mess. The alternative is not worth thinking about. Live music might never recover.” (On a similar note, Clapton allegedly lent a van to a British band that continues to perform live music throughout the U.K. as a protest against lockdown measures.)
Clapton also revealed in his letter that he performs on Morrison’s “Where Have All the Rebels Gone?,” a track off Latest Record Project Vol. 1, the Irish singer’s “darkly strange and delightfully terrible” new album, as Rolling Stone called it. (Clapton mistakenly calls the track “The Rebels” in his letter.)
“It’s not aggressive or provocative, it just asks ‘Where have all the rebels gone? Hiding behind their computer screens. Where’s the spirit, where is the soul. Where have all the rebels gone,’” Clapton wrote.
“I’ve been a rebel all my life, against tyranny and arrogant authority, which is what we have now,” Clapton wrote. “But I also crave fellowship, compassion and love… I believe with these things we can prevail.”
From https://www.nature.com/articles/d41586-020-02973-3
Young children transmit lessResearchers suspect that one reason schools have not become COVID-19 hot spots is that children — especially those under the age of 12–14 — are less susceptible to infection than adults, according to a meta-analysis4 of prevalence studies. And once they are infected, young children, including those aged 0–5 years, are less likely to pass the virus on to others, says Haas. In an analysis5 of German schools, Haas’s team found that infections were less common in children aged 6–10 years than in older children and adults working at the schools.
That's good news.
I hadn't read that. I think I read that teenage kids are as likely to infect others as adults. The table below shows that children from age 0 to 4 years are somewhat more likely to be hospitalized or die than children 5 - 17 years old. It does not cover how much they transmit.
The 1918 influenza was more dangerous for young people than old people. Many army recruits in WWI camps died from it. We are fortunate that COVID-19 is more serious in old people. Here is a CDC table of risk factors by age:
https://www.cdc.gov/coronaviru…ization-death-by-age.html
Updated Feb. 18, 2021
Rate ratios compared to 18-29 year olds
| 0—4 years old | 5—17 years old | 18—29 years old | 30—39 years old | 40—49 years old | 50—64 years old | 65—74 years old | 75—84 years old | 85+ years old | |
|---|---|---|---|---|---|---|---|---|---|
| Cases2 | <1x | Reference group | 2x | 2x | 2x | 2x | 1x | 1x | 2x |
| Hospitalization3 | 2x | Reference group | 6x | 10x | 15x | 25x | 40x | 65x | 95x |
| Death4 | 2x | Reference group | 10x | 45x | 130x | 440x | 1300x | 3200x | 8700x |
All rates are relative to the 5—17-year-old age category. Sample interpretation: Compared with 5—17-year-olds, the rate of death is 45 times higher in 30—39-year-olds and 8,700 times higher in 85+-year-olds. Rate compared to 5-17-years-old (1)” in the top left header column of the html graphic (see jpeg graphic)
Imagine if the situation were reversed and children were 1300 times more likely to die from COVID-19 than adults. There would be zero opposition to wearing masks and to severe lockdowns. Everyone in society would agree to do anything necessary to prevent 600,000 children from dying. To some extent, that is as it should be. We should be more upset about children dying than old people, who will soon die anyway. On the other hand, people who dismiss the pandemic as fake news, and people who refuse to wear masks are saying -- in effect -- they don't care about the lives of 60-year-old people. They don't mind endangering them, or killing them. They will not even put up with the minor inconvenience of putting on a mask. This is a cavalier attitude. Extremely antisocial. And unfortunately, typical of the our era.
Very unfortunate world we live in.... follow the science or follow the politics? It is a blurred vision these days...
Texas reported zero deaths from COVID-19 on Sunday, just two months after Gov. Greg Abbott drew heat from the White House for rolling back business restrictions and lifting the state's mask mandate.
It marked the first time the Lone Star State reported no coronavirus deaths in about 14 months, according to state health data. Abbott said the case numbers reported on Sunday – 388 – were the lowest in more than 13 months, while the number of hospitalizations was the lowest in 11 months.
President Biden skewered Texas, as well as Mississippi, at the beginning of March for relaxing lockdown measures, accusing state officials of "Neanderthal thinking." At the time, Abbott had announced that businesses would be allowed to operate at full capacity – even though some health experts cautioned at the time that dropping preventative measures could lead to a spike in cases.
It IS good that Texas had zero deaths reported.... a good milestone indeed.... hopefully that trend will continue.....
and yes....we all know what a certain response to this will be.... 
Texas reported zero deaths from COVID-19 on Sunday, just two months after Gov. Greg Abbott drew heat from the White House for rolling back business restrictions and lifting the state's mask mandate.
It marked the first time the Lone Star State reported no coronavirus deaths in about 14 months, according to state health data.
Texas is doing much better than it was in January and February, but it probably had about 45 deaths on Sunday. Look at the graph and you see that reporting is delayed on weekends. The same is true in Georgia. There is nothing wrong with this, and no distortions to a 7-day average, but it does mean there were probably deaths that will be recorded later in the week.
https://www.worldometers.info/coronavirus/usa/texas/
Cases and deaths have not declined much since February. They have plateaued. If public health officials can persuade people to get vaccinated, the numbers will decline again, but right now they are stuck.
President Biden skewered Texas, as well as Mississippi, at the beginning of March for relaxing lockdown measures, accusing state officials of "Neanderthal thinking.
As you see in the graph above, at the beginning of March Texas was still close the peak number of deaths per day, although infections were down. There were 9,000 new cases per day. That does not seem like many compared to the 22,000 per day peak, but it is a large absolute number. Supposing in January 2020 someone in Texas had said, "we will have 9,000 new COVID cases per day." The politicians and public health officials would have dismissed that as an impossibly high number. They would have said it was too pessimistic.
Eric Clapton detailed his “disastrous” health experience after receiving the Covid-19 vaccine and blamed “the propaganda” for overstating the safety of the vaccine in a letter the guitarist shared with an architect/anti-lockdown activist.
Only an idiot makes the same mistake twice...Why did he not switch to J&J? Or the Chinese one?
Risk for COVID-19 Infection, Hospitalization, and Death By Age Group
Updated Feb. 18, 2021
This data is very different among countries. We so far had 2.4 Mio cases 3/4 undetected. So far no death at age <30 as we do not count people on late stage chemo as CoV-19 death.
But in India where children in average have 2 diseases and half of the population is chronically sick, we see something very different. Also in the Obese nation of USA, the V-D3 deficit among dark skin people etc...
We also never had a lock down for school children age <19. Just two longer vacations +1, +2 weeks.
Science did tell us a year ago already that children do spread a fraction of the adults load as children have fewer ACE-2 receptors in the upper air way. Further most children have regular contact with classic corona that makes them more or less immune.
