Lockdowns and the Science of COVID June 24, 2021 Jay Bhattacharya, MD, PhD Stanford University Table of Contents A. Does Covid-19 pose a real or imminent serious threat to the health of the population? ........... 2 B. What Does the Scientific Evidence Indicate Regarding the Possibility that a Person with No COVID-19 symptoms, but Infected With SARS-CoV-2, Can Spread the Virus to Others? .......... 7 C. What principles of good health policy and public health practice do lockdown policies violate? .......................................................................................................................................... 10 D. Are lockdown measures necessary to maintain and enhance the health and well-being of the general population? ....................................................................................................................... 12 E. Are governmental actions aiming to slow down the propagation of the disease harmful to the health of the population? ............................................................................................................... 18 F. Do the Emergence of Variant Strains of the SARS-CoV-2 Virus Justify Continuing Lockdowns? .................................................................................................................................. 21 G. Are the harms of the lockdowns equitably distributed? ........................................................... 26 H. Do Children Pose A High Risk of Disease Spread? ................................................................ 27 I. How Effective is contact tracing in controlling disease spread? ............................................... 34 J. What Specific Harms Do Young Adults Face From Lockdowns? ........................................... 35 K. How Beneficial Are Religious Services For Participants And Can They Be Held Safely? .... 36 L. Can Restaurants And Bars Be Opened Safely? ........................................................................ 39 M. What Benefits Do Gyms, Martial Arts Studios, And Other Physical Fitness Venues Provide For Public Health And Can They Operate With Minimal Risk Of Disease Spread? ................... 41 N. Do Alternate Policies Exist That Can Protect the Population, That Do Not Impair Human Rights, Civil Liberties, Constitutional Freedoms, And Basic Principles of Public Health? ......... 43 O. Is There Lasting Natural Immunity After Recovering From COVID-19 Infection? ............... 46 P. What Concrete Policies Would Provide Focused Protection of the Vulnerable? ..................... 48 Q. Does A Positive RT-PCR Test For the SARS-CoV-2 Virus Imply That A Patient Poses A Substantial Risk Of Infecting Others? .......................................................................................... 51 Surveillance Case Definition .................................................................................................... 55 Appendix A: Is The Case of Manaus, Brazil A Counter Example To The Possibility of Focused Protection? .................................................................................................................................... 57 Reader Note: This paper has been prepared from submissions to the Manitoba Court of Queen’s Bench by Dr. Jay Bhattacharya on behalf of several Applicants in a Charter challenge against the Government of Manitoba. Most of this material was prepared in December 2020, with some updates in March 2021 and June 2021. It thus reflects the scientific literature up to those dates. The Applicants allege that the provincial lockdown response to COVID-19 is unconstitutional and unjustifiably violates the Charter freedoms of Manitobans. 1 A. Does Covid-19 pose a real or imminent serious threat to the health of the population? The mortality danger from COVID-19 infection varies substantially by age and a few chronic disease indicators.1 For much of the population, including the vast majority of children and young adults, COVID-19 infection poses less of a mortality risk than seasonal influenza. By contrast, for older populations – especially those with severe comorbid chronic conditions – COVID-19 infection poses a high risk of mortality, on the order of a 5% infection fatality rate. The best evidence on the infection fatality rate from SARS-CoV-12 infection (that is, the fraction of infected people who die due to the infection) comes from seroprevalence studies. The definition of seroprevalence of COVID-19 is the fraction of people within a population who have specific antibodies against SARS-CoV-2 in their bloodstream. Seroprevalence studies provide better evidence on the total number of people who have been infected than do case reports or positive reverse transcriptase-polymerase chain reaction (RT-PCR) test counts; these both miss infected people who are not identified by the public health authorities or do not volunteer for RT- PCR testing. Because they ignore unreported cases in the denominator, fatality rate estimates based on case reports or positive test counts are substantially biased upwards. According to a meta-analysis2 by Dr. John Ioannidis of every seroprevalence study conducted to date of publication with a supporting scientific paper (74 estimates from 61 studies and 51 different localities around the world), the median infection survival rate from COVID-19 infection is 99.77%. For COVID-19 patients under 70, the meta-analysis finds an infection survival rate of 99.95%. A separate meta-analysis3 by scientists independent of Dr. Ioannidis’ group, reaches qualitatively similar conclusions. A US CDC report4 found that there were between six and 24 times more SARS-CoV-2 infections than cases reported between March and May 2020. This study is based on serological analysis of blood samples incidentally collected by commercial laboratories in 10 cities nationwide, although the CDC does not provide the infection fatality rate estimate implied by their seroprevalence studies reviewed by Dr. Ioannidis above. In September 2020, the CDC updated its current best estimate of the infection fatality ratio - the 1 Public Health England (2020) Disparities in the Risk and Outcomes of COVID-19. August 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk _and_outcomes_of_COVID_August_2020_update.pdf 2 John P.A. Ioannidis , The Infection Fatality Rate of COVID- 19 Inferred from Seroprevalence Data, Bulletin of the World Health Organization BLT 20.265892. 3 Andrew T. Levin, et al., Assessing the Age Specificity of Infection Fatality Rate for COVID- 19: Meta-Analysis & Public Policy Implications (Aug. 14,2020)MEDRXIV, http://bit.ly/3gplolV. 4 Fiona P. Havers, et al., Seroprevalence of Antibodies to SARS-CoV-2 in 10 Sites in the United States, March 23-May 12, 2020 (Jul. 21, 2020) JAMA INTERN MED., https://bit.ly/3goZUgy. 2 ratio of deaths to the total number of people infected - for various age groups.5 The CDC estimates that the infection fatality rate for people ages 0-19 years is 0.003%, meaning infected children have a 99.997% survivability rate. The CDC’s best estimate of the infection fatality rate for people ages 20-49 years is 0.02%, meaning that young adults have a 99.98% survivability rate. The CDC’s best estimate of the infection fatality rate for people aged 50-69 years is 0.5%, meaning this age group has a 99.5% survivability rate. The CDC’s best estimate of infection fatality rate for people ages 70+ years is 5.4%, meaning seniors have a 94.6% survivability rate. A study of the seroprevalence of COVID-19 in Geneva, Switzerland (published in the Lancet)6 provides a detailed age breakdown of the infection survival rate in a preprint companion paper7 99.9984% for patients 5 to 9 years old; 99.99968% for patients 10 to 19 years old; 99.991% for patients 20 to 49 years old; 99.86% for patients 50 to 64 years old; and 94.6% for patients above 65. I estimated the age-specific infection fatality rates from the Santa Clara County seroprevalence study8 data (for which I am the senior investigator). The infection survival rate is 100% among people between 0 and 19 years (there were no deaths in Santa Clara in that age range up to that date); 99.987% for people between 20 and 39 years; 99.84% for people between 40 and 69 years; and 98.7% for people above 70 years. In fact, in all of California9 through August 20, there have been only two deaths at all among COVID-19 patients below age 18. Also, 74.2% of all COVID- 19 related deaths occurred in patients 65 and older. Further, COVID-19 case fatality rates have been dropping steadily since the disease emerged. Peer-reviewed studies document these trends.10 One study in England found that “30-day mortality peaked for people admitted to critical care in early April… There was subsequently a sustained decrease in mortality risk until the end of the study period” in late June. This trend was found for people of all age groups, and survived adjustment for patient characteristics, which strongly suggests an improvement in treatment and patient management as the cause.11 Ventilator protocols which were used during the early days of the epidemic were too aggressive, 5 COVID- 19 Pandemic Planning Scenarios, Centers for Disease Control and Prevention, https://www.cdc.gov/coronavirus/2019- ncov/hep/planning-scenarios.html. 6 Silvia Stringhini, et al., Seroprevalence of Anti-SARS-CoV-2 lgG Antibodies in Geneva, Switzerland (SEROCoV-POP): A Population Based Study (June 11,2020) THE LANCET, https://bit.ly/3187S13.