Dear Clients,
Back in Business Physiotherapy has been operating for most of the June - September 2021 spike in COVID. This has been at a limited capacity to minimise risk of infection. In October 2021, we will recommence having reception staff in the mornings only. During November, we're hoping to have our full reception capacity and no longer limit the number of appointments we have on offer. However, this will be in line with NSW health recommendations. If Singapore on 29 September 2021, is anything to go by, their 80% double vaccination rate hasn't prevented them to commit to another lock down, so that hospital capacity isn't over-stretched. A similar approach occurred in Scotland, where a 3 week lock down was commenced in September 2021, to allow the NHS to 'catch up'. Hence, at BinBPhysio we're committed to ensuring the safety of our clients and staff.
Online bookings
When you make a booking online, you will see some COVID screening questionnaire.
Emails
As a client you may receive an email with a signature detailing our expectations of our clients.
We are in the process of installing an air filtration unit, fans, cough/sneeze shields and continue to maintain clean surfaces using hospital grade disinfectant wipes.
Air Purifier
The Samsung AX500K air purifier has been recommended by the CDC in the United States. This unit is recommended for 90m2, which is sufficient for our suite.
Additionally, we have A/C units specifically for our suite, as well the capacity to open windows from the bottom and the top, thereby allowing further ventilation and air exchange.
Rapid antigen testing kits
Consideration also needs to be given to the possibility that relatively high COVID-19 rates are required in a population before rapid antigen self-test results are reliable. The March 2021 Cochrane systematic review assessing rapid tests for the detection of SARS-CoV-2 infection
(COVID-19) suggested that at 0.5% prevalence asymptomatic screening would result in 70-90% of rapid tests being false positives and 30-50% of cases being missed.
NSW health and the TGA are considering rapid antigen testing to become available to all households by December 2021. By this stage it is expected the sensitivity and reliability of the self testing kits to become verified. As of September 2021 neither the Australian Physiotherapy Association nor NSW health were recommending the use of kits in Private Practice. Back in Business Physiotherapy will continue to review the use of these kits and will be prepared to use them if they become recommended.
Late September 2021 - vaccination rates against the virus
A road map to opening was outlined in late September 2021 after 3 months of 'lock down' in the Greater Sydney Region. This included gradually opening up in mid October 2021 when a predicted 70% of the NSW population was doubly vaccinated. A projected 85-93% double vaccination rate was considered feasible to suggest complete 'opening' by early December 2021. As such, the NSW government wasn't aiming for zero COVID cases but a population 'living with the virus'. Such an amazing vaccination rate suggests that the NSW hospital system will be able to cope with the virus.
COVID-19 NSW Delta strain outbreak : June/July 2021
Late June, the delta variant of COVID-19 was introduced into the Eastern Suburbs of Sydney by a driver, presumably contracted whilst transporting flight crew. Initial LGA partial lockdowns for 1 week and partial lockdowns across Sydney for 2 weeks did little to stop the spread, particularly in South Western Sydney. By the second week of July a strict lockdown has been ordered and 12 July 2021, numbers were still rising (112 new cases). Unfortunately, nationwide only 8% of Australians are fully vaccinated.
Towards the end of September 2021, Australia had recorded almost 100 000 COVID cases, with the majority, ~ 61 000, occurring in NSW.
All staff at BinBPhysio had been fully vaccinated by September 2021. Hence, during July and August 2021, Back in Business Physiotherapy was partially open, whilst using strict hygiene and contamination control protocols. Nearly all clients attending the practice during the first weeks of July were fully vaccinated.
We are requesting that all clients use the NSW Health QR check in code when attending the practice. This procedure has already been in place since mid 2020. Mandatory mask wearing as stipulated by NSW Health.
Masks : A standard medical face mask is more effective at preventing the wearer from inhaling aerosols without causing substantial breathing resistance than various cloth, medical, or respirator masks (Christian M. et al 2021, March 3, PLOS One, https://doi.org/10.1371/journal.pone.0248099 Tara Haelle Medscape Sunday, July 18, 2021)
We will be using P2 and N95 masks at our practice. Some staff may also use perspex face shields
Cough/sneeze shield
As of October 2021, sneeze/cough shields will be installed at the reception desk.
Seating, appointment time spacing and cleaning
Two seats, 1.5m apart as well as seating outside, in the hallway, will be provided. Additionally, appointment times will be made to reduce client cross over as well as allow sufficient time to thoroughly clean cubicles, gym and reception areas. Cleaning agents with at least 40% alcohol content will be used, both as aerosols and as surface wipes.
NSW health has a list of warnings for COVID exposed locations
Please look at the NSW health COVID updates daily. Even if you feel well, if you were in one of the COVID hotspots please get tested. Depending on their recommendations you may still need to quarantine for 7-14 days, whilst testing negative.
Vaccinations : 12 July 2021
In July 2021, BinBPhysio reduced working hours to accommodate acute clients and those whose chronic condition would worsen considerably, as only 8% of all Australians were fully vaccinated. In July, only two vaccines were available - Astra Zeneca, which was recommended for over 60's but became available at NSW pharmacies for over 40's. Some blood clotting risks with Astra Zeneca have been known to occur. Frontline workers and health care workers had been prioritised. Pfizer has been recommended for people under 60. Some heart and brain inflammation side effects have been reported. As the outbreak worsened, people were encouraged to vaccinate regardless of age or vaccine type. Later in September 2021, Moderna vaccines arrived in Australia.
Researchers in the UK reported up to 80% protection against hospitalisation in over 80 year olds (https://www.bmj.com/content/373/bmj.n1088#)
Researchers in Israel, where almost the entire population has been vaccinated with A-Z and Pfizer reported,
- one shot of the vaccine was partially effective, offering 58% protection against infection, 76% against hospitalisation, and 77% against death
- by seven days after the second dose (Pfizer), the vaccine was giving people 95.3% protection against infection and 96∙7% protection against death (https://www.google.com.au/amp/s/amp.theguardian.com/world/2021/may/05/two-pfizer-covid-vaccine-doses-give-over-95-protection-shows-israel-study)
However, this provocative graph came our on 12 July 2021, which is somewhat misleading when compared with serious illness, hospitalisation and death.
More uplifting are the preliminary results from the UK on hospitalisation : According to an analysis by PHE, the Pfizer/BioNTech jab was linked to a 94% vaccine effectiveness against hospital admission with the Delta variant after one dose and 96% after two doses, while the figures for the Oxford/AstraZeneca jab were 71% and 92% respectively (The Guardian, Australia 16 June 2021)
"it's not a race" (Scott Morrison PM)
Unfortunately, many reports in the media (and the fact that only 8% of Australians have been vaccinated) suggest the Morrison government is yet again (eg 2019 Bushfires), hopeless in a crisis. Australia is in a mess because the federal government bungled its vaccine procurement strategy – in particular its dealings with Pfizer, which it seems to have skimped on initially. The most damning part of Tingle’s report, and a point Rudd no doubt wanted to highlight, is the apparent confirmation that Australia got off on the wrong foot with Pfizer, with an anonymous business leader saying the government had displayed a “rude, dismissive and penny pinching” approach towards Pfizer, and sent “relatively junior bureaucrats” to the table. (A Guardian Australia report over the weekend backed this narrative, with Pfizer’s former president of global R&D John LaMattina describing Australia’s original order as “unconscionable”.) The health department has long been denying reports it botched its early meetings with the maker of the vaccine we are now desperately waiting on. But Tingle reports that well-connected Australian businesspeople in the US were “hearing even more graphic accounts of how badly offended the company had been by the response to its early approaches to Australia” (www.themonthly.com.au)
Vaccine order : 25 July 2021
The Morrison government announced the acquisition of 52 million doses of Pfizer, suggesting that eventually everyone will eventually be vaccinated with Pfizer
Vaccination totals : 13 July 2021
The delta variant appears to be highly transmissible and, unlike previous strains, affects children and young adults. The Sydney outbreak caught everyone by surprise, as the 'gold standard' contact tracing wasn't able to keep up with all those locations and people who have been asymptomatic and unknowingly spreading it in the community. It soon became apparent that the key to getting out of this outbreak was for everyone to get vaccinated, not only for themselves but for their country.
COVID-19 vaccinations and musculoskeletal side effects - 8 August 2021
Last week, two separate clients presented with an exacerbation of injuries which I had treated previously. One was a 57 year old lady, who I had successfully treated for low back pain and nerve inflammation, a year previously. Three days after the Pfizer vaccine, she felt 'like a horse had kicked her in her back'. Luckily, her symptoms resolved after a few days. Another client, a 21 year old female, presented with severe ankle and foot pain. Similarly, three days after a Pfizer vaccination. I had treated her for a 'strange presentation' of calf and ankle swelling three years previously, for which multiple investigations found no explanation. Some form of vascular condition was suspected in the previuos presentation. This time around, her symptoms resolved within a week, however, her presenting symptoms were similar to someone with CRPS of the ankle and foot!
Further reading : https://www.back-in-business-physiotherapy.com/health-advocacy/exercise-and-the-immune-system-during-covid-19.html
In the beginning : a historical perspective of BinBPhysio continued review and analysis of the COVID pandemic - March 2020
The following is an historical timeline of our analysis and review of the unfolding pandemic. Our work policies reflected the ever changing environment of this unprecedented situation. The following gives some perspective on how and why we responded in our work practices. North Sydney, was hit particularly hard, in terms of it becoming a 'ghost town', as most people worked from home over the past 18 months. Although this strategy was highly effective in reducing the rates of infections, peoples mental and physical well-being were affected, due to social isolation as well as poor work station home ergonomics. Read more....
Hence, updates of our policy, regarding COVID-19, has been a work in progress, with reflection of old information and the introduction of new information, which explained our reasoning for closing and re-opening of our practice. The questions at the time were : What are the rates of infection? What happens when we do nothing? How do we get herd immunity? Hospitalisation rate? Death rate of 1%, sickness rate of 20% and intensive/special care rate of 5%.Which countries are doing best? What is the political context of doing nothing? Should we wear masks? Can hot weather reduce the rate of infection? Economics versus health when closing the economy and re-opening gradually from a low base, using data, versus political expediency? Why people should not be complacent? On-going health and immune compromise? What are the symptoms in young versus old? Is this a hoax? Is this just another influenza? What are the signs and symptoms? What is Kawasaki disease? Is it just in the lungs? What are the mechanisms and treatments?
COVID-19 growth : 29 April 2020
Flattening and Delaying the Curve : 30 March 2020
The reasoning for flattening the curve is to avoid over-whelming the health system. This strategy, has been advocated by the Imperial College Response Team. They have shown that those countries which isolated early, tested frequently and used personal protective equipment (PPE) liberally and appropriately had fewer deaths. Early in the pandemic, countries such as Taiwan, Singapore and Hong Kong were able to maintain a functioning economy by selectively isolating people who were testing positive for COVID-19. In countries, where recognition of the pandemic came too late, such as Italy, Spain and France, they required total shut down of peoples movements. Staggering death rates of 800 people in Bergamo alone and the death of 50 doctors in Northern Italy demonstrate the veracity of this virus, especially in the presence of inadequate personal protective equipment (PPE). Millions of face masks arrived today (30 March 2020) in Venice. Britain who commenced late, hoping for herd immunity, was on the precipice and still has rising fatalities. The PM himself, late to the party and a denier, also contracted the disease, and recovered just before the birth of his child. Those countries with a high sense of civic duty, such as Germany, who were airlifting Italian and French intensive care patients to Germany for treatment, where their mortality rate sat around 0.5%. Taking a 'nothing approach' such as advocated by President Trump in the USA and Bolsonaro, in Brazil, are showing high and prolonged mortality rates. However, these figures were likely to be skewed from lack of testing. Which brings us to Australia's measured response, of working from home and only essential services encouraged to be working outside of home. Isolation and testing, testing and testing. For the time being, this appears to have worked. Hence the regrettable decision to shut down of Back in Business Physiotherapy on 22 March 2020, could be partially reversed, with a gradual recommencement of services from the 5 May 2020. However, on 3 August, Victoria announced a 6 week stage 4 hard shut down. We will continue to monitor the situation locally, as well as head public health warning advice. We are taking all precautions, with regular cleaning, etc. All our staff are wearing masks. We'd like our clients to do so as well.
Which countries have isolated best? 29 April 2020
The scary thing about this graph is that it shows that we'll be dealing with this for quite some time. 100 days is just over three moths, whilst 250 days is closer to 8 months! This brings the Northern Hemisphere back into the autumn/winter traditional influenza cycle!
COVID-19 infection rates (17 July 2020) and those of influenza
Infections
COVID-19: The first cases appeared in China in late 2019 and the first confirmed case in the United States appeared in January 2020.
Approximately 13,832,242 cases have been confirmed worldwide. There have been 3,576,430 cases in the U.S. as of July 17, 2020.*
Flu: The World Health Organization estimates that 1 billion people worldwide get the flu every year.
In the U.S., for Oct. 1, 2019 – Apr. 4, 2020, the CDC estimates that there were 39 million to 56 million cases of flu. (The CDC does not know the exact number because the flu is not a reportable disease in most parts of the U.S.)
Deaths
COVID-19: There have been approximately 590,608 deaths reported worldwide. In the U.S, 138,360 people have died of COVID-19, as of July 17, 2020.* On 3 August 2020, total deaths were 697,189. A large jump from 17 July 2020!
Flu: The World Health Organization estimates that 290,000 to 650,000 people die of flu-related causes every year worldwide.
In the U.S., from Oct. 1, 2019 – Apr. 4, 2020, the CDC estimates that 24,000 to 62,000 people died from the flu. (The CDC does not know the exact number because the flu is not a reportable disease in most parts of the U.S.)
The COVID-19 situation is changing rapidly. Since this disease is caused by a new virus, people do not have immunity to it, and a vaccine may be many months away. Doctors and scientists are working to estimate the mortality rate of COVID-19, but at present, it is thought to be substantially higher than that of most strains of the flu. 140 institutions world wide are working on a vaccine. Two likely candidates are mRNA vaccines being developed at Finders University in South Australia and another one from The University of Queensland
Footnote : the UQ vaccine although the first effective vaccine in the world had to be abandoned as they used an AIDS derived protein carrier, which unfortunately meant that a diagnosis of AIDS could not be made in people vaccinated in this way (2021)
*This information comes from the Coronavirus COVID-19 Global Cases map developed by the Johns Hopkins Center for Systems Science
Herd Immunity : 29 May 2020 vs 12 July 2020
The coronavirus pandemic has shown clearly what happens when a new pathogen gets loose in a population where no one has had it before: It spreads like wildfire. Long-familiar viruses, even ones that are every bit as contagious, can’t do that, because of a phenomenon called herd immunity. It works like this: The more people there are in a community who have protective antibodies, either through vaccination or past exposure, the less likely an infected patient is to encounter someone who lacks them and pass the virus along. Above a certain threshold, the virus can’t spread readily enough for an outbreak to grow. That’s why diseases like measles and chickenpox have become rare in countries like Australia and the United States even though not everyone gets vaccinated: if enough people do, then we achieve herd immunity. Notably, 90% of the population needs to have immunity for certain diseases such as Measles. Scientists and policymakers hope the world will get to that point with the coronavirus, too. But a crop of new studies suggests that herd immunity is still very far away. Additionally, thanks to the bush fires keeping tourists away, which meant keeping our COVID-19 numbers low, together with our isolation means, we'll be reliant on the rest-of-the-world for herd immunity. Gradual re-opening of our borders will be a tricky thing. Similarly, our nearest neighbour, New Zealand, went for eradication, so we won't be getting our herd immunity from there.
The USA went down the politically expedient pathway of early re-opening without heading CDC guidelines. On the 12 July 2020 the USA had 62,653 new cases of COVID-19. Total confirmed infections were 3.29M with 137 000 deaths. Suggestions are that the number of unconfirmed : confirmed cases is 80 : 1, meaning that the total number of potential cases are 263.2M in a population of 328M. This is about 66% of the population which some people suggest that herd immunity may commence to take effect. Time will tell. Never-the-less, with the current infection rates, around 20% of positively tested and probably symptomatic people end up needing hospitalisation, 5% of those requiring ventilation or respiratory aid and around 1% die. Ideally, we can identify why some people remain asymptomatic, whilst others become critically ill. Furthermore, which young people are susceptible to blood vessel inflammation and megakaryocyte infiltration needs to be ascertained. However, concurrently, if the susceptible people are identified, those non-susceptible individuals should be considerate of those less fortunate, and maintain social distancing, use of masks, hand sanitation, etc.
Interestingly, it appears that the death rate curve, in the USA, has started to flatten, or even trending downward. Comparing the infection and death rates in areas affected early by COVID-19, such as New Jersey and New York with Texas and Arizona, it may be that the treatment and preparedness for the pandemic has improved, and/or the virus is less virulent? However, on 19 July 2020, hospital bed capacity, in Arizona, had reached 100% occupancy and people were being moved to neighbouring states. Initially, clinicians considered it to be a respiratory disease, however now it's also considered a vascular disease. ICU survival rates in Australia are approx 85%, in the UK approx 60%, whilst in the USA it's as low as 30%. Apparently, it's been very hard to ween people off ventilators, so positive airways pressure masks, as used traditionally for sleep apnoea, and developed by ResMed, Australia, are preferred to intubation.
International death rate : 14 July 2020
Interestingly, china appears in the 'rest of Asia' category.
A medical case presentation in a NHS health care worker: early April 2020
The following is from a online clinical forum to which i belong. This pertains to emergency medical treatment, of a 47 year old RN (registered nurse). Although it is not describing physiotherapy, I feel it contains a lot of useful information for those who have been confused by social media..
The ensuing discussion related to the use of anti-biotics such as erythromicin. The consensus was to use it in case of secondary bacterial infection. However, one clinician pointed out that at least one publication demonstrated it's use for viral infections as well as significant anti-inflammatory side effects in the lungs. '#Azithromycin and erythromycin are unusual — for example erythromycin is given to increase gastric emptying time for GI issues. In the case of #Azithromycin, it might be that in addition to being anti inflammatory, it also has antiviral properties: Gielen V, Johnston SL, Edwards MR. Azithromycin induces anti-viral responses in bronchial epithelial cells. Eur Respir J. 2010 Sep;36(3):646-54. However, erythromycin may be treating co-morbidity factors due to increased vulnerability, to bacterial infections, in a compromised immune system? ' The reduced gastric emptying is also interesting as the gastric biome is one of largest sources of immune material in the body. The patient was later transferred to a special care unit. Let's hope that this front line care worker, as many others, survive.
COVID-19 is not just a pulmonary disease - digestive symptoms : 7 May 2020
Breathlessness due to vascular complications in younger people : 11 April 2020
Breathlessness is a symptom that occurs 5-10 days into the disease. A gradual build up of hypoxia has been reported which may be accompanied by a loss of taste and smell, culminating in 50% oxygen saturation when people were turning up at hospitals. Pulse oxcimeters have been recommended. An example made, was Germany, where people diagnosed with COVID-19 are tested daily in their homes, hereby predicting morbidity, and resulting in the lowest mortality rates in the world. Other symptoms may include a temperature and sore throat, which can be accompanied by headaches, deep aches and pains. In some younger people stroke like symptoms such as drowsiness, slurred speech and paralysis. Additional symptoms are now evolving which include skin reactions and frostbite like rashes on the toes.
"Of the first 200 reports analysed for the study, out of a total of 300 in the registry today, about half were toe rashes. The other skin conditions reported include hives, those itchy red bumps that are usually a sign of an allergic reaction; water blisters; and something that looks a lot like chickenpox".
( https://www.washingtonpost.com/health/2020/04/29/coronavirus-rashes-toes/ ).
Federal government Health Direct website allows people to answer questions on symptoms and gives them a course of action. https://www.health.gov.au/resources/apps-and-tools/healthdirect-coronavirus-covid-19-symptom-checker
Kawasaki disease in very young people during COVID-19
Although very rare, worldwide there have been around 100 reported deaths in children with Kawasaki syndrome (26 May 2020 Vancouver Health Official - Dr Henry Minister Dix). This appears to be a post viral syndrome. Additionally, there appears to be children to adult cross infection, rather than vice versa. Most likely, the very low incidence of COVID-19 in children is due to the limited number of ACE 2 angiotensin receptors in children compared with adults. These ACE 2 receptors are found in the upper respiratory tract, lungs, heart, intestines and kidneys (responsible for blood pressure). The conversion of angiotensin II to angiotensin which lowers blood pressure occurs here. Unfortunately, ACE 2 receptor sites are an entry point for COVID-19.
Angiotensin II and ACE 2 receptor - Wikipedia 26 May 2020
ACE2 lowers blood pressure by catalysing the hydrolysis of angiotensin II (a vasoconstrictor peptide) into angiotensin (a vasodilator). As a transmembrane protein, ACE2 serves as the main entry point into cells for some coronaviruses, including HCoV-NL63, SARS-CoV (the virus that causes Severe Acute Respiratory Syndrome {SARS}) and SARS-CoV-2 (the virus that causes COVID-19). ACE2 mRNA expression is also found in the cerebral cortex, striatum, hypothalamus, and brainstem. The expression of ACE2 in cortical neurons and glia make them susceptible to a SARS-CoV-2 attack, which was the possible basis of anosmia and incidences of neurological deficits seen in COVID-19. As anosmia and dysgeusia (loss of smell and taste) are seen early in many COVID-19 patients, it was suggested to be considered to be a heralding clue in COVID-19, which subsequently was declared as "significant symptoms" in COVID-19 by the American Academy of Otolaryngology–Head and Neck Surgery.
ACE 2
Practice Closure
As you may be aware, the practice was closed from 6 March 2020 until 4 May 2020. It was a tough decision to make, however we were unable to be sure that we would not contribute to cross contamination of our clients with COVID-19. Although we are deemed an essential service, in the light of the Ruby Princess, we believed in the Australian Government and NSW Government policy of a shut down of non-essential services. When there was some loosening of these restrictions we were prepared to treat our clients so long as they were using the COVIDsafe app, and we are able to gain access to PPE (Personal Protective Equipment) and sanitising agents. At the time of closure, these latter resources were scant, and were better used at 'coal face' settings, whose role in fighting this virus was of a higher priority, than us.
The practice re-opened on 4 May - with limited sessions and COVID-19 procedures in place. 'Normal' opening occurred after the Queens birthday long weekend, June 2020.
We require all of our clients to be symptom free and to be using the COVIDSafe app. We also request all clients to wear masks.
Projected deaths 26 March 2020
Look at the North American and world numbers and compare them to these real numbers on 29 April 2020. Deaths vs number of infections is worrying and suggests a large number of unconfirmed cases. Compared to 22 June 2020. Exponential growth, with an extra million in the past month and many countries, such as Brasil, Russia, China and the USA, deliberately under-reporting the numbers, whereas other countries don't have the epidemiology tools to analyse let alone test symptomatic and asymptomatic people. Importantly, compare these numbers with those predicted by the Imperial College shown above. The fact that the USA has 120,000 deaths (23 June 2020) would suggest that the asymptomatic or untested population is much higher (over 17,730,000) or that the disease may be more deadly than predicted?
Compare these results with those of America on 12/06/2020 where these numbers doubled in just over 6 weeks. This is in the midst of the Black Lives Matter protests. Considering that the infection takes 2 weeks to incubate, it is interesting to watch these numbers as America moves into summer, where in theory the virus should be less virulent. The following demonstrates that those 'hot' states are still showing high rates of infection as well as high rates of hospitalisation (Texas was at 97% capacity in early July).
USA death rate almost 160 000 : 3 August 2020 - height of summer!
Texas daily infection rate : 14 July 2020
Florida daily infection rates : 14 July 2020
Daily infection rates USA : 19 July 2020
USA death rate : 16 September 2020
Trump - do nothing approach - 5% of the world population but almost 20% of the world deaths
Worldwide Status of COVID-19 - 30 March 2020 vs 30 April 2020 (1 million recoveries) vs 29 May 2020 vs 23 June 2020 (Opening, Post Shut Down) vs 1 August 2020 vs 16 Sept 2020 vs 12 July 2021
Heartening, are the number of 1 million recovered cases on 30 April. However, testing in many countries is still woefully inadequate and many people have now shown mild and severe symptoms which weren't previously associated with COVID-19. Big jump in numbers with testing and gradual opening up of the movement restrictions. In countries, such as Brasil and the USA, their presidents discourage social distancing and wearing of masks.
Wearing a mask : 14 July 2020
Health authorities, in Australia, don't recommend wearing a mask, in all states, except Victoria. Reasons for this vary, but the major one, is that people gain a false sense of security and that they play, with their hands, with their masks. Worldwide, where there has been a significant outbreak and where a sensible health care administration exists, mask wearing has been recommended in places where social distancing cannot be practised.
Australian Cases : 29 May 2020 vs 23 June 2020 vs 19 July 2020 vs 3 August 2020
Sudden increase in infection rates in Victoria, resulting in resumption of total stage 4 lock down, to stop the spread.
Australian Cases : 8 April 2020 vs 22 June 2020
Bush Fires
Australia is doing extremely well. Some of this can be attributed to the closing of borders and partial closure and social distancing measures. However, the borders weren't closed until the end of March. This was extremely late. By this time, the virus was rampant in Europe and other parts of the world. We also know that the virus existed since at least November 2019. The first death from COVID-19 in France was in December and evidence suggests that the virus was present in Washington State and California in late December.
During November 2019 through to February 2020 Australia suffered the worst bush fires in history. A billion dead animals and 19 million hectres of burnt countryside. This meant that overseas tourists didn't come and visit Australia. Moreover, Australians themselves didn't move around to the usual holiday spots. Furthermore, thanks to the appalling smoke haze, most people avoided going outside. We were quarantining and self isolating, even though we weren't aware of this, at the time.
Social Distancing : 10 April 2020 vs 19 July 2020
Note that the curve of new incidents is going down, which means social distancing is working. Clearly, we need to maintain this.
Then, unfortunately, due to two security guards, doing the wrong thing, whilst guarding hotel quarantine people, a sudden surge of infections in Victoria : 19 July 2020
Recovery vs Death Rate - 15 April 2020 Australia
The flattening curve in Australia 24 April 2020
Social distancing and partial shut down had been working. The curve of new cases was flattening. Then the tricky situation was the gradual re-opening. Testing testing and testing is critically important to contain areas of focal contagion.
The other big question was what will happen as we go into winter?....as well as what happens when we gradually re-open?
Active New Cases : 29 May 2020
Thanks to social distancing and government policy we were gradually able to re-open. But we became complacent.
Letter from Spain - 7 April 2020
Hi Martin,
thanks for your facebook message. We are going through a nightmare of which it will take time to wake up.
I look after infected patients at my hospital, most of them frail and elderly. This disease is a death sentence for many of them.
It is not particularly challenging in my context from a clinical point of view, as you give them support and little else, either they survive or not. The problem are young people at general hospitals sometimes without availability of critical care beds and ventilators. There are many reasons to understand why Italy and Spain are hit so badly. I just wish your country does not get into this ordeal. Aside from purely clinical aspects, logistics and psychological topics are the problem: lock down, isolation, lack of equipment at the hospitals and long-term facilities, giving bad news through the telephone instead of face to face, people die alone, consequences of all this for mental health ...
We still have quite a few weeks of lock down ahead and the social and economic consequences of all this are going to be catastrophic, but we shall have to manage somehow. Political situation is highly unstable and deeply worrying. Hope we shall survive that aspect too.
How are you getting on yourselves and your relatives?
I´m not aware of the situation in your continent, to be honest, but I do not think anywhere in the world will be spared, under very effective countermeasures are timely taken in the places where it has not set foot yet.
Take care and keep social distancing and ancillary measures, for now we do not have any other approach. Politicians ignored all advice and did not realise that a pandemic was approaching and it could have devastating consequences. From an infectious diseases keen student as I am, this virus compounds the perfect storm.
All the best for now from Spain,
Angel
Optimism : 31 March 2020
Currently, there is room for optimism. Last night's (31 March 2020) new cases were down from double digits to around 9%. Australia has one of the highest rates of testing in the world. Social distancing, self isolation and isolation of people testing positive seems to be finally having an effect Work on using blood 'pin prick' testing kits is demonstrating a result within 15 minutes of testing and should become more readily available shortly. Unfortunately, there seems to be an unacceptable high rate of false negatives (up to 48%), which may give people a false sense of security. However, apart from the upside of 'ease of use', this type of testing allows people to monitor the production of anti-bodies to COVID-19. Such production, is synonymous with a persons immune system actively fighting the virus. In people, who have recovered or who only had mild symptoms, it may be possible to harvest their blood plasma and use those in transfusions for people who are critically ill. It's a similar principle to the methodology used, in the past, for immunisation against Hepatitis A.
Antimalarial drugs based on chloroqine were showing some potential benefit, but should only have been prescribed under medical supervision. For some odd reason, the president of the USA thought it was OK to recommend it to the general public!!!! However, a gin and tonic to calm the nerves, at the end of day may be used, as the tonic contains a small amount of quinine.......ha ha
In theory, chloroquine could be used as a prophylactic against COVID-19, as it has been used as a prophylactic against Malaria and is used in people with auto-immune inflammatory disorders. We do know, that people who do badly, are the ones who have a compromised immune response, where there is an over-activity of immune substances creating a 'cytokine storm' in older individuals, or platelet over-activity resulting in blood clots in younger people.
Anti viral drugs will probably be paramount in the fight against this virus. Anybody watching the news from the United States will notice the immunologist Dr Anthony Fauci. He was at the forefront of AIDS research in the infancy of that epidemic back in the 1980's. He's advised every president on pandemics and epidemics since then. Considering that the man is in his early 80's, he's an incredibly tough and brilliant guy and a sane sight at Trumps hopeless press conference briefings.
Another reason for optimism is the use of the TB antigen. The TB vaccine has been shown to reactive the innate immune system and has been used over the past few years in the treatment of bladder cancer. In fact, a few years ago, my mother-in-law, was diagnosed with an inoperable tumour, sitting on the kidney and next to the aorta. Over the following month, the tumour continued to grow, when suddenly it began to shrink, without any form of intervention. The diagnosis was never clear, however, all the puzzled specialists felt that it could have shrunk thanks to the fact she had had TB as a child!?
http://malthus.micro.med.umich.edu/lab/pubs/nrmicro1919.pdf
The innate immune system is the one we're born with. As we go through life, we are exposed to various pathogens, which create an innate immune reaction which produces the anti-bodies of the acquired immune system. Unfortunately, as we age, we have less protein in our body to produce such anti-bodies. The classic immune substances involved with this process are heat shock proteins (HSP). These are the basic building blocks of multi-cellular life. In mammals, the HSP's act with muscle protein to produce immune conversion. Unfortunately, after the 3rd decade of life, sedentary adults lose 1% muscle mass per year and after the 6th decade of life they lose 2% of their muscle mass. This process is called sarcopenia. To avoid sarcopenia individuals need to do at least 40 minutes of quality exercise, around twice a week. Hence, stay healthy, keep exercising and maintain muscle mass so that you have the reservoir of protein needed to fight infections and decay. Furthermore, regular exercise in this age of partial shut down is another good way to maintain mental health.
mRNA vaccines : 3 August 2020
Just like normal vaccines, RNA vaccines are intended to induce the production of antibodies which will bind to potential pathogens. The RNA sequence codes for antigens, proteins that are identical or resembling those of the pathogen. Upon the delivery of the vaccine into the body, this sequence is translated by the host cells to produce the encoded antigens, which then stimulate the body’s adaptive immune system to produce antibodies against the pathogen.
mRNA vaccines have never been used before. They differ to traditional vaccines, in that they encode the protein sequencing to produce antibodies (IgG) identical to those found in people who have immunity to novel corona viruses. They may also have a potential role in the treatment of cancer.
Novovax : Australia
For Phase 1 only. Additional information will be provided if Phase 2 is implemented. 2019nCoV-101 is a 2-part, randomized, observer-blinded, placebo-controlled, Phase 1/2 trial designed to evaluate the immunogenicity and safety of SARS-CoV-2 rS nanoparticle vaccine with or without Matrix-M adjuvant in healthy participants ≥ 18 to 59 (inclusive) years of age. The study will be conducted in 2 parts. In Part 1, at least 1 and up to two SARS-CoV-2 rS constructs will be evaluated in up to 2 cohorts, which may be enrolled in parallel. An interim analysis of Part 1 safety and immunogenicity data will be performed prior to an optional expansion to Part 2. https://clinicaltrials.gov/ct2/show/NCT04368988?term=vaccine&recrs=a&cond=covid-19&draw=2
University of Queensland
University Queensland COVID19 Trial Vaccine
Astra Zenica, UK
http://www.isrctn.com/ISRCTN89951424
WHO
https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines
A possible concern could be that some mRNA-based vaccine platforms induce potent type I interferon responses, which have been associated not only with inflammation but also potentially with autoimmunity. Thus, identification of individuals at an increased risk of autoimmune reactions before mRNA vaccination may allow reasonable precautions to be taken.
Exercise and the immune system
Your muscles are a major endocrine organ of the immune system. Their lean muscle bulk, is of utmost importance to ensure a sufficient reservoir of protein, which is needed to mobilise an immune defence.
People should exercise muscles regularly, not only to prevent sarcopenia, but also to mobilise and fine tune your immune system, as well as maintain a healthy BMI
Progressive resistance exercise and endurance training
Physiotherapy and the enhancement of perception of musculoskeletal and hence immune health
Investigation into combined drug treatment : Chloroquine and Azithromycin : 20 March 2020
Chloroquine and hydroxychloroquine have been found to be efficient on SARS-CoV-2, and reported to be efficient in Chinese COVID-19 patients. They evaluated the role of hydroxychloroquine on respiratory viral loads.
Patients and methods
French Confirmed COVID-19 patients were included in a single arm protocol from early March to March 16th, to receive 600mg of hydroxychloroquine daily and their viral load in nasopharyngeal swabs was tested daily in a hospital setting. Depending on their clinical presentation, azithromycin was added to the treatment. Untreated patients from another centre and cases refusing the protocol were included as negative controls. Presence and absence of virus at Day 6-post inclusion was considered the end point.
Results
Six patients were asymptomatic, 22 had upper respiratory tract infection symptoms and eight had lower respiratory tract infection symptoms.
Twenty cases were treated in this study and showed a significant reduction of the viral carriage at D6-post inclusion compared to controls, and much lower average carrying duration than reported of untreated patients in the literature. Azithromycin added to hydroxychloroquine was significantly more efficient for virus elimination.
Conclusion
Despite its small sample size our survey shows that hydroxychloroquine treatment is significantly associated with viral load reduction/disappearance in COVID-19 patients and its effect is reinforced by azithromycin.
Philippe Gautret et al (20 March 2020)
https://www.sciencedirect.com/science/article/pii/S0924857920300996
Importantly, this small n=6 investigation is what the president of the USA and Fox News were basing all their hopes on. It could also be dangerous to treat some patients in this manor. As we've outlined on our FB page, we suggest people follow the facts and not believe in an orange Buffoon.
President George W Bush predicted and prepared for a pandemic in 2005.
The orange buffoon and taking prophylactic hydroxychloroquine - 26 May 2020
Chloroquine - 12 June 2020
After WHO discontinuing research into Chloroquine, they have reversed that decision as it is thought that that the above investigation was flawed. It might be best to take the medical interventions and directions of research out of the hands of non-specialists and the media!
The orange buffoon - recommending internal UV and disinfectants - 26 April 2020
This is 'fake news' ?......but continues on with the appalling handling of COVID-19 by the President of the United States.
President Obama continued along this path for preparing the USA for pandemics by creating a global pandemic detection and deterrent department in the CDC.
The orange buffoon dismantled all these things!!!! Additionally, it would appear he was given warnings of the impending pandemic as early as January 2020. But since he watches Fox, for his news, he remained ignorant of them.
The key to good leadership is knowing when you aren't the smartest person in the room.
The warning, (in late January 2020) written in a memo by Peter Navarro, President Trump’s trade adviser, is the highest-level alert known to have circulated inside the West Wing as the administration was taking its first substantive steps to confront a crisis that had already consumed China’s leaders and would go on to upend life in Europe and the United States
“The lack of immune protection or an existing cure or vaccine would leave Americans defenceless in the case of a full-blown coronavirus outbreak on U.S. soil,” Mr. Navarro’s memo said. “This lack of protection elevates the risk of the coronavirus evolving into a full-blown pandemic, imperilling the lives of millions of Americans.” ( https://www.nytimes.com/2020/04/06/us/politics/navarro-warning-trump-coronavirus.html )
The orange buffoon and World Health Organisation (WHO)
WHO was warned by Taiwan, in late November 2019 about an N!H1 like virus in Wuhan. WHO ignored this, as Taiwan isn't a part of WHO. Additionally, Taiwan is considered by China as a part of it's sovereignty. The Washington Post, Taipei desk, warned of a H1N1 like virus (SARS) coming out of Wuhan on 6 December 2019. WHO declared a pandemic after Chinese New Year (mid January 2020) to pander to China's sensitivities. Never-the-less, a pandemic was declared by the end of January 2020.
Apart from letting a precarious situation fester for two months and get out of control, it's given the orange buffoon someone to blame!!! Basically, all of February was lost with inaction by him, 'it's a hoax", "it will go away, just disappear", This narcissistic attitude, as well as posturing by his sycophants, has not only exposed health care workers to unacceptable danger, it probably has resulted in tens of thousands of potentially avoidable deaths. Lack of PPE and ventilators, institutions specifically for such a crisis having been dismantled, being some of his many failings. Just listen to the governor of New York, Andrew Cuomo.
Then, the incredible news in mid April, when WHO gave the green light for the wet market in Wuhan to re-open. Clearly, WHO has to walk a political tight rope, considering various cultural sensitivities and needing to appease many disparate parties with varying geopolitical considerations. Ultimately what is of paramount importance is the health and well-being of the worlds population. Hopefully, going forward, a constructive relationship can be developed by all parties within and outside of WHO, in the fight against the virus.
Erythromycin
Erythromycin is an antibiotic which has been used for many decades. Unlike many antibiotics, people do not develop resistance to it's effect. Classically, the drug was used for lung conditions. Interestingly, my father, Norbert Krause, is probably the last living person in Australia who knows the industrial process of making erythromycin. He was involved, as an industrial chemist, in it's production, at Abbott Laboratories, in Kurnell, NSW, Australia, until production was shut down some time in the 1980's, for cheaper options overseas. Another victim of globalisation.
Heat Shock Protein 90 (HSP-90), Geldanamycin and COVID-19 : 19 May 2020
An intersting artcile on drug repositioning (defined as the use of approved drugs for new indications), offering an unmatched opportunity to offer novel therapeutics to treat SARS family of coronaviruses (SARS-FCoVs); Reaserchers analyzed, a dataset of patients who presented with SARS during the 2003 outbreak whereby they established a gene signature that defines differential gene expression in patients who were sick with SARS vs. healthy controls and convalescent patients. They used a robust platform to conduct drug repositioning based on clustered gene expression and pathway enrichment to identify best matching drugs. They identified 55 agents of potential benefit. In most of these drugs they were able to establish a link to previous related research, use as antiviral, or at least a hypothetical role in treating SARS-FCoVs. Most notably, the heat shock protein 90 (hsp90) emerged as a major component that enables viruses to hijack infected cells through the process of autophagy. Almost half of the drugs identified could be linked to hsp90. As such, they propose using hsp90 inhibitors, mainly geldanamycin and its derivatives, to treat COVID-19. (https://www.researchsquare.com/article/rs-18714/v1)
Based on their findings, they suggest adding more drugs to the experimental arsenal deployed against SARS-FCoVs. They suggested using nontoxic drugs that are readily available for wide scale prophylaxis or the treatment of mild cases of COVID–19. These drugs would include omeprazole, nonsteroidal anti-inflammatory drugs, colchicine, sulfoanamide antibiotics, antimalarial drugs and clozapine/chlorpromazine. For patients with serious COVID–19 illnesses, the above drugs can be combined with immune modulators like sirolimus, and direct Hsp90 inhibitors under well-designed clinical trials. Given the high pathogenicity of the current ongoing epidemic, they suggested that it seems prudent to attempt to use multiple drugs in combination if low risk for toxicity and drug-drug interaction is established. Choosing a combination of drugs identified in this study or other drug-repositioning studies and careful reporting of the efficacy of these experiences can result in rapid accumulation of knowledge.(Iyad Sultan, Scott Howard, Abdelghani Tbakhi (2020, DOI : 10.21203/rs.3.rs-18714/v1)
Added Complication - 27 April 2020 Pulmonary embolus and venous pulmonary clots
Growing clinical evidnece is finding severe clotting in some individuals with COVID-19. Moreover, pulmonary clots and even strokes have been reported in young individuals (aged 20-40) by an Australian physician in New York (Washington Post 26 April 2020), In fact, the clotting was so profound that re-clotting was occuring during clot busting surgery. Pulmonary venous clotting has also been described by French physicians.
A research letter from Hôpitaux Universitaires de Strasbourg published today in Radiology reported that of 106 pulmonary CT angiograms performed for COVID-19 patients over a one-month period in a tertiary care centre in France, 32 patients (30%) had acute pulmonary embolus (PE). This rate of PE is much higher than usually encountered in critically ill patients without COVID-19 infection (1.3%,) or in emergency department patients (3 to 10%). In the study, a D-dimer threshold of 2660 μg/L detected all patients with PE on chest CT.
A second research letter published today described a study from Centre Hospitalier Universitaire de Besancon in France pointed to high proportion (23%) of COVID-19 patients with contrast CT had PE. PE was diagnosed at mean of 12 days from symptom onset. Patients with PE were more likely require care in the critical care unit and to require mechanical ventilation. (https://www.sciencedaily.com/releases/2020/04/200423143100.htm)
Therefore, there is strong evidence of a combined airway-vascular response leading to organ failure. Such a combination of a 'cytokine storm' and thrombocytic events incorporating auto-immune responses leading to respiratory failure and the need for intubation and ventilation, even in young people.
Obesity and COVID-19 in younger people : 5 May 2020
Health Minister announcement 31 March 2020
The Australian minister of health announced the take over of private hospitals with the already announced cancellation of elective surgery. This will bring the total capacity of beds in Australia to 35000, of which 2200 are ICU beds. Currently, 47 ICU beds are occupied by a COVID-19 patient. Furthermore, respirators for anaesthesia are being remodelled to become ventilators, bringing the total number to around 5000 ventilators. ResMed is currently building more ventilators to bring the total number to around 7500 by the end of April. Additionally, CPAP masks, normally used for sleep apnoea, will be manufactured and deployed, as their positive pressure should help prevent lungs from collapsing.
Countries begin to re-open : 16 April 2020
Denmark and Germany have announced partial re-opening of the country from quite strict shut-down implementation. Denmark announced that pre-schools and primary schools would begin to re-open. The thinking here, is that children and parents of young children, who are generally part of the younger population are more resilient to COVID-19. Speaking with my wife's cousin, whose a GP in Denmark, he said that there was still a general lack of PPE, even in his practice, let alone in the general population. He also stated that if there wasn't a relaxation of the restrictions, there could be social issues, such as alcoholism, domestic violence and even civil unrest. On the other hand, Germany has gone the furthest with testing, PPE, health implementation and even taken patients from France and Italy. Their confidence for a general but gradual re-opening is because of their high rates of testing and epidemilogical capabilities.
Australian re-opening : 29 May 2020
Looks like there is a predicted gradual re-opening in Australia around mid May is going ahead as scheduled. NRL played their first game post lock down. Community sports have been given the green light to start training with no more than 10 people in a group. Matches may start as early as July. No doubt, some parts of the country will re-open at different rates to others, depending on active cases. Until a vaccine is found, it's also possible that roll back and shut downs will also occur along the way. Interestingly, this week an anti-viral Remdesivir, a vaccine out of Baltimore, is being trialled in Victoria. Early days, but wouldn't it be great if Australian becomes part of the cure. In NSW, two clinical trials and peer consensus recommended approach to treatment are the current policy.
Assurance
Please bear with us in this time of crisis. Rest assured, we have begun to re-open as as we feel it is safe to do so. However, remember, North Sydney has a working population from all over Sydney, making it even more prudent to be cautious with our re-opening. We are cleaning morning and night as well as between each client. We are also keeping the number of people at anyone time, in the practice to 5 in 84m2. In the mean time, don't hesitate to contact us via email or make a booking on-line. https://www.myhealth1st.com.au/find/physiotherapists/nsw/nsw-region/north-sydney/back-in-business-physiotherapy. Additionally, you can stay up-to-date using our Facebook Page : https://www.facebook.com/backinbusinessphysio/
Download the tracking app - 26 April 2020
Today I downloaded the tracking app for COVID-19. Testing, testing, testing is super important to track and contain the virus. It is impossible to test everyone, and even if someone who has tested negative one day, can still test positive a week later. Therefore, downloading the tracking app will allow authorities to notify us if we've inadvertently been in contact with someone who has tested positive. If there isn't universal download of this app, then further spreading and ensuing deaths could occur. The alternative would be to have more 'shut downs' and even more serious restrictions of our liberty, re-imposed!
Unfortunately, at the end of May only 6 million people have downloaded the app. I've downloaded the COVID-19 tracking app. It's imperative that we all do so. It makes our invisible mortal enemy visible. Not knowing that we've been in contact with the virus is disconcerting enough, let alone if the authorities are powerless to act, because they don't have the knowledge, to know where, to contain it. This becomes even more important as we begin to open up the country. Do everyone a favour and download the App
https://www.health.gov.au/resources/apps-and-tools/covidsafe-app
Opening - 4 May 2020
Currently, at Back in Business Physiotherapy, we are considering A VERY LIMITED OPENING of 2 DAYS PER WEEK, with very strict 1 client per hour schedule. This should minimise any client overlap as well as give us sufficient time to clean all surfaces and the treatment room. Stay tuned, but it could be as early as 1 May 2020. Currently, 14 July 2020, we are open 4 days a week, whilst still maintaining a strict cleaning regime. I also do wear a mask.
Psychiatric issues amongst health workers who had contracted COVID-19 - 28 April 2020
There was very sad news of a young previously healthy doctor who went back to work after recovering COVID-19 and subsequently took her own life!!
"She went down in the trenches and was killed by the enemy on the front line," Philip Breen said. "She loved New York and wouldn't hear about living anywhere else. She loved her coworkers and did what she could for them.""I just want people to know how special she was," he added. Health care workers face a mental health crisis as they battle the coronavirus pandemic. Philip Breen is a retired trauma surgeon, and he and his daughter would speak frequently about work, he said. Lorna Breen told her father that her colleagues were putting in 18-hour days and sleeping in hallways, and that ambulances couldn't get in because it was so busy. She worked in the emergency department and had been on the front lines for weeks, handling the onslaught of cases, her father said. New York City has been the US' pandemic epicentre, recording nearly 300,000 cases and more than 22,000 deaths as of Tuesday morning. Breen contracted Covid-19 and took a week and a half off to recover, but when she went back to work, she couldn't last through a 12-hour shift, her father said. Still, she felt like she had to get back in there to help her colleagues.
"Frontline healthcare professionals and first responders are not immune to the mental or physical effects of the current pandemic," said Charlottesville Police Chief RaShall Brackney. "On a daily basis, these professionals operate under the most stressful of circumstances, and the Coronavirus has introduced additional stressors."
"Words cannot convey the sense of loss we feel today," the New York City hospitals where Breen worked said in a statement.
"Dr. Breen is a hero who brought the highest ideals of medicine to the challenging front lines of the emergency department," they said. "Our focus today is to provide support to her family, friends, and colleagues as they cope with this news during what is already an extraordinarily difficult time."
https://edition.cnn.com/2020/04/28/us/er-doctor-coronavirus-help-death-by-suicide-trnd/index.html
Dr Fauci comes under attack - 13/05/2020
Unbelievably, the Trumpster and his favourite TV organisation FOX, attacked Dr Fauci's opinion on children return to school timetable. During a senate hearing testimony, Dr Fauci suggested that it would be more prudent to wait for a vaccine before children return to school. FOX suggested that Dr Fauci was unqualified as he wasn't elected to do so. They also suggested that he is a mouthpiece of the democrats. This is unbelievable in the face of the increasing prevalence of Kawasaki Disease during COVID-19.
Additionally, a former Trump administration official who was controversially removed from his post has warned that the US faces its "darkest winter in modern history" unless the federal government develops a coordinated response to the coronavirus.
Dr Rick Bright, the former head of the Biomedical Advanced Research and Development Authority, was in charge of the federal agency responsible for developing a vaccine and therapeutic treatments for COVID-19 until he was reassigned to a less significant position in April.
Bright has filed a whistleblower complaint accusing the Trump administration of improperly pushing unproven treatments such as hydroxychloroquine and failing to grasp the seriousness of the outbreak until it was too late.
The real heroes are the health officials and front line care workers not narcissistic self serving politicians, surrounded by their sycophants..
Health Care Workers being attacked
There have been very disturbing reports of health care workers being attacked, doused in bleach and chlorine, evicted from their homes, etc. THIS IS TOTALLY UNACCEPTABLE - THE DEPRAVITY OF HUMANITY AT ITS WORST!! But when people are scared for their survival, those primival instincts come to the fore.
https://www.theguardian.com/world/2020/apr/23/mexico-health-workers-attacked-covid-19-fears
.......and to all our 'coal face' front line health workers - a tribute to them
Potentially, the virus has been around since October 2019
A novel research approach by Harvard University, using satellite images of car parking movements of a Wuhan car park, suggest that some kind of epidemic was already commencing much earlier than we thought. Correlation doesn't necessarily mean causality, so in the abscence of Chinese openess to researching the origins of the COVID-19 virus, these results should be taken with a grain of salt.
Exercise and the immune system, especially when ageing
If you would like to understand how exercise affects the immune system, please take a look at this page, on another part of this website.
Uploaded : 30 March 2020
Updated : 20 September 2021
