How Many Dermatologists Does It Take to Start a Global Pandemic?

There is typically nothing useful or entertaining about epidemiological studies. Not this time. An early release article about a bunch of dermatologists at a meeting in Munich this past February has elements of both.

TIME FOR QUOTES

But first, quotes on dermatology and meetings, which, if not entirely true are certainly relevant. Maybe even prescient.

On dermatology:

"Dermatology is the best specialty. The patient never dies – or gets better."  - Anonymous

On meetings:

“Be polite, be professional, but have a plan to kill everyone you meet.”  - Oliver North, Counterfeit Lies

The article, which was written by DirkJan Hijnen of Erasmus MC University Medical Center in the Netherlands and colleagues from five other EU countries, discusses something we all know by now – how insanely contagious SARS-2 (1) is and how the dermatologists (2) didn't comply with medical dogma at the time. Perhaps we need another quote.

"Practice what you preach squeeze."  - J. Bloom, May 2020

WHAT HAPPENED AT THAT MEETING?

At an advisory meeting in Munich during late February, 14 people, the majority of whom were dermatologists, showed up. One of the 14 – a presymptomatic carrier managed to infect at least 11 of the other 13 participants. Did they behave rashly*? You tell me. (* = pun alert)

"Eight dermatologists from 7 countries and 6 scientists from the same company attended the meeting at a hotel in central Munich [February 20–21]. The meeting was held in a room (≈70 m²) [the size of the room can be estimated to be 750 sq. feet - 30 X 25] with conventional radiators; a U-shaped setup of tables were separated by a central aisle >1 m wide."

Typical meeting set up. It's roughly equivalent to having 14 prisoners guests in a large living room.

"During the meeting, refreshments were served buffet style in the same room 4 times."

Uh oh. Don't buffet-style meals kind of skeeve you out even in the absence of a pandemic? 

"In addition to 9.5 hours of discussions..."

I'm betting that some of you are thinking that a full-blown case of COVID-19 might be more humane than the meeting.

"Additional direct contacts between participants were handshakes during welcome and farewell with few short hugs..." 

OK, by early January – more than a month before the meeting – handshakes were already becoming a no-no (Here is a January 12th podcast from the Radio Health Journal about stopping the practice). And it was banned following soccer matches in Canada in late January, even though there hadn't yet been a single reported case in the country.

BAD THINGS START TO HAPPEN

According to the paper, one of the participants infected all/most of the others, but I'm having some trouble with the timeline. "Participant 1," who is "Patient Zero," showed no signs of infection during the two-day meeting. 

"None of the participants, including the index patient (participant [Pt] 1), showed any signs of infection (e.g., coughing, sneezing, respiratory symptoms, shivering, fever) before or during the meeting. No one wore a mask during the meeting. After the meeting, the index patient (Pt 1) shared a taxi with Pt 2, 4, and 9 for ≈45 min."

I guess these four guys felt that they didn't have significant bonding time over the course of two unending days and chose not to take their own taxis. Or the company was too cheap to pay for them. And what's with the 45-minute taxi ride? That's a pretty long ride. In Germany, one can approximate that 45 a minute ride will get you something like 300 miles. (In Manhattan, you're lucky to get crosstown.)

STRANGE TIMING?

On the second day of the interminable conference (and also the interminable taxi ride), Patient Zero feels fine. But that evening he "sought care for fever," and was tested (the RT-PCR method, which measures active infection. Of course, it was positive, and Zero ended up in the hospital for supportive care. Doesn't this seem awfully fast? On the same day he's drooling on a pork chop at the buffet and that night he's heading to the hospital with COVID. Perhaps it was the pork chop.

The pork chop from hell

WHAT ABOUT THE OTHER GUYS?

Since people who are infected with SARS-2 are infectious days before they have symptoms you can't blame Zero for infecting others. But he/she did an admirable job. The other participants were contacted less than a week later. The results may not be entirely precise, but the message is obvious. Ten of the 13 (excluding Zero) tested positive by RT-PCR. One participant had no access to that test but later tested positive for coronavirus antibodies, and another had no symptoms but wasn't tested. So, in total, 11 (probably 12 and possibly all 13 of people at the meeting caught the virus from Pt 1. Nothing if not efficient.

Where did Pt 1 get it? Milan, of course - the first and worst hotspot in Italy. 

HOW WAS THE VIRUS TRANSMITTED?

The answer to this is probably "you name it," since these people did pretty much everything except share dental floss. The paper suggests some possibilities:

• "Face-to-face contacts lasting >5 min with the index patient and the 11 infected participants during 2 lunches (30 min each)"
• "Two coffee breaks (15 min each)."
• "A social dinner (sitting close to Pt 2, 4, 5, and 11)."
• The index patient sat ≈2.60 m [6 feet ain't enough in a closed room] away from the closest participant opposite to him and had an average talk time during the meeting. 

TO BELABOR THE OBVIOUS - THE CONCLUSION

"Our findings indicate that handshaking, aerosolization, and face-to-face contact may be relevant modes of transmission in this COVID-19 outbreak."

Damn, I would have put my money on the buffet. But it's OK, I have no skin* in the game.

NOTES:

(1) I'm sick of writing out SARS-CoV-2. If SARS-2 isn't sufficient, deal with it.

(2) Yes, I know dermatologists save lives. I saw that Seinfeld episode 10 times.