So drastični ukrepi res upravičeni? Odprto pismo nemški kanclerki

Sucharit Bhakdi, odlikovan in upokojen profesor medicinske mikrobiologije na Johannes Gutenberg University Mainz ter dolgoletni direktor Institute for Medical Microbiology, še sedaj pa gostujoči profesor na Univerzi v Kielu, je nemški kanclerki Angeli Merkel poslal odprto pismo s petimi ključnimi vprašanji glede same epidemije COVID-19 in pristopa k obvladovanju epidemije. Bhakdi opozarja, da je pri strategiji glede obvladovanja epidemije potrebno upoštevati podatke in jih postaviti v kontekst z ostalimi nalezljivimi boleznimi, sicer lahko države zaradi sprejema preveč drastičnih ukrepov povzročijo ogromne dolgoročne socio-ekonomske posledice.

Bhakdi se s tem pridružuje kritičnim mnenjem mnogih drugih strokovnjakov s področja epidemiologije, infektologije, pulmologije in mikrobiologije (nekatere sem tukaj že objavil, denimo John Ioannidis, Wolfgang Wodarg, Igor Rudan, druge še bom). Njihove poglede potrjujejo strategije nekaterih držav, ki so izbrale manj drastične pristope k obvladovanju epidemije (predvsem Singapur in Južna Koreja) in ki dajejo izjemno dobre rezultate tako z vidika zajezitve širjenja virusa kot minimiziranja gospodarske škode.

Bhakdijevo odprto pismo je glas razuma in veljalo bi si odgovoriti na njegovih 5 vprašanj, preden gremo z določenimi ukrepi predaleč.

Open Letter

Dear Chancellor,

As Emeritus of the Johannes-Gutenberg-University in Mainz and longtime director of the Institute for Medical Microbiology, I feel obliged to critically question the far-reaching restrictions on public life that we are currently taking on ourselves in order to reduce the spread of the COVID-19 virus.

It is expressly not my intention to play down the dangers of the virus or to spread a political message. However, I feel it is my duty to make a scientific contribution to putting the current data and facts into perspective – and, in addition, to ask questions that are in danger of being lost in the heated debate.

The reason for my concern lies above all in the truly unforeseeable socio-economic consequences of the drastic containment measures which are currently being applied in large parts of Europe and which are also already being practiced on a large scale in Germany.

My wish is to discuss critically – and with the necessary foresight – the advantages and disadvantages of restricting public life and the resulting long-term effects.

To this end, I am confronted with five questions which have not been answered sufficiently so far, but which are indispensable for a balanced analysis.

I would like to ask you to comment quickly and, at the same time, appeal to the Federal Government to develop strategies that effectively protect risk groups without restricting public life across the board and sow the seeds for an even more intensive polarization of society than is already taking place.

With the utmost respect,

Prof. em. Dr. med. Sucharit Bhakdi

  1. Statistics

In infectiology – founded by Robert Koch himself – a traditional distinction is made between infection and disease. An illness requires a clinical manifestation. [1] Therefore, only patients with symptoms such as fever or cough should be included in the statistics as new cases.

In other words, a new infection – as measured by the COVID-19 test – does not necessarily mean that we are dealing with a newly ill patient who needs a hospital bed. However, it is currently assumed that five percent of all infected people become seriously ill and require ventilation. Projections based on this estimate suggest that the healthcare system could be overburdened.

My question: Did the projections make a distinction between symptom-free infected people and actual, sick patients – i.e. people who develop symptoms?

  1. Dangerousness

A number of coronaviruses have been circulating for a long time – largely unnoticed by the media. [2] If it should turn out that the COVID-19 virus should not be ascribed a significantly higher risk potential than the already circulating corona viruses, all countermeasures would obviously become unnecessary.

The internationally recognized International Journal of Antimicrobial Agents will soon publish a paper that addresses exactly this question. Preliminary results of the study can already be seen today and lead to the conclusion that the new virus is NOT different from traditional corona viruses in terms of dangerousness. The authors express this in the title of their paper „SARS-CoV-2: Fear versus Data“. [3]

My question: How does the current workload of intensive care units with patients with diagnosed COVID-19 compare to other coronavirus infections, and to what extent will this data be taken into account in further decision-making by the federal government? In addition: Has the above study been taken into account in the planning so far?  Here too, of course, „diagnosed“ means that the virus plays a decisive role in the patient’s state of illness, and not that previous illnesses play a greater role.

  1. Dissemination

According to a report in the Süddeutsche Zeitung, not even the much-cited Robert Koch Institute knows exactly how much is tested for COVID-19. It is a fact, however, that a rapid increase in the number of cases has recently been observed in Germany as the volume of tests increases. [4]

It is therefore reasonable to suspect that the virus has already spread unnoticed in the healthy population. This would have two consequences: firstly, it would mean that the official death rate – on 26 March 2020, for example, there were 206 deaths from around 37,300 infections, or 0.55 percent [5] – is too high; and secondly, it would mean that it would hardly be possible to prevent the virus from spreading in the healthy population.

My question: Has there already been a random sample of the healthy general population to validate the real spread of the virus, or is this planned in the near future?

  1. Mortality

The fear of a rise in the death rate in Germany (currently 0.55 percent) is currently the subject of particularly intense media attention. Many people are worried that it could shoot up like in Italy (10 percent) and Spain (7 percent) if action is not taken in time.

At the same time, the mistake is being made worldwide to report virus-related deaths as soon as it is established that the virus was present at the time of death – regardless of other factors. This violates a basic principle of infectiology: only when it is certain that an agent has played a significant role in the disease or death may a diagnosis be made. The Association of the Scientific Medical Societies of Germany expressly writes in its guidelines: „In addition to the cause of death, a causal chain must be stated, with the corresponding underlying disease in third place on the death certificate. Occasionally, four-linked causal chains must also be stated.“ [6]

At present there is no official information on whether, at least in retrospect, more critical analyses of medical records have been undertaken to determine how many deaths were actually caused by the virus.

My question: Has Germany simply followed this trend of a COVID-19 general suspicion? And: is it intended to continue this categorisation uncritically as in other countries? How, then, is a distinction to be made between genuine corona-related deaths and accidental virus presence at the time of death?

  1. Comparability

The appalling situation in Italy is repeatedly used as a reference scenario. However, the true role of the virus in that country is completely unclear for many reasons – not only because points 3 and 4 above also apply here, but also because exceptional external factors exist which make these regions particularly vulnerable.

One of these factors is the increased air pollution in the north of Italy. According to WHO estimates, this situation, even without the virus, led to over 8,000 additional deaths per year in 2006 in the 13 largest cities in Italy alone. [7] The situation has not changed significantly since then. [8] Finally, it has also been shown that air pollution greatly increases the risk of viral lung diseases in very young and elderly people. [9]

Moreover, 27.4 percent of the particularly vulnerable population in this country live with young people, and in Spain as many as 33.5 percent. In Germany, the figure is only seven percent [10]. In addition, according to Prof. Dr. Reinhard Busse, head of the Department of Management in Health Care at the TU Berlin, Germany is significantly better equipped than Italy in terms of intensive care units – by a factor of about 2.5 [11].

My question: What efforts are being made to make the population aware of these elementary differences and to make people understand that scenarios like those in Italy or Spain are not realistic here?

References:

[1] Fachwörterbuch Infektionsschutz und Infektionsepidemiologie. Fachwörter – Definitionen – Interpretationen. Robert Koch-Institut, Berlin 2015. (abgerufen am 26.3.2020)

[2] Killerby et al., Human Coronavirus Circulation in the United States 2014–2017. J Clin Virol. 2018, 101, 52-56

[3] Roussel et al. SARS-CoV-2: Fear Versus Data. Int. J. Antimicrob. Agents 2020, 105947

[4] Charisius, H. Covid-19: Wie gut testet Deutschland? Süddeutsche Zeitung. (abgerufen am 27.3.2020)

[5] Johns Hopkins University, Coronavirus Resource Center. 2020. (abgerufen am 26.3.2020)

[6] S1-Leitlinie 054-001, Regeln zur Durchführung der ärztlichen Leichenschau. AWMF Online (abgerufen am 26.3.2020)

[7] Martuzzi et al. Health Impact of PM10 and Ozone in 13 Italian Cities. World Health Organization Regional Office for Europe. WHOLIS number E88700 2006

[8] European Environment Agency, Air Pollution Country Fact Sheets 2019, (abgerufen am 26.3.2020)

[9] Croft et al. The Association between Respiratory Infection and Air Pollution in the Setting of Air Quality Policy and Economic Change. Ann. Am. Thorac. Soc. 2019, 16, 321–330.

[10] United Nations, Department of Economic and Social Affairs, Population Division. Living Arrange­ments of Older Persons: A Report on an Expanded International Dataset (ST/ESA/SER.A/407). 2017

Vir: Swiss Propaganda Research

17 responses

  1. Res tehtna vprašanja, za katere v dnevnem poročanju prikladno zmanjka časa.
    Kdo bi jih lahko postavil našim politikom in strokovnjakom, npr.ministru za zdravje Tomažu Gantarju, priznani infektologinji dr. Mojci Matičič in dr. Ivanu Erženu (vršilec dolžnosti direktorja Nacionalnega inštituta)?

  2. Jože – čestitam, za pogum! Še to analizo, če kdo prevede, pa gremo lahko nazaj delati:
    https://swprs.org/a-swiss-doctor-on-covid-19/
    Lepa misel, ki jo navaja portal:
    Danski raziskovalec Peter Gøtzsche, ustanovitelj priznanega Cochrane Medical Collaborat, pravi: Corona je epidemija množične panike in logika je bila ena prvih žrtev.

    Ko prebereš današnje članke v naših medijih in primerjaš analizo, ki jo naredi ta portal za isti dan, postane vse skupaj prav grozljivo – čista propaganda:

    March 31, 2020 (II)
    • A graphical analysis of the European monitoring data impressively shows that, irrespective of the measures taken, overall mortality throughout Europe remained in the normal range or below by March 25, and often significantly below the levels of previous years. Only in Italy (65+) was the overall mortality rate somewhat increased (probably for several reasons), but it was still below previous flu seasons.
    • The president of the German Robert Koch Institute confirmed again that pre-existing conditions and actual cause of death do not play a role in the definition of so-called „corona deaths“. From a medical point of view, such a definition is clearly misleading. It has the obvious and generally known effect of putting politics and society in fear.
    • In Italy the situation is now beginning to calm down. As far as is known, the temporarily increased mortality rates (65+) were rather local effects, often accompanied by mass panic and a breakdown in health care. A politician from northern Italy asks, for example, „how is it possible that Covid patients from Brescia are transported to Germany, while in the nearby Verona two thirds of intensive care beds are empty?“

  3. https://www.zdf.de/nachrichten/panorama/coronavirus-faktencheck-bhakdi-100.html

    https://www.zeit.de/wissen/gesundheit/2020-03/clemens-wendtner-coronavirus-covid-19-intensivstationen-beatmung-krankenhaus

    http://www.euromomo.eu/outputs/zscore_country_total.html
    zaenkrat še ni posodobljeno na 13. KT
    pa treba je upoštevati, da bo tudi posodobljena slika smrtnosti odražala stanje ca 17 dni nazaj (po spominu povprečni čas od okužbe do smrti)

  4. Upravicem dvom in smiselna vprasanja, ki jih lahko strnemo v eno samo pravno normo, to je sorazmernost ukrepov. Zelo mogoce je, da je bila zaradi strahu pred okuzbo mezinca odrezana cela roka.

    • Žal odgovor ZDF ni na nivoju Prof.Bhakdi-ja. Opira se ravno na tisto statistiko, ki jo osporava Bhakdi in Ioannides. Če je statistaka napačna, potem padejo vsi argumenti. Zelo zanimivi so komentarji zdravnikov na Bhakdi-jevo pobudo (glej video), kjer se večina strinja z njim.

      Glej:

      https://swprs.org/a-swiss-doctor-on-covid-19/

      “A model from Imperial College London predicted between 250,000 and 500,000 deaths in the UK „from“ Covid-19, but the authors of the study have now conceded that many of these deaths would not be in addition to, but rather part of the normal annual mortality rate, which in the UK is about 600,000 people per year. In other words, excess mortality would remain low.”

      Od začetnih 2 milijona mrtvih so prišli avtorji iz Impeial College-a na 20.000 v roku manj kot 2 tednov.?!?!. Mimogrede gre za tisto študijo, ki ste mijo tako vehemento servirali pred dnevi.

      Ne da so se sami korigirali (za faktor 100!!!) poponoma jih je sesula tudi skupina raziskovalcev pod vodstvom Sunetra Gupta, (professor of theoretical epidemiology) iz Oxforda (Financial Times 24.3.2020: Coronavirus may have infected half of UK population — Oxford study), med drugimi.

      Kar se argumentov iz ZDF tiče glej spodaj:

      The following passages are taken from the article: https://www.telegraph.co.uk/global-health/science-and-disease/have-many-coronavirus-patients-died-italy/

      “According to Prof Walter Ricciardi, scientific adviser to Italy’s minister of health, the country’s mortality rate is far higher due to demographics – the nation has the second oldest population worldwide – and the manner in which hospitals record deaths. ”

      “‘The way in which we code deaths in our country is very generous in the sense that all the people who die in hospitals with the coronavirus are deemed to be dying of the coronavirus.’

      “’On re-evaluation by the National Institute of Health, only 12 per cent of death certificates have shown a direct causality from coronavirus, while 88 per cent of patients who have died have at least one pre-morbidity – many had two or three,’ he says. ”

      Another possible factor for Italy’s high mortality rate is that 2.6 million of its citizens suffer from Chronic Obstructive Pulmonary Disease that causes around 18,000 deaths each year. Covid-19 would probably be a serious threat to people with this disease.
      https://www.ncbi.nlm.nih.gov/pubmed/12647942

      As of 2015, Chronic obstructive pulmonary disease (COPD – kronični bronhitis ) affected about 174.5 million people (2.4% of the global population).[6] It typically occurs in people over the age of 40.[3] Males and females are affected equally commonly.[3] In 2015, it resulted in 3.2 million deaths, up from 2.4 million deaths in 1990.[7][18] More than 90% of these deaths occur in the developing world.[3] The number of deaths is projected to increase further because of higher smoking rates in the developing world, and an ageing population in many countries.[19] It resulted in an estimated economic cost of $2.1 trillion in 2010.[20]

      Italy is known for its enormous morbidity in respiratory problems, more than three times any other European country.“

    • Je pa opazna živčnost pri ZDF (beri: nemški nomenklaturi) Če se izkaže (na primerih Švedske, Belorusije (nobenih ukrepov!), Singapur-ja,.., da so bili ukrepi pretirani, potem bo zelo težko opravičevati stotine in tisoče milijard evrov, ki bodo šli v omilitev posledic teh ukrepov.

      Na odgovor na 5 vprašanj (brez ovinkarjenja) direktno na vprašanja še vedno čakamo. Če so Nemci pod Mutti Merkel dali več kot 800 milijard Evrov, lahko javnosti, ki bo vse to plačala odgovorijo še na teh 5 vprašanj. Profesorja emeritus-a pač ne moreš odpraviti s člankov v ZDF.

      Prof Sukharit Bhakdi ni kdorsibodi , je svetovna legenda mikrobiologije in med drugim:

      1979 Preis der Justus-Liebig-Universität Gießen

      1979 Konstanzer Medizinischer Förderpreis

      1987 Preis der Deutschen Gesellschaft für Hygiene und Mikrobiologie

      1988 Dr. Friedrich–Sasse Preis 1989 Robert Koch Förderpreis der Stadt Clausthal-Zellerfeld

      1989 Ludwig-Schunk-Preis für Humanmedizin

      1990 Gotthard-Schettler-Award

      1991 Gay-Lussac-Humboldt-Preis[22]

      1999 Schwarz-Pharma Preis

      2001 Aronson-Preis für “wegweisende Arbeiten auf dem Gebiet des Komplementsystems und bakterieller Toxine”[23]

      2005 H. W. Hauss Award[24]

      2005 Verdienstorden des Landes Rheinland-Pfalz

      • Glejte, lahko bi vam odgovoril na dolgo in široko in vam seciral vaš odgovor, ki ima kar nekaj šibkih točk, ampak ne vidim smisla. Kolikor vidim, vi že imate neko stališče, ki ga na vsak način branite in v ta namen selektivno navajate vire in “dokaze”, pri tem pa po pravilu zagrešite še marsikatero drugo logično napako (appeal to accomplishment vam je recimo zelo domač). Hkrati ste še nagnjeni k teorijam zarote, kar je povsem legitimno, ni pa podlaga za kakršnokoli argumentirano izmenjavo.

        Moje osnovno stališče na kratki rok je better safe than sorry. Na dolgi rok pa se mi zdi edina etična pozicija globalna minimizacija smrtnih izidov in hudih posledic za zdravje. V trenutni situaciji vidim že v sami znanstveni skupnosti ogromno nasprotujočih si razlag. Ne bi na dolgo ugibal o vzrokih, vendar je pomanjkanje in neprimerljivost podatkov gotovo eden izmed njih. Kar je še dodaten argument, da je v situaciji treba ravnati po previdnostnem načelu.

      • Ne imputirajte drugim ljudem kaj mislijo, če jih ne poznate. Gre za preveč usodne zadeve, da jih ne bi premislili iz vseh možnih vidikov. Nekritično pristajanje na čredno miselnost to ni, še posebej, kot navajate, tudi v znanosti ni konsenza.

        Dilema med življenji in gospodarstvom je zavajajoča. Gre v resnici za življenja direktno in za življenja posredno, za življenja na kratki in življenja na srednji in dolgi rok. Ker če gospodarstvo katastrofalno pade, bodo padla življenja ker v zdravstvenem budžetu ne bo denarja za zdravljenje, bo poraslo število samomorov, depresije, socialnih bolezni kot npr. tuberkuloze za katero letno umre več kot pol milijona ljudi, pa se zaradi tega nihče prav dosti ne razburja. V sezoni 2017/2018 smo v razvitem svetu doživeli katastrofalno gripo z več kot 600.000 umrlih, pa ni nihče ustavljal celotne družbe, vsak dan poročal kot iz fronte in ustvarjal paniko? Zakaj ne?

        Isto velja za kritično distanco do ukrepov oblasti. Imel sem priliko to videti od blizu- levo in desno vlado. Nikar ne mislite, da tam sedijo vrhunske strokovne perle (prej nasprotno) katerih ukrepe je potrebno molče in brez premisleka sprejeti. Tudi njih vodi čredna mentaliteta (do EU) in motiv ugajanja javnosti ter politične primernosti vsaj toliko kot strokovni premisleki. In tudi drugje gre bolj ali manj po istih vzorcih.

        Podobno velja za zdravstveni sektor. Bolj okostenelega in ujetega v obstoječe dogme sistema boste težko našli. Še posebej velja to pri nas v Sloveniji. Pa nočem vsepovprek kritizirati, daleč od tega , na marsikaj smo lahko v našem javnem zdravstvu ponosni. Del tega lahko spremljam, glede na veliko število sorodnikov, ki delajo v zdravstvu, v sami razširjeni družini.

        Vsak kritičen pogled še ni pristajanje na teorije zarote. Hvala Bogu, da obstajajo ljudje kot je prof. Bhakdi, ki premorejo pogum, moralen profil in znanje. Zaradi takih ne zdrvimo kot lemingi v katastrofo.

  5. Spoštovani,

    • A graphical analysis of the European monitoring data impressively shows that, irrespective of the measures taken, overall mortality throughout Europe remained in the normal range or below by March 25, and often significantly below the levels of previous years. Only in Italy (65+) was the overall mortality rate somewhat increased (probably for several reasons), but it was still below previous flu seasons.

    Smrtnost do 25. marca kaže stanje za ca 17 dni nazaj za vsak posamezen dan (po spominu je to povprečen čas od okužbe do smrti). Poleg tega je treba upoštevati, da je to smrtnost ob sprejetih ukrepih (za tiste države, ki so jih sprejele). Počakajmo torej, kakšni bodo te grafi čez ca 3 tedne.

    Glede napačne metodologije štetja umrlih (z ali zaradi virusa) se strinjam, ampak ta konec koncev niti ne bo tako pomembna, ko bomo enkrat imeli podatke o presežni smrtnosti.

  6. Vprasanja so zelo na mestu. Bi oz. bo zelo zanimivo branje odgovorov, ce jih bo gospod ali javnost v Nemciji dobila.

  7. Tudi berete površno. In mi pripisujete nekritičen pogled, čredno miselnost itd. brez osnove za tako sklepanje. Naj vas razsvetlim: metakritika še ne pomeni strinjanja z objektom kritike. S tem zaključujem najino izmenjavo, ker je ob zatečenih parametrih brezplodna.

  8. Argument ‘Smrtnost do 25. marca kaže stanje za ca 17 dni …’ nima posebne teže, ker je jasno, da se smrtnost gleda na dani teden.
    Tudi sicer je za Evropo zadnji teden število novih okužb in smrti za večino držav stabilno in ne narašča, sploh pa ne eksponentno.
    Seveda to ne pomeni, da je popolnoma jasno, da je covid19 epidemija primerljiva z gripo, ampak sedanji razpoložljivi podatki so taki, da lahko bo (veliko) hujša, primerljiva ali pa bo celo manj žrtev.
    Je pa osnovna logična napaka iz tega potegniti sklep, da je treba poseči po drastičnih ukrepih, kakor s(m)o marsikje po svetu. Recimo za Slovenijo je očitno, da so žarišča domovi za starostnike in tam bi moral biti fokus. Oziromanaa celotno rizično populacijo, npr.nad 65 ali 70 let in na ljudeh z že obstoječimi perečimi zdravstvenimi težavami.
    Da ne bo nesporazuma, lahko se bo izkazalo, da so ti drastični ukrepi bili na mestu, a zaenkrat je to samo ugibanje.

    • “Non sequitur? Me zanima bolj točna razlaga te trditve.”
      Podatki so za 12. teden (sicer ne piše, katerih sedem dni je to) in ne, kaj bo čez 17 dni. Številke za 13. teden bi lahko bile seveda višje in posledično še kakšna država poleg Italije v nadpovprečni smrtnosti.
      Če se pogleda podatke za tri velike države, Italijo, Španijo in Nemčijo (na https://www.worldometers.info/coronavirus), ni opaziti bistvenega časovnega zamika konsolidacije, in upajmo upadanja, števila novih primerov in števila smrti (oboje na dnevni ravni).

%d bloggers like this: