023 7 March 2023 Paul Greatrix, Registrar Registrar’s Office Trent Building University of Nottingham University Park Nottingham, NG7 2RD Dear Registrar, In confidence I am making a disclosure in the public interest under the Whistleblowing Code. A summary and full details of my disclosure are included in the following pages. Relevant documents including research papers form part of this disclosure and are included in PDF format at the continuation of this text. There are 128 pages in total. Links to webpages are also included below and these too should be considered as part of my disclosure. I ask for confidentiality, as I am entitled to do, while you investigate my disclosure. Thereafter I do not require anonymity and trust you will publish this letter, and the attached documents in full, along with the findings of your investigation. My disclosure relates to recommendations and omissions, made by senior University staff and the University as an employer and corporate body, falling under these sections of the University’s Whistleblowing Code: 4.3.ii: that a person has failed, is failing, or is likely to fail to comply with their legal obligations; 4.3.iv: that the health and safety of any individual has been, is being, or is likely to be endangered; and 4.3.vi: that information tending to show any matter falling within any of the above sections has been, is being, or is likely to be, deliberately concealed. I trust that you will investigate as required under appropriate legislation and the University’s Whistleblowing Code. I have provided you with my personal contact details separately. I am happy to provide further information if necessary. With sincere thanks, Page 1 of 9 023 Personal background From 2009 until February 2023 I was employed as a tutor in the School of Education. My work involved teaching international students, helping to improve their English language ability and preparing them to become postgraduate research students in a variety of disciplines. I was pleased to receive the Vice-Chancellor’s Medal, in March 2022, in recognition of my voluntary work with a food distribution charity. I am an alumnus of the University, gaining distinction grades on both the PG Dip PCET teaching diploma (2007) and the PG Dip in Education Research (2018). I have grave concerns about the University’s recommendations during the period from March 2020 onwards. I am making this disclosure under the University’s Whistleblowing (Public Interest Disclosure) Code and the applicable legislation. My statements relate to demonstrable facts. References are provided wherever possible and a reference list is included on page 9 below. I am not raising a personal grievance nor am I providing a personal opinion. I am morally and legally obligated to make this disclosure. I am aware that despite legislation designed to support them, whistleblowers are sometimes ignored or subjected to ad hominem attacks (Heffernan, 2011). I am aware also that the issues of cognitive dissonance, wilful blindness and ‘the bystander effect’ mean that whistleblowing in the public interest is not always successful (Heffernan, 2011; Desmet, 2022). However, I trust that you will thoroughly investigate the issues as detailed below. Summary of my disclosure In recommending multiple doses of covid-19 vaccines for staff and students, the University has behaved unethically and has committed moral and legal wrongdoing (malpractice). With respect to the University’s ‘get vaccinated’ campaign and messaging in 2021 and 2022, the University failed to consider individual risks/benefits, individual informed consent, the available alternative treatments, or the consistently very low infection fatality rate (IFR) of the illness. Given that the vaccines employ novel technologies, and that no medium- or long-term safety data was available, the University has failed to apply the precautionary principle. In making medical recommendations to individuals, including during class time, University staff members including teaching staff may have been practising medicine without a licence or appropriate medical qualifications. The University repeatedly recommended products from two pharmaceutical companies (AstraZeneca and Pfizer) with which it maintains close links but which have extensive criminal records for fraud, corruption, bribery, racketeering and criminal marketing. The University did not mention those links or criminal records in its ‘get vaccinated’ messaging. In relation to covid-19 vaccines, the University failed to communicate to its staff and students vital information about known risks and harms, including data on serious adverse reactions, which it had in its possession. As a consequence of its recommendations and omissions, the University may have caused lasting physical harm to staff and students. Vaccinations In December 2020, covid-19 vaccines, which are commercial, injectable genetic products, became available. For the UK market, almost all of these are manufactured by the pharmaceutical companies Pfizer, AstraZeneca, and Moderna. Seneff and Nigh (2021, p 39; paper attached) explain that these products are unprecedented in eight important ways: Page 2 of 9 2023 ‘First to use PEG (polyethylene glycol) in an injection First to use mRNA vaccine technology [in the case of the Pfizer and Moderna products] against an infectious agent First time Moderna [US mRNA product developer] has brought any product to market First to have public health officials telling those receiving the vaccination to expect an adverse reaction First to be implemented publicly with nothing more than preliminary efficacy data First vaccine to make no clear claims about reducing infections, transmissibility, or deaths First coronavirus vaccine ever attempted in humans First injection of genetically modified polynucleotides in the general population’. In 2021 and 2022 the University promoted vaccination with these products to all staff and students without mentioning, in its messaging, any of the eight points listed above. Posters were displayed in all University buildings recommending that staff and students ‘get vaccinated’. This and similar messages also appeared on postcards and in regular emails from senior University staff (sent to everyone at the University) and on the electronic displays of cash tills in campus cafés and shops. Teaching staff were urged to use class time to promote vaccine take-up among students and a ‘champion toolkit’ PowerPoint file (Brewitt, 2021; attached) and other resources were provided to assist in this promotional work. At the time of writing (Feb 2023), this advice to students remains on the University’s website: ‘Vaccination is the most important defence against Covid-19. Take up the free vaccine when it is offered and remember to get both doses to ensure you are fully protected’ (www.nottingham.ac.uk/coronavirus/current-students/covid-19-vaccine.aspx#FAQs). No references or citations are provided by the University for the claims made in that statement. This advice directly contradicts the statement made in Jan 2022 by Albert Bourla, CEO of Pfizer, that ‘The two doses of the vaccine offer very limited protection, if any.’ (www.youtube.com/ watch?v=lhMbKyDq9_w&t=98s). The AstraZeneca vaccine is no longer available in the UK, although the Government has not explained why. (www.nhs.uk/conditions/coronavirus-covid-19/ coronavirus-vaccination/coronavirus-vaccine/). In March 2021, the European Journal of Clinical Investigation published a study by John Ioannidis at Stanford University. He estimated the infection fatality rate (IFR) for SARS-CoV-2/covid-19 to be ~0.15% (Ioannidis, 2021; attached). This is a very low IFR, indicating a negligible risk for most people, and comparable to that of seasonal flu (ibid.). A more recent peer-reviewed paper, published in Environmental Research, analysed data from 38 countries. The IFR for the global non-elderly population was revised further downwards, with the analysis yielding ‘median IFR of 0.025–0.032% for 0–59 years and 0.063–0.082% for 0–69 years’ (Pezzullo et al., 2023; attached; p 1). The University’s ‘get vaccinated’ campaign and email messages did not mention this consistently very low IFR nor the fact that SARS-CoV-2/covid-19 is not listed (since March 2020) as a High Consequence Infectious Disease (HCID) by the British Government. The very low IFR and Page 3 of 9 2023 corresponding very high recovery rate for healthy people led physician and microbiologist Dr Marcus De Brun to determine in April 2021 that ‘Healthy people do not require genetic vaccination’ (https://cassandravoices.com/science-environment/science/healthy-people-do-not- require-genetic-vaccination/). The University’s campaign did not mention the many other successful treatments (including prophylaxis treatments) for SARS-CoV-2/covid-19 which were already available and well documented in the medical literature by early 2021. These treatments include generic medicines with good safety records, including Vitamin C (https://c19early.org/c), Vitamin D (https:// c19early.org/d), zinc (https://c19early.org/z), and aspirin (https://c19early.org/e). To date, some 2,400 academic studies have been published on these treatments and the papers, with detailed analyses and meta-analyses, are being collated in real-time by academic researchers at https:// c19early.org. However, the University has only ever recommended the novel genetic vaccines as a treatment for this illness and has never shared this link with staff and students. The University’s messaging also made no mention of the extensive criminal records for fraud, corruption, bribery, racketeering and criminal marketing held by Pfizer and AstraZeneca, the two main vaccine manufacturing companies. In 2009 Pfizer paid a record fine of US$2.3 billion in the US to settle a case of fraudulent marketing of antibiotics and painkillers (www.salon.com/ 2009/09/03/pharma_2/); in 2010, AstraZeneca paid US$520 million in fines to settle charges that it illegally marketed the anti-psychotic drug Seroquel to children and elderly patients. (https:// abcnews.go.com/Politics/Health/astrazeneca-pay-520-million-illegally-marketing-seroquel- schizophrenia/story?id=10488647. These are just two examples; the long criminal records of these two ‘repeat offender’ corporations are a matter of public record (www.corp-research.org/ pfizer; www.corp-research.org/astrazeneca). Overall, since 2000, Pfizer has incurred US$4.661 billion in penalties, including US$3.374 billion for unapproved promotion of medical products; US$1.110 billion for government-contracting- related offences; US$103.8 million for drug/medicine safety-related offences; US$60 million under the US Foreign Corrupt Practices Act; and US$34.7 million for kickbacks and bribery offences (https://violationtracker.goodjobsfirst.org/parent/pfizer). In the same period, AstraZeneca has incurred US$1.381 billion in penalties, including US$594 million for unapproved promotion of medical products; US$556 million for government-contracting-related offences; US$198 million for drug/medicine safety-related offences; US$21 million under the US Foreign Corrupt Practices Act; and US$5.52 million for kickbacks and bribery offences (https:// violationtracker.goodjobsfirst.org/parent/astrazeneca). The University maintains industry partnerships with both AstraZeneca and Pfizer. The School of Medicine’s webpage currently (Feb 2023) includes these descriptions: ‘AstraZeneca: A global pharmaceutical company pushing the boundaries of science to deliver life-changing medicines. Some of our studies into respiratory disease have received investment from AstraZeneca. We’ve also worked with them on trials on thrombosis and haemostasis.’ … ‘Pfizer: One of the world’s premier innovative biopharmaceutical companies, discovering, developing and providing over 170 different medicines, vaccines and consumer healthcare products. Pfizer have helped fund our studies into respiratory disease.’ (www.nottingham.ac.uk/medicine/research/research-industry-partnerships.aspx) Senior University staff are aware of the criminal records of these two corporations but did not mention them when advising staff and students to ‘get vaccinated’ with their novel products. Knowledge of these ‘repeat offender’ criminal cases and large fines and penalties would have been helpful to staff and students in making decisions about their health. Page 4 of 9 023 The University’s ‘get vaccinated’ campaign also made no mention of the lack of any medium- or long-term safety data for the vaccines, or the novel, genetic nature of the two types of injection (mRNA and viral vector DNA). mRNA is a completely new vaccination technology, never previously used in human beings (Seneff and Nigh, 2021). The precautionary principle should apply with regard to any new technology, but was ignored by the University in this case. The attached report by Dr Tess Lawrie, Director of the Evidence-Based Medicine Consultancy Ltd, details serious covid-19 vaccine adverse reactions in the UK (Lawrie, 2021). These harms, unprecedented in number, were clear to many researchers by the spring of 2021. Dr Lawrie's report was completed in June 2021 and sent to all health authorities and relevant government departments. It was also sent to senior University of Nottingham staff; for example, it was emailed to Sarah Speight, Pro-Vice Chancellor, in June 2021, and a printed copy was handed to HR staff and a senior professor during a meeting at King’s Meadow Campus in February 2022, after which it was retained on file. The University has, to my knowledge, never mentioned this expert report in its covid-19 communications with staff or students. Again, knowledge of the information in this report would have helped staff and students greatly in their decision-making about vaccination. In her report, Dr Lawrie reviews the data collected by the Government’s Yellow Card scheme, which serves as a warning system for medicines in the UK. She concludes: ‘It is now apparent that these products in the blood stream are toxic to humans. An immediate halt to the vaccination programme is required whilst a full and independent safety analysis is undertaken to investigate the full extent of the harms, which the UK Yellow Card data suggest include thromboembolism, multisystem inflammatory disease, immune suppression, autoimmunity and anaphylaxis, as well as Antibody Dependent Enhancement (ADE)’ (p 6). Dr Lawrie continues: ‘The MHRA now has more than enough evidence on the Yellow Card system to declare the COVID-19 vaccines unsafe for use in humans. Preparation should be made to scale up humanitarian efforts to assist those harmed by the COVID-19 vaccines and to anticipate and ameliorate medium to longer term effects. As the mechanism for harms from the vaccines appears to be similar to COVID-19 itself, this includes engaging with numerous international doctors and scientists with expertise in successfully treating COVID-19’ (p 7). Dr Lawrie is a GP and an independent researcher experienced in analysing health data and formulating policy recommendations for health authorities including the WHO. The information in her report should have been shared with staff and students once it had been received, reviewed and verified by appropriately-qualified members of staff. Instead, the University continued to recommend that healthy staff and students should receive multiple covid-19 vaccinations including ‘boosters’ (third doses). The number of reported adverse reactions for these novel products is much higher than for any other medicine. In Jan 2023 the Yellow Card reporting system showed these data (collected up to 23 Nov 2022) for adverse reactions to the covid-19 vaccines: Pfizer: 177,925 Yellow Card reports received; 71 per cent (125,711 reports) are categorised as ‘serious’, including: 2,640 disorders of the immune system, 7,950 vascular disorders; 14,380 cardiac disorders; 17,670 blood disorders; 23,070 respiratory disorders; 31,790 reproductive system and breast disorders; 58,340 musculoskeletal and connective tissue disorders; and 84,730 disorders of the nervous system. Page 5 of 9 023 Of the above, 65 per cent of the serious adverse reactions were reported by people aged under 50. (https://yellowcard.mhra.gov.uk/idaps/TOZINAMERAN) Astra-Zeneca: 246,866 Yellow Card reports received; 77 per cent (190,997 reports) are categorised as ‘serious’, including: 3,481 disorders of the immune system; 14,078 vascular disorders; 11,599 cardiac disorders; 7,922 blood disorders; 23,070 respiratory disorders; 20,983 reproductive system and breast disorders; 105,331 musculoskeletal and connective tissue disorders; and 183,978 disorders of the nervous system. Of the above, 48 per cent of the serious adverse reactions were reported by people aged under 50. (https://yellowcard.mhra.gov.uk/idaps/CHADOX1%20NCOV-19) Moderna: 47,045 Yellow Card reports received, 72 per cent (33,896 reports) are categorised as ‘serious’, including: 738 disorders of the immune system; 1,641 vascular disorders; 2,862 blood disorders; 5,438 reproductive system and breast disorders; 14,152 cardiac disorders; 17,071 musculoskeletal and tissue disorders; 23,070 respiratory disorders; and 24,861 disorders of the nervous system. Of the above, 65 per cent of the serious adverse reactions were reported by people aged under 50. (https://yellowcard.mhra.gov.uk/idaps/ELASOMERAN) According to the UK Government, the ‘passive’ Yellow Card scheme is estimated to report only around 10 per cent of the actual serious adverse reactions to vaccines (www.gov.uk/drug-safety- update/yellow-card-please-help-to-reverse-the-decline-in-reporting-of-suspected-adverse-drug- reactions); therefore the figures quoted above are likely to represent only a small fraction of the real total. In April 2022 a paper entitled ‘Innate immune suppression by SARS-CoV-2 mRNA vaccinations: The role of G-quadruplexes, exosomes, and MicroRNAs’ was published in the journal Food and Chemical Toxicology (Seneff, Nigh, Kyriakopoulos and McCullough, 2022; attached). The authors state that: ‘We present evidence that [covid-19] vaccination induces a profound impairment in type I interferon signaling, which has diverse adverse consequences to human health. Immune cells that have taken up the vaccine nanoparticles release into circulation large numbers of exosomes containing spike protein along with critical microRNAs that induce a signaling response in recipient cells at distant sites. We also identify potential profound disturbances in regulatory control of protein synthesis and cancer surveillance. These disturbances potentially have a causal link to neurodegenerative disease, myocarditis, immune thrombocytopenia, Bell’s palsy, liver disease, impaired adaptive immunity, impaired DNA damage response and tumorigenesis [cancer formation]. We show evidence from the VAERS [US Vaccine Adverse Event Reporting System] database supporting our hypothesis. We believe a comprehensive risk/benefit assessment of the mRNA vaccines questions them as positive contributors to public health’ (p 1). Page 6 of 9 023 The authors conclude: ‘In this paper, we call attention to three very important aspects of the safety profile of these vaccinations. First is the extensively documented subversion of innate immunity, primarily via suppression of IFN-α and its associated signaling cascade. This suppression will have a wide range of consequences, not the least of which include the reactivation of latent viral infections and the reduced ability to effectively combat future infections. Second is the dysregulation of the system for both preventing and detecting genetically driven malignant transformation within cells and the consequent potential for vaccination to promote those transformations. Third, mRNA vaccination potentially disrupts intracellular communication carried out by exosomes, and induces cells taking up spike glycoprotein mRNA to produce high levels of spike-glycoprotein-carrying exosomes, with potentially serious inflammatory consequences. Should any of these potentials be fully realized, the impact on billions of people around the world could be enormous and could contribute to both the short-term and long-term disease burden our health care system faces … In the end, billions of lives are potentially at risk, given the large number of individuals injected with the SARS-CoV-2 mRNA vaccines and the broad range of adverse outcomes we have described’ (pp 14-15). In an editorial for the April 2022 edition of the journal Surgical Neurology International (attached), neurosurgeon Russell Blaylock notes that ‘Hospitals are being flooded with vaccine complications … A dramatic number of these people are now dying, with the spike occurring after the vaccines were introduced’ (Blaylock, 2022; p 11). The above papers, Dr Lawrie’s report, and the website https://c19early.org have been brought repeatedly to the attention of key staff in the University but no action has been taken to update the advice given to staff and students in regard to the vaccines or other treatments. This British documentary film includes interviews with key scientists and doctors researching this issue: www.oraclefilms.com/safeandeffective (Oracle Films, 2022). It also includes personal testimony from several members of the public who are now suffering severe health problems that are temporally linked with being vaccinated with the covid-19 products. Finally, the Doctors for Patients group (DFPUK) published this press release and video in Dec 2022: https://doctorsforpatientsuk.com/press-release/. The authors state: ‘Many doctors, in the UK and internationally, have become increasingly concerned about the safety profile of Covid-19 vaccines and the continued rollout of these products to the public, including pregnant women and children. Several doctors in DFPUK have submitted multiple Yellow Card reports of adverse events to the MHRA, and have signed letters to the JCVI, MHRA, the RCOG, Prime Minister and others to express their concerns, but have seen little or no response or action taken. They have, therefore, now compiled the video above [see webpage] in which they share their individual perspectives, clinical experiences and serious ethical concerns, in the hope that urgent action will finally be taken by the authorities’ (Doctors for Patients, 2022). Although the University repeatedly recommended covid-19 vaccination to all staff and students, it has not shared with them any of the above evidence of serious adverse reactions and harm. In recommending these vaccines to individuals, the University appears to have been practising medicine without a licence or any medical qualification to do so. Concluding Recap remarks To recap, in 2021 and 2022 the University ran a ‘get vaccinated’ campaign involving posters, emails, postcards and other messaging, targeted at staff and students. The University did not pass on to its staff and students key information, which it had in its possession, about the known Page 7 of 9 2023 risks and harms of these products including the many tens of thousands of reports of serious adverse reactions temporally linked to vaccination. The University’s campaign did not tell staff and students about the novel nature of the vaccine technology, about the lack of any medium- or long-term safety data for these products, or about the consistently low IFR of the illness. The University recommended only these novel vaccines, and did not provide information about or recommend any of the other treatments for SARS-CoV-2/covid-19 which are fully documented in the medical literature and widely used in many countries. In recommending the novel, commercial vaccine products, almost all of which in the UK were provided by Pfizer and Astra-Zeneca, the University did not provide any information about the extensive criminal records of those two corporations or its own partnerships with them. It is a matter of public record that Pfizer and Astra-Zeneca have long practised fraud, corruption, bribery, racketeering and criminal marketing. In recommending these novel vaccines without any medium- or long-term safety data being available, the University ignored the precautionary principle. The University’s ‘get vaccinated’ campaign, and its financial and other relationships with the pharmaceutical industry, require thorough independent investigation. Concluding notes The foregoing, along with the attached documents, references and links, forms my disclosure under the Whistleblowing Code. The following are additional remarks which I hope the University will take into consideration; I make these comments as a concerned professional teacher. Personal anecdotes cannot provide scientists and investigators with objective data, and I understand the problem of confirmation bias. In addition, correlation does not imply causation (although it can provide the basis on which to form a hypothesis about cause and effect). Notwithstanding these points, I would like to note here that several of my former colleagues experienced new illnesses temporally linked to (that is, following) ‘covid-19 vaccination’, some of them very serious. These illnesses include cardiac disorders, blurred vision, neurological problems, ongoing fatigue, cognitive/memory issues, and, importantly, apparent infection with SARS-CoV-2/covid-19 itself, the disease against which these people were meant to have been immunised by the Pfizer, AstraZeneca and Moderna vaccines. The University has at is disposal the resources needed to properly research the health outcomes and types and levels of adverse reactions to these products among its own staff and students. A control group is available, since not all staff and students have received these injections. Such a study would help to clarify the situation and add greatly to the literature; a long-term project, tracking health outcomes over several years, is possible, but such a research project has not yet been commenced. As stated above, the University maintains strong partnerships with the pharmaceutical industry, including the vaccine manufacturers Pfizer and AstraZeneca. Several physician-led groups including the World Council for Health and the FLCCC are currently working to help those affected by adverse reactions to these products, including making recovery protocols available (https:// worldcouncilforhealth.org/; https://covid19criticalcare.com/). The University may consider forming working partnerships with these organisations too, so that the best medical research and advice can be disseminated as widely as possible in the academic community and beyond. Page 8 of 9 023 References (key texts* are attached) Blaylock, R. L. (2022). COVID UPDATE: What is the truth? Surgical Neurology International. Vol 13, issue 167.* Brewitt, T. (2021). Champion toolkit for staff (PowerPoint presentation slides). University of Nottingham, Human Resources Department.* c19early.org (2023). COVID-19 early treatment: real-time analysis of 2,400 studies. https:// c19early.org. Desmet, M (2022). The Psychology of Totalitarianism. London: Chelsea Green Doctors for Patients (2022). UK Doctors Call For Government Investigation of mRNA Covid Vaccines. https://doctorsforpatientsuk.com/press-release/. Heffernan, M. (2011). Wilful Blindness: Why we ignore the obvious at our peril. London: Simon & Schuster. Ioannidis, J. P. A. (2021). Reconciling estimates of global spread and infection fatality rates of COVID-19: An overview of systematic evaluations. European Journal of Clinical Investigation. Vol 51, Issue 5.* Lawrie, T. (2021). Urgent preliminary report of Yellow Card data up to 26th May 2021: Letter to Dr Clare Raine at the Medicines and Healthcare Products Regulatory Agency. The Evidence-Based Medicine Consultancy Ltd.* Oracle Films (2022). Safe and Effective: A Second Opinion (documentary film). www.oraclefilms.com/safeandeffective. Pezzullo A. M., Axfors, C., Contopoulos-Ioannidis, D. G., Apostolatos, A. and Ioannidis, J. P. A. (2022). Age-stratified infection fatality rate of COVID-19 in the non-elderly population. Environmental Research. Issue 216.* Seneff, S. and Nigh, G. (2021). Worse Than the Disease? Reviewing Some Possible Unintended Consequences of the mRNA Vaccines Against COVID-19. International Journal of Vaccine Theory, Practice, and Research. Vol 2, Issue 1.* Seneff, S., Nigh G., Kyriakopoulos A. M. and McCullough P. A. (2022). Innate immune suppression by SARS-CoV-2 mRNA vaccinations: The role of G-quadruplexes, exosomes, and MicroRNAs. Food and Chemical Toxicology. Issue 164.* Page 9 of 9 www.surgicalneurologyint.com Surgical Neurology International . SNI: Infection Editor Ali Akhaddar, MD, IFAANS Avicenne Military Hospital, Marrakech, Morocco Open Access Editorial COVID UPDATE: What is the truth? Russell L. Blaylock Retired Neurosurgeon, Theoretical Neuroscience Research, LLC, Ridgeland, Mississippi, United States. E-mail: *Russell L. Blaylock - Blay6307@gmail.com The COVID-19 pandemic is one of the most manipulated infectious disease events in history, characterized by official lies in an unending stream lead by government bureaucracies, medical associations, medical boards, the media, and international agencies.[3,6,57] We have witnessed a long list of unprecedented intrusions into medical practice, including attacks on medical experts, destruction of medical careers among doctors refusing to participate in killing their patients and a massive regimentation of health care, led by non-qualified individuals with enormous wealth, *Corresponding author: power and influence. Russell L. Blaylock, Theoretical Neuroscience For the first time in American history a president, governors, mayors, hospital administrators Research, LLC, Ridgeland, and federal bureaucrats are determining medical treatments based not on accurate scientifically Mississippi, United States. based or even experience based information, but rather to force the acceptance of special forms Blay6307@gmail.com of care and “prevention”—including remdesivir, use of respirators and ultimately a series of essentially untested messenger RNA vaccines. For the first time in history medical treatment, Received : 06 February 2022 protocols are not being formulated based on the experience of the physicians treating the largest Accepted : 11 February 2022 number of patients successfully, but rather individuals and bureaucracies that have never treated Published : 22 April 2022 a single patient—including Anthony Fauci, Bill Gates, EcoHealth Alliance, the CDC, WHO, state public health officers and hospital administrators.[23,38] DOI 10.25259/SNI_150_2022 The media (TV, newspapers, magazines, etc), medical societies, state medical boards and the owners of social media have appointed themselves to be the sole source of information concerning Quick Response Code: this so-called “pandemic”. Websites have been removed, highly credentialed and experienced clinical doctors and scientific experts in the field of infectious diseases have been demonized, careers have been destroyed and all dissenting information has been labeled “misinformation” and “dangerous lies”, even when sourced from top experts in the fields of virology, infectious diseases, pulmonary critical care, and epidemiology. These blackouts of truth occur even when this information is backed by extensive scientific citations from some of the most qualified medical specialists in the world.[23] Incredibly, even individuals, such as Dr. Michael Yeadon, a retired ex-Chief Scientist, and vice-president for the science division of Pfizer Pharmaceutical company in the UK, who charged the company with making an extremely dangerous vaccine, is ignored and demonized. Further, he, along with other highly qualified scientists have stated that no one should take this vaccine. Dr. Peter McCullough, one of the most cited experts in his field, who has successfully treated over 2000 COVID patients by using a protocol of early treatment (which the so-called experts completely ignored), has been the victim of a particularly vicious assault by those benefiting financially from the vaccines. He has published his results in peer reviewed journals, reporting an 80% reduction in hospitalizations and a 75% reduction in deaths by using early treatment. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. ©2022 Published by Scientific Scholar on behalf of Surgical Neurology International Surgical Neurology International • 2022 • 13(167) | 1 Blaylock: Update on Covid-19 pandemic events Despite this, he is under an unrelenting series of attacks [44] pharmaceutical companies exerted their influence on owners by the information controllers, none of which have treated a of these journals to remove articles that in any way question single patient. these companies’ products.[13,34,35] Neither Anthony Fauci, the CDC, WHO nor any medical Worse still is the actual designing of medical articles for governmental establishment has ever offered any early promoting drugs and pharmaceutical products that involve treatment other than Tylenol, hydration and call an fake studies, so-called ghostwritten articles.[49,64] Richard ambulance once you have difficulty breathing. This is Horton is quoted by the Guardian as saying “journals unprecedented in the entire history of medical care as have devolved into information laundering operations early treatment of infections is critical to saving lives and for the pharmaceutical industry.”[13,63] Proven fraudulent preventing severe complications. Not only have these medical “ghostwritten” articles sponsored by pharmaceutical giants organizations and federal lapdogs not even suggested early have appeared regularly in top clinical journals, such as treatment, they attacked anyone who attempted to initiate JAMA, and New England Journal of Medicine—never to be such treatment with all the weapons at their disposal—loss of removed despite proven scientific abuse and manipulation license, removal of hospital privileges, shaming, destruction of data.[49,63] of reputations and even arrest.[2] Ghostwritten articles involve using planning companies A good example of this outrage against freedom of speech whose job it is to design articles containing manipulated data and providing informed consent information is the recent to support a pharmaceutical product and then have these suspension by the medical board in Maine of Dr. Meryl articles accepted by high-impact clinical journals, that is, Nass’ medical license and the ordering of her to undergo a the journals most likely to affect clinical decision making of psychiatric evaluation for prescribing Ivermectin and sharing doctors. Further, they supply doctors in clinical practice with her expertise in this field.[9,65] I know Dr, Nass personally and free reprints of these manipulated articles. The Guardian can vouch for her integrity, brilliance and dedication to truth. found 250 companies engaged in this ghostwriting business. Her scientific credentials are impeccable. This behavior by a The final step in designing these articles for publication in medical licensing board is reminiscent of the methodology the most prestigious journals is to recruit well recognized of the Soviet KGB during the period when dissidents were medical experts from prestigious institutions, to add their incarcerated in psychiatric gulags to silence their dissent. name to these articles. These recruited medical authors are either paid upon agreeing to add their name to these pre- written articles or they do so for the prestige of having their OTHER UNPRECEDENTED ATTACKS name on an article in a prestigious medical journal.[11] Another unprecedented tactic is to remove dissenting Of vital importance is the observation by experts in the field doctors from their positions as journal editors, reviewers and of medical publishing that nothing has been done to stop retracting of their scientific papers from journals, even after this abuse. Medical ethicists have lamented that because these papers have been in print. Until this pandemic event, of this widespread practice “you can’t trust anything.” I have never seen so many journal papers being retracted— While some journals insist on disclosure information, the vast majority promoting alternatives to official dogma, most doctors reading these articles ignore this information especially if the papers question vaccine safety. Normally a or excuse it and several journals make disclosure more submitted paper or study is reviewed by experts in the field, difficult by requiring the reader to find the disclosure called peer review. These reviews can be quite intense and nit statements at another location. Many journals do not police picking in detail, insisting that all errors within the paper be such statements and omissions by authors are common and corrected before publication. So, unless fraud or some other without punishment. major hidden problem is discovered after the paper is in As concerns the information made available to the print, the paper remains in the scientific literature. public, virtually all the media is under the control of these We are now witnessing a growing number of excellent pharmaceutical giants or others who are benefitting from scientific papers, written by top experts in the field, being this “pandemic”. Their stories are all the same, both in retracted from major medical and scientific journals weeks, content and even wording. Orchestrated coverups occur months and even years after publication. A careful review daily and massive data exposing the lies being generated by indicates that in far too many instances the authors dared these information controllers are hidden from the public. question accepted dogma by the controllers of scientific All data coming over the national media (TV, newspaper publications—especially concerning the safety, alternative and magazines), as well as the local news you watch every treatments or efficacy of vaccines.[12,63] These journals rely on day, comes only from “official” sources—most of which are extensive adverting by pharmaceutical companies for their lies, distortions or completely manufactured out of whole revenue. Several instances have occurred where powerful cloth—all aimed to deceive the public. Surgical Neurology International • 2022 • 13(167) | 2 Blaylock: Update on Covid-19 pandemic events Television media receives the majority of its advertising budget to find other hospitals staffs to join since they too may be from the international pharmaceutical companies—this owned by the same corporate giant. As a result, vaccine creates an irresistible influence to report all concocted studies mandate policies include far larger numbers of hospital supporting their vaccines and other so-called treatments.[14] employees. For example, Mayo Clinic fired 700 employees In 2020 alone the pharmaceutical industries spent 6.56 billion for exercising their right to refuse a dangerous, essentially dollars on such advertising.[13,14] Pharma TV advertising untested experimental vaccine.[51,57] Mayo Clinic did this amounted to 4.58 billion, an incredible 75% of their budget. despite the fact that many of these employees worked during That buys a lot of influence and control over the media. the worst of the epidemic and are being fired when the World famous experts within all fields of infectious diseases Omicron variant is the dominant strain of the virus, has the are excluded from media exposure and from social media pathogenicity of a common cold for most and the vaccines should they in any way deviate against the concocted lies and are ineffective in preventing the infection. distortions by the makers of these vaccines. In addition, these In addition, it has been proven that the vaccinated pharmaceutical companies spend tens of millions on social asymptomatic person has a nasopharyngeal titer of the virus media advertising, with Pfizer leading the pack with $55 as high as an infected unvaccinated person. If the purpose million in 2020.[14] of the vaccine mandate is to prevent viral spread among While these attacks on free speech are terrifying enough, even the hospital staff and patients, then it is the vaccinated worse is the virtually universal control hospital administrators who present the greatest risk of transmission, not the have exercised over the details of medical care in hospitals. unvaccinated. The difference is that a sick unvaccinated These hirelings are now instructing doctors which treatment person would not go to work, the asymptomatic vaccinated protocols they will adhere to and which treatments they will spreader will. not use, no matter how harmful the “approved” treatments What we do know is that major medical centers, such as are or how beneficial the “unapproved” treatments are.[33,57] Mayo Clinic, receive tens of millions of dollars in NIH grants Never in the history of American medicine have hospital each year as well as monies from the pharmaceutical makers administrators dictated to its physicians how they will of these experimental “vaccines”. In my view, that is the real practice medicine and what medications they can use. The consideration driving these policies. If this could be proven CDC has no authority to dictate to hospitals or doctors in a court of law the administrators making these mandates concerning medical treatments. Yet, most physicians should be prosecuted to the fullest extent of the law and sued complied without the slightest resistance. by all injured parties. The federal Care Act encouraged this human disaster by The hospital bankruptcy problem has grown increasingly offering all US hospitals up to 39,000 dollars for each ICU acute due to hospitals vaccine mandates and resulting patient they put on respirators, despite the fact that early on it large number of hospitals staff, especially nurses, refusing was obvious that the respirators were a major cause of death to be forcibly vaccinated.[17,51] This is all unprecedented in among these unsuspecting, trusting patients. In addition, the history of medical care. Doctors within hospitals are the hospitals received 12,000 dollars for each patient that responsible for the treatment of their individual patients and was admitted to the ICU—explaining, in my opinion and work directly with these patients and their families to initiate others, why all federal medical bureaucracies (CDC, FDA, these treatments. Outside organizations, such as the CDC, NIAID, NIH, etc) did all in their power to prevent life- have no authority to intervene in these treatments and to do saving early treatments.[46] Letting patients deteriorate to the so exposes the patients to grave errors by an organization point they needed hospitalization, meant big money for all that has never treated a single COVID-19 patient. hospitals. A growing number of hospitals are in danger of When this pandemic started, hospitals were ordered by bankruptcy, and many have closed their doors, even before the CDC to follow a treatment protocol that resulted in this “pandemic”.[50] Most of these hospitals are now owned the deaths of hundreds of thousands of patients, most of by national or international corporations, including teaching whom would have recovered had proper treatments been hospitals.[10] allowed.[43,44] The majority of these deaths could have been It is also interesting to note that with the arrival of this prevented had doctors been allowed to use early treatment “pandemic” we have witnessed a surge in hospital corporate with such products as Ivermectin, hydroxy-chloroquine and chains buying up a number of these financially at-risk a number of other safe drugs and natural compounds. It has hospitals.[1,54] It has been noted that billions in Federal Covid been estimated, based on results by physicians treating the aid is being used by these hospital giants to acquire these most covid patients successfully, that of the 800,000 people financially endangered hospitals, further increasing the that we are told died from Covid, 640,000 could have not only power of corporate medicine over physician independence. been saved, but could have, in many cases, returned to their Physicians expelled from their hospitals are finding it difficult pre-infection health status had mandated early treatment Surgical Neurology International • 2022 • 13(167) | 3 Blaylock: Update on Covid-19 pandemic events with these proven methods been used. This neglect of early We have known that brain development continues long treatment constitutes mass murder. That means 160,000 after the grade school years. A recent study found that would have actually died, far less than the number dying at children born during the “pandemic” have significantly the hands of bureaucracies, medical associations and medical lower IQs—yet school boards, school principals and other boards that refused to stand up for their patients. According educational bureaucrats are obviously unconcerned.[18] to studies of early treatment of thousands of patients by brave, caring doctors, seventy-five to eighty percent of the TOOLS OF THE INDOCTRINATION TRADE deaths could have been prevented.[43,44] The designers of this pandemic anticipated a pushback by Incredibly, these knowledgeable doctors were prevented the public and that major embarrassing questions would be from saving these Covid-19 infected people. It should be asked. To prevent this, the controllers fed the media a number an embarrassment to the medical profession that so many of tactics, one of the most commonly used was and is the doctors mindlessly followed the deadly protocols established “fact check” scam. With each confrontation with carefully by the controllers of medicine. documented evidence, the media “fact checkers” countered with One must also keep in mind that this event never satisfied the charge of “misinformation”, and an unfounded “conspiracy the criteria for a pandemic. The World Health Organization theory” charge that was, in their lexicon, “debunked”. Never changed the criteria to make this a pandemic. To qualify were we told who the fact checkers were or the source of their for a pandemic status the virus must have a high mortality “debunking” information—we were just to believe the “fact rate for the vast majority of people, which it didn’t (with a checkers”. A recent court case established under oath that 99.98% survival rate), and it must have no known existing facebook “fact checkers” used their own staff opinion and not treatments—which this virus had—in fact, a growing number real experts to check “facts”.[59] When sources are in fact revealed of very successful treatments. they are invariably the corrupt CDC, WHO or Anthony Fauci The draconian measures established to contain this contrived or just their opinion. Here is a list of things that were labeled as “pandemic” have never been shown to be successful, such “myths” and “misinformation” that were later proven to be true. as masking the public, lockdowns, and social distancing. • The asymptomatic vaccinated are spreading the virus A number of carefully done studies during previous flu equally as with unvaccinated symptomatic infected. seasons demonstrated that masks, of any kind, had never • The vaccines cannot protect adequately against new prevented the spread of the virus among the public.[60] variants, such as Delta and Omicron. • Natural immunity is far superior to vaccine immunity In fact, some very good studies suggested that the masks and is most likely lifelong. actually spread the virus by giving people a false sense of • Vaccine immunity not only wanes after several months, security and other factors, such as the observation that people but all immune cells are impaired for prolonged periods, were constantly breaking sterile technique by touching their putting the vaccinated at a high risk of all infections and mask, improper removal and by leakage of infectious aerosols cancer. around the edges of the mask. In addition masks were being • COVID vaccines can cause a significant incidence of disposed of in parking lots, walking trails, laid on tabletops in blood clots and other serious side effects restaurants and placed in pockets and purses. • The vaccine proponents will demand numerous boosters Within a few minutes of putting on the mask, a number of as each variant appears on the scene. pathogenic bacteria can be cultured from the masks, putting • Fauci will insist on the covid vaccine for small children the immune suppressed person at a high risk of bacterial and even babies. pneumonia and children at a higher risk of meningitis.[16] • Vaccine passports will be required to enter a business, fly A study by researchers at the University of Florida cultured in a plane, and use public transportation over 11 pathogenic bacteria from the inside of the mask worn • There will be internment camps for the unvaccinated (as by children in schools.[40] in Australia, Austria and Canada) • The unvaccinated will be denied employment. It was also known that children were at essentially no risk of • There are secret agreements between the government, either getting sick from the virus or transmitting it. elitist institutions, and vaccine makers In addition, it was also known that wearing a mask for • Many hospitals were either empty or had low occupancy over 4 hours (as occurs in all schools) results in significant during the pandemic. hypoxia (low blood oxygen levels) and hypercapnia (high • The spike protein from the vaccine enters the nucleus of CO2 levels), which have a number of deleterious effects on the cell, altering cell DNA repair function. health, including impairing the development of the child’s • Hundreds of thousands have been killed by the vaccines brain.[4,72,52] and many times more have been permanently damaged. Surgical Neurology International • 2022 • 13(167) | 4 Blaylock: Update on Covid-19 pandemic events • Early treatment could have saved the lives of most of the In the case of all other drugs and previous conventional 700,000 who died. vaccines under review by the FDA, the otherwise unexplained • Vaccine-induced myocarditis (which was denied deaths of 50 or less individuals would result in a halt in initially) is a significant problem and clears over a short further distribution of the product, as happened on 1976 period. with the swine flu vaccine. With over 18,000 deaths being • Special deadly lots (batches) of these vaccines are mixed reported by the VAERS system for the period December with the mass of other Covid-19 vaccines 14, 2020 and December 31st, 2021 as well as 139,126 serious injuries (including deaths) for the same period there is still no Several of these claims by those opposing these vaccines now interest in stopping this deadly vaccine program.[61] Worse, appear on the CDC website—most still identified as “myths”. there is no serious investigation by any government agency Today, extensive evidence has confirmed that each of these to determine why these people are dying and being seriously so-called “myths” were in fact true. Many are even admitted and permanently injured by these vaccines.[15,67] What we do by the “saint of vaccines”, Anthony Fauci. For example, we see is a continuous series of coverups and evasions by the were told, even by our cognitively impaired President, that vaccine makers and their promoters. once the vaccine was released all the vaccinated people could take off their masks. Oops! We were told shortly afterward— The war against effective cheap and very safe repurposed the vaccinated have high concentrations (titers) of the virus in drugs and natural compounds, that have proven beyond all their noses and mouths (nasopharynx) and can transmit the doubt to have saved millions of lives all over the world, has virus to others in which they come into contact—especially not only continued but has stepped up in intensity.[32,34,43] their own family members. On go the masks once again— Doctors are told they cannot provide these life-saving in fact double masking is recommended. The vaccinated compounds for their patients and if they do, they will be are now known to be the main superspreaders of the virus removed from the hospital, have their medical license removed and hospitals are filled with the sick vaccinated and people or be punished in many other ways. A great many pharmacies suffering from serious vaccine complications.[27,42,45] have refused to fill prescriptions for lvermectin or hydroxy- Another tactic by the vaccine proponents is to demonize chloroquine, despite the fact that millions of people have taken those who reject being vaccinated for a variety of reasons. these drugs safely for over 60 years in the case of hydroxy The media refers to these critically thinking individuals chloroquine and decades for Ivermectin.[33,36] This refusal to as “anti-vaxxers”, “vaccine deniers”, “Vaccine resisters”, fill prescriptions is unprecedented and has been engineered by “murders”, “enemies of the greater good” and as being the those wanting to prevent alternative methods of treatment, all ones prolonging the pandemic. I have been appalled by the based on protecting vaccine expansion to all. Several companies vicious, often heartless attacks by some of the people on that make hydroxy chloroquine agreed to empty their stocks of social media when a parent or loved one relates a story of the the drug by donating them to the Strategic National Stockpile, terrible suffering and eventual death, they or their loved one making this drug far more difficult to get.[33] Why would the suffered as a result of the vaccines. Some psychopaths tweet government do that when over 30 well-done studies have that they are glad that the loved one died or that the dead shown that this drug reduced deaths anywhere from 66% to vaccinated person was an enemy of good for telling of the 92% in other countries, such as India, Egypt, Argentina, France, event and should be banned. This is hard to conceptualize. Nigeria, Spain, Peru, Mexico, and others?[23] This level of cruelty is terrifying, and signifies the collapse of The critics of these two life-saving drugs are most often a moral, decent, and compassionate society. funded by Bill Gates and Anthony Fauci, both of which are It is bad enough for the public to sink this low, but the making millions from these vaccines.[48,15] media, political leaders, hospital administrators, medical To further stop the use of these drugs, the pharmaceutical associations and medical licensing boards are acting in a industry and Bill Gates/Anthony Fauci funded fake research similar morally dysfunctional and cruel way. to make the case that hydroxy chloroquine was a dangerous drug and could damage the heart.[34] To make this fraudulent LOGIC, REASONING, AND SCIENTIFIC case the researchers administered the sickest of covid EVIDENCE HAS DISAPPEARED IN THIS EVENT patients a near lethal dose of the drug, in a dose far higher than used on any covid patient by Dr. Kory, McCullough and Has scientific evidence, carefully done studies, clinical other “real”, and compassionate doctors, physicians who were experience and medical logic had any effect on stopping actually treating covid patients.[23] these ineffective and dangerous vaccines? Absolutely not! The draconian efforts to vaccinate everyone on the planet The controlled, lap-dog media, of course, hammered continues (except the elite, postal workers, members of the public with stories of the deadly effect of hydroxy- Congress and other insiders).[31,62] chloroquine, all with a terrified look of fake panic. All these Surgical Neurology International • 2022 • 13(167) | 5 Blaylock: Update on Covid-19 pandemic events stories of ivermectin dangers were shown to be untrue and Most new vaccines must go through extensive safety testing some of the stories were incredibly preposterous.[37,43] for years before they are approved. New technologies, such The attack on Ivermectin was even more vicious than against as the mRNA and DNA vaccines, require a minimum of hydroxy-chloroquine. All of this, and a great deal more is 10 years of careful testing and extensive follow-up. These new meticulously chronicled in Robert Kennedy, Jr’s excellent so-called vaccines were “tested” for only 2 months and then new book—The Real Anthony Fauci. Bill Gates, Big Pharma, the results of these safety test were and continue to be kept and the Global War on Democracy and Public Health.[32] If secret. Testimony before Senator Ron Johnson by several who you are truly concerned with the truth and with all that has participated in the 2 months study indicates that virtually no occurred since this atrocity started, you must not only read, follow-up of the participants of the pre-release study was ever but study this book carefully. It is fully referenced and covers done.[67] Complains of complications were ignored and despite all topics in great detail. This is a designed human tragedy promises by Pfizer that all medical expenses caused by the of Biblical proportions by some of the most vile, heartless, “vaccines” would be paid by Pfizer, these individuals stated psychopaths in history. that none were paid.[66] Some medical expenses exceed 100,000 dollars. Millions have been deliberately killed and crippled, not only by this engineered virus, but by the vaccine itself and by the As an example of the deception by Pfizer, and the other draconian measures used by these governments to “control makers of mRNA vaccines, is the case of 12-year-old Maddie the pandemic spread”. We must not ignore the “deaths by de Garay, who participated in the Pfizer vaccine pre-release despair” caused by these draconian measures, which can safety study. At Sen. Johnson’s presentation with the families exceed hundreds of thousands. Millions have starved in third of the vaccine injured, her mother told of her child’s recurrent world countries as a result. In the United States alone, of the seizures, that she is now confined to a wheelchair, must be 800,000 who died, claimed by the medical bureaucracies, well tube fed and suffers permanent brain damage. On the Pfizer over 600,000 of these deaths were the result of the purposeful safety evaluation submitted to the FDA her only side effect neglect of early treatment, blocking the use of highly effective is listed as having a “stomachache”. Each person submitted and safe repurposed drugs, such as hydroxy-chloroquine and similar horrifying stories. Ivermectin, and the forced use of deadly treatments such The Japanese resorted to a FOIA (Freedom of Information as remdesivir and use of ventilators. This does not count the Act) lawsuit to force Pfizer to release its secret biodistribution deaths of despair and neglected medical care caused by the study. The reason Pfizer wanted it kept secret is that it lockdown and hospital measures forced on healthcare systems. demonstrated that Pfizer lied to the public and the regulatory To compound all this, because of vaccine mandates among agencies about the fate of the injected vaccine contents (the all hospital personnel, thousands of nurses and other hospital mRNA enclosed nano-lipid carrier). They claimed that it workers have resigned or been fired.[17,30,51] This has resulted remained at the site of the injection (the shoulder), when in in critical shortages of these vital healthcare workers and fact their own study found that it rapidly spread throughout dangerous reductions of ICU beds in many hospitals. In the entire body by the bloodstream within 48 hours. addition, as occurred in the Lewis County Healthcare The study also found that these deadly nano-lipid carriers System, a specialty-hospital system in Lowville, N.Y., closed collected in very high concentrations in several organs, its maternity unit following the resignation of 30 hospital staff including the reproductive organs of males and females, the over the state’s disastrous vaccine mandate orders. The irony heart, the liver, the bone marrow, and the spleen (a major in all these cases of resignations is that the administrators immune organ). The highest concentration was in the ovaries unhesitatingly accepted these mass staffing losses despite and the bone marrow. These nano-lipid carriers also were rantings about suffering from short staffing during a deposited in the brain. “crisis”. This is especially puzzling when we learned that the vaccines did not prevent viral transmission and the present Dr. Ryan Cole, a pathologist from Idaho reported a dramatic predominant variant is of extremely low pathogenicity. spike in highly aggressive cancers among vaccinated individuals, (not reported in the Media). He found a DANGERS OF THE VACCINES ARE frighteningly high incidence of highly aggressive cancers in INCREASINGLY REVEALED BY SCIENCE vaccinated individuals, especially highly invasive melanomas in young people and uterine cancers in women.[26] Other While most researchers, virologists, infectious disease reports of activation of previously controlled cancers are also researchers and epidemiologists have been intimidated into appearing among vaccinated cancer patients.[47] Thus far, no silence, a growing number of high integrity individuals studies have been done to confirm these reports, but it is with tremendous expertise have come forward to tell the unlikely such studies will be done, at least studies funded by truth—that is, that these vaccines are deadly. grants from the NIH. Surgical Neurology International • 2022 • 13(167) | 6 Blaylock: Update on Covid-19 pandemic events The high concentration of spike proteins found in the ovaries • Vertical transmission of defects and disorders in the biodistribution study could very well impair fertility • Cancer in young women, alter menstruation, and could put them at • Autoimmune disorders an increased risk of ovarian cancer. The high concentration Previous experience with the flu vaccines clearly in the bone marrow, could also put the vaccinated at a high demonstrates that the safety studies done by researchers risk of leukemia and lymphoma. The leukemia risk is very and clinical doctors with ties to pharmaceutical companies worrisome now that they have started vaccinating children were essentially all either poorly done or purposefully as young as 5 years of age. No long-term studies have been designed to falsely show safety and coverup side effects and conducted by any of these makers of Covid-19 vaccines, complications. This was dramatically demonstrated with the especially as regards the risk of cancer induction. Chronic previously mentioned phony studies designed to indicate inflammation is intimately linked to cancer induction, that hydroxy Chloroquine and Ivermectin were ineffective growth and invasion and vaccines stimulate inflammation. and too dangerous to use.[34,36,37] These fake studies resulted Cancer patients are being told they should get vaccinated in millions of deaths and severe health disasters worldwide. with these deadly vaccines. This, in my opinion, is insane. As stated, 80% of all deaths were unnecessary and could Newer studies have shown that this type of vaccine inserts have been prevented with inexpensive, safe repurposed the spike protein within the nucleus of the immune cells (and medications with a very long safety history among millions most likely many cell types) and once there, inhibits two very who have taken them for decades or even a lifetime.[43,44] important DNA repair enzymes, BRCA1 and 53BP1, whose It is beyond ironic that those claiming that they are duty it is to repair damage to the cell’s DNA.[29] Unrepaired responsible for protecting our health approved a poorly DNA damage plays a major role in cancer. tested set of vaccines that has resulted in more deaths in There is a hereditary disease called xeroderma pigmentosum less than a year of use than all the other vaccines combined in which the DNA repair enzymes are defective. These given over the past 30 years. Their excuse when confronted ill-fated individuals develop multiple skin cancers and was—“we had to overlook some safety measures because this a very high incidence of organ cancer as a result. Here was a deadly pandemic”.[28,46] we have a vaccine that does the same thing, but to a less In 1986 President Reagan signed the National Childhood extensive degree. Vaccine Injury Act, which gave blanket protection One of the defective repair enzymes caused by these vaccines to pharmaceutical makers of vaccines against injury is called BRCA1, which is associated with a significantly litigation by families of vaccine injured individuals. The higher incidence of breast cancer in women and prostate Supreme Court, in a 57-page opinion, ruled in favor cancer in men. of the vaccine companies, effectively allowing vaccine makers to manufacture and distribute dangerous, often It should be noted that no studies were ever done on several ineffective vaccines to the population without fear of legal critical aspects of this type of vaccine. consequences. The court did insist on a vaccine injury • They have never been tested for long term effects compensation system which has paid out only a very • They have never been tested for induction of small number of rewards to a large number of severely autoimmunity injured individuals. It is known that it is very difficult to • They have never been properly tested for safety during receive these awards. According to the Health Resources any stage of pregnancy and Services Administration, since 1988 the Vaccine • No follow-up studies have been done on the babies of Injury Compensation Program (VICP) has agreed to pay vaccinated women 3,597 awards among 19,098 vaccine injured individuals • There are no long-term studies on the children of applying amounting to a total sum of $3.8 billion. This vaccinated pregnant women after their birth (Especially was prior to the introduction of the Covid-19 vaccines, in as neurodevelopmental milestone occur). which the deaths alone exceed all deaths related to all the • It has never been tested for effects on a long list of vaccines combined over a thirty-year period. medical conditions: • Diabetes In 2018 President Trump signed into law the “right-to-try” • Heart disease law which allowed the use of experimental drugs and all • Atherosclerosis unconventional treatments to be used in cases of extreme • Neurodegenerative diseases medical conditions. As we have seen with the refusal of • Neuropsychiatric effects many hospitals and even blanket refusal by states to allow • Induction of autism spectrum disorders and Ivermectin, hydroxy-chloroquine or any other unapproved schizophrenia “official” methods to treat even terminal Covid-19 cases, • Long term immune function these nefarious individuals have ignored this law. Surgical Neurology International • 2022 • 13(167) | 7 Blaylock: Update on Covid-19 pandemic events Strangely, they did not use this same logic or the law when receives a vaccine from that lot, which includes thousands of it came to Ivermectin and Hydroxy Chloroquine, both of vaccine doses. which had undergone extensive safety testing by over 30 He examined all manufactured vaccines—Pfizer, Moderna, clinical studies of a high quality and given glowing reports on Johnson and Johnson (Janssen), etc. He found that among both efficacy and safety in numerous countries. In addition, every 200 batches of the vaccine from Pfizer and other we had a record of use for up to 60 years by millions of makers, one batch of the 200 was found to be over 50x people, using these drugs worldwide, with an excellent safety record. It was obvious that a group of very powerful people more deadly than vaccines batches from other lots. The in conjunction with pharmaceutical conglomerates didn’t other vaccine lots (batches) were also causing deaths want the pandemic to end and wanted vaccines as the only and disabilities, but nowhere near to this extent. These treatment option. Kennedy’s book makes this case using deadly batches should have appeared randomly among extensive evidence and citations.[14,32] all “vaccines” if it was an unintentional event. However, he found that 5% of the vaccines were responsible for 90% of Dr. James Thorpe, an expert in maternal-fetal medicine, the serious adverse events, including deaths. The incidence demonstrates that these covoid-19 vaccines given during of deaths and serious complications among these “hot pregnancy have resulted in a 50-fold higher incidence of lots” varied from over 1000% to several thousand percent miscarriage than reported with all other vaccines combined. higher than comparable safer lots. If you think this was by [28] When we examine his graph on fetal malformations there accident—think again. This is not the first time “hot lots” was a 144-fold higher incidence of fetal malformation with were, in my opinion, purposefully manufactured and sent the Covid-19 vaccines given during pregnancy as compared across the nation—usually vaccines designed for children. In to all other vaccines combined. Yet, the American Academy one such scandal, “hot lots” of a vaccine ended up all in one of Obstetrics and Gynecology and the American College of Obstetrics and Gynecology endorse the safety of these state and the damage immediately became evident. What was vaccines for all stages of pregnancy and among women breast the manufacture’s response? It wasn’t to remove the deadly feeding their babies. batches of the vaccine. He ordered his company to scatter the hot lots across the nation so that authorities would not see It is noteworthy that these medical specialty groups have the obvious deadly effect. received significant funding from Pfizer pharmaceutical company. The American College of Obstetrics and All lots of a vaccine are numbered—for example Modera Gynecology, just in the 4th quarter of 2010, received a total labels them with such codes as 013M20A. It was noted that of $11,000 from Pfizer Pharmaceutical company alone.[70] the batch numbers ended in either 20A or 21A. Batches Funding from NIH grants are much higher.[20] The best way ending in 20A were much more toxic than the ones ending to lose these grants is to criticize the source of the funds, in 21A. The batches ending in 20A had about 1700 adverse their products or pet programs. Peter Duesberg, because events, versus a few hundred to twenty or thirty events for of his daring to question Fauci’s pet theory of AIDS caused the 21A batches. This example explains why some people had by HIV virus, was no longer awarded any of the 30 grant few or no adverse events after taking the vaccine while others applications he submitted after going public. Prior to this are either killed or severely and permanently harmed. To episode, as the leading authority on retroviruses in the world, see the researcher’s explanation, go to https://www.bitchute. he had never been turned down for an NIH grant.[39] This is com/video/6xIYPZBkydsu/ In my opinion these examples how the “corrupted” system works, even though much of the strongly suggest an intentional alteration of the production grant money comes from our taxes. of the “vaccine” to include deadly batches. I have met and worked with a number of people concerned HOT LOTS—DEADLY BATCHES OF THE with vaccine safety and I can tell you they are not the evil VACCINES anti-vaxxers you are told they are. They are highly principled, A new study has now surfaced, the results of which are moral, compassionate people, many of which are top terrifying.[25] A researcher at Kingston University in London, researchers and people who have studied the issue extensively. has completed an extensive analysis of the VAERs data (a Robert Kennedy, Jr, Barbara Lou Fisher, Dr. Meryl Nass, subdepartment of the CDC which collects voluntary vaccine Professor Christopher Shaw, Megan Redshaw, Dr. Sherri complication data), in which he grouped reported deaths Tenpenny, Dr. Joseph Mercola, Neil Z. Miller, Dr. Lucija following the vaccines according to the manufacturer’s lot Tomjinovic, Dr. Stephanie Seneff, Dr. Steve Kirsch and numbers of the vaccines. Vaccines are manufactured in large Dr. Peter McCullough just to name a few. These people have batches called lots. What he discovered was that the vaccines nothing to gain and a lot to lose. They are attacked viciously are divided into over 20,000 lots and that one out of every 200 by the media, government agencies, and elite billionaires who of these batches (lots) is demonstrably deadly to anyone who think they should control the world and everyone in it. Surgical Neurology International • 2022 • 13(167) | 8 Blaylock: Update on Covid-19 pandemic events WHY DID FAUCI WANT NO AUTOPSIES OF a perceived worldwide “deadly pandemic”, were hiding an THOSE WHO DIED AFTER VACCINATION? important secret that autopsies could document. Namely, just how many of the deaths were actually caused by the virus? There are many things about this “pandemic” that are To implement draconian measures, such as mandated mask unprecedented in medical history. One of the most startling wearing, lockdowns, destruction of businesses, and eventually is that at the height of the pandemic so few autopsies, mandated forced vaccination, they needed very large numbers especially total autopsies, were being done. A mysterious of covid-19 infected dead. Fear would be the driving force for virus was rapidly spreading around the world, a selected all these destructive pandemic control programs. group of people with weakened immune systems were getting seriously ill and many were dying and the one way we Elder et al in his study classified the autopsy findings into could rapidly gain the most knowledge about this virus—an four groups.[22] autopsy, was being discouraged. 1. Certain Covid-19 death 2. Probably Covid-19 death Guerriero noted that by the end of April, 2020 approximately 3. Possible Covid-19 death 150,000 people had died, yet there were only 16 autopsies 4. Not associated with Covid-19, despite the positive test. performed and reported in the medical literature.[24] Among these, only seven were complete autopsies, the remaining 9 What possibly concerned or even terrified the engineers of being partial or by needle biopsy or incisional biopsy. Only this pandemic was that autopsies just might, and did, show after 170,000 deaths by Covid-19 and four months into the that a number of these so-called Covid-19 deaths in truth pandemic were the first series of autopsies actually done, that died of their comorbid diseases. In the vast majority of is, more than ten. And only after 280,000 deaths and another autopsy studies reported, pathologists noted multiple month, were the first large series of autopsies performed, comorbid conditions, most of which at the extremes of life some 80 in number.[22] Sperhake, in a call for autopsies to could alone be fatal. Previously it was known that common be done without question, noted that the first full autopsy cold viruses had an 8% mortality in nursing homes. reported in the literature along with photomicrographs In addition, valuable evidence could be obtained from the appeared in a medico-legal journal from China in February autopsies that would improve clinical treatments and could 2020.[41,68] Sperhake expressed confusion as to why there possibly demonstrate the deadly effect of the CDC mandated was a reluctance to perform autopsies during the crisis, protocols all hospitals were required to follow, such as the but he knew it was not coming from the pathologists. The use of respirators and the deadly, kidney-destroying drug medical literature was littered with appeals by pathologist remdesivir. The autopsies also demonstrated accumulating for more autopsies to be performed.[58] Sperhake further medical errors and poor-quality care, as the shielding of noted that the Robert Koch Institute (The German health doctors in intensive care units from the eyes of family monitoring system) at least initially advised against doing members inevitably leads to poorer quality care as reported autopsies. He also knew that at the time 200 participating by several nurses working in these areas.[53-55] autopsy institutions in the United States had done at least 225 As bad as all this was, the very same thing is being done autopsies among 14 states. in the case of Covid vaccine deaths—very few complete Some have claimed that this dearth of autopsies was based autopsies have been done to understand why these people on the government’s fear of infection among the pathologists, died, that is, until recently. Two highly qualified researchers, but a study of 225 autopsies on Covid-19 cases demonstrated Dr. Sucharit Bhakdi a microbiologist and highly qualified only one case of infection among the pathologist and this was expert in infectious disease and Dr. Arne Burkhardt, a concluded to have been an infection contracted elsewhere.[19] pathologist who is a widely published authority having been Guerriero ends his article calling for more autopsies with a professor of pathology at several prestigious institutions, this observation: “Shoulder to shoulder, clinical and forensic recently performed autopsies on 15 people having died pathologists overcame the obstructions of autopsy studies in after vaccination. What they found explains why so many Covid-19 victims and hereby generated valuable knowledge are dying and experiencing organ damage and deadly on the pathophysiology of the interaction between the blood clots.[5] SARS-CoV-2 and the human body, thus contributing to our They determined that 14 of the fifteen people died as a result understanding of the disease.”[24] of the vaccines and not of other causes. Dr. Burkhardt, the Suspicion concerning the worldwide reluctance of nations pathologist, observed widespread evidence of an immune to allow full post mortem studies of Covid-19 victims attack on the autopsied individuals’ organs and tissues— may be based on the idea that it was more than by chance. especially their heart. This evidence included extensive There are at least two possibilities that stand out. First, those invasion of small blood vessels with massive numbers of leading the progression of this “non-pandemic” event into lymphocytes, which cause extensive cell destruction when Surgical Neurology International • 2022 • 13(167) | 9 Blaylock: Update on Covid-19 pandemic events unleashed. Other organs, such as the lungs and liver, were for example, assumed the position of medical dictators, observed to have extensive damage as well. These findings ordering doctors to follow protocols derived not from those indicate the vaccines were causing the body to attack itself having extensive experience in treating this virus, but rather with deadly consequences. One can easily see why Anthony from a medical bureaucracy that has never treated a single Fauci, as well as public health officers and all who are heavily COVID-19 patient. The mandated use of respirators on ICU promoting these vaccines, publicly discouraged autopsies on Covid-19 patients, for example, was imposed in all medical the vaccinated who subsequently died. One can also see that systems and dissenting physicians were rapidly removed from in the case of vaccines, that were essentially untested prior to their positions as caregivers, despite their demonstration of being approved for the general public, at least the regulatory markedly improved treatment methods. Further, doctors agencies should have been required to carefully monitor and were told to use the drug remdesivir despite its proven analyze all serious complications, and certainly deaths, linked toxicity, lack of effectiveness and high complication rate. to these vaccines. The best way to do that is with complete They were told to use drugs that impaired respiration and autopsies. mask every patient, despite the patient’s impaired breathing. In each case, those who refused to abuse their patients While we learned important information from these autopsies were removed from the hospital and even faced a loss of what is really needed are special studies of the tissues of those license—or worse. who have died after vaccination for the presence of spike protein infiltration throughout the organs and tissues. This For the first time in modern medical history, early medical would be critical information, as such infiltration would result treatment of these infected patients was ignored nationwide. in severe damage to all tissues and organs involved—especially Studies have shown that early medical treatment was saving the heart, the brain, and the immune system. Animal studies 80% of higher number of these infected people when initiated have demonstrated this. In these vaccinated individuals the by independent doctors.[43,44] Early treatment could have source of these spike proteins would be the injected nanolipid saved over 640,000 lives over the course of this “pandemic”. carriers of the spike protein producing mRNA. It is obvious Despite the demonstration of the power of these early that the government health authorities and pharmaceutical treatments, the forces controlling medical care continued this manufacturers of these “vaccines” do not want these critical destructive policy. studies done as the public would be outraged and demand Families were not allowed to see their loved ones, forcing an end to the vaccination program and prosecution of the these very sick individuals in the hospitals to face their involved individuals who covered this up. deaths alone. To add insult to injury, funerals were limited to a few grieving family members, who were not allowed to CONCLUSIONS even sit together. All the while large stores, such as Walmart We are all living through one of the most drastic changes in and Cosco were allowed to operate with minimal restrictions. our culture, economic system, as well as political system in Nursing home patients were also not allowed to have our nation’s history as well as the rest of the world. We have family visitations, again being forced to die a lonely death. been told that we will never return to “normal” and that a All the while, in a number of states, the most transparent great reset has been designed to create a “new world order”. being in New York state, infected elderly were purposefully This has all been outlined by Klaus Schwab, head of the transferred from hospitals into nursing homes, resulting in World Economic Forum, in his book on the “Great Reset”.[66] a very high death rates of these nursing home residents. At This book gives a great deal of insight as to the thinking of the beginning of this “pandemic” over 50% of all death were the utopians who are proud to claim this pandemic “crisis” occurring in nursing homes. as their way to usher in a new world. This new world order Throughout this “pandemic” we have been fed an unending has been on the drawing boards of the elite manipulators series of lies, distortions and disinformation by the media, for over a century.[73,74] In this paper I have concentrated the public health officials, medical bureaucracies (CDC, FDA on the devastating effects this has had on the medical care and WHO) and medical associations. Physicians, scientists, system in the United States, but also includes much of the and experts in infectious treatments who formed associations Western world. In past papers I have discussed the slow designed to develop more effective and safer treatments, were erosion of traditional medical care in the United States and regularly demonized, harassed, shamed, humiliated, and how this system has become increasingly bureaucratized and experience a loss of licensure, loss of hospital privileges and, in regimented.[7,8] This process was rapidly accelerating, but the at least one case, ordered to have a psychiatric examination.[2,65,71] appearance of this, in my opinion, manufactured “pandemic” Anthony Fauci was given essentially absolute control of all has transformed our health care system over night. forms of medical care during this event, including insisting As you have seen, an unprecedented series of events have that drugs he profited from be used by all treating physicians. taken place within this system. Hospital administrators, He ordered the use of masks, despite at first laughing at the Surgical Neurology International • 2022 • 13(167) | 10 Blaylock: Update on Covid-19 pandemic events use of masks to filter a virus. Governors, mayors, and many The head of the insurance company OneAmerica stated businesses followed his orders without question. that their data indicated that the death rate for individuals aged 18 to 64 had increased 40% over the pre-pandemic The draconian measures being used, masking, lockdowns, period.[21] Scott Davidson, the company’s CEO, stated that testing of the uninfected, use of the inaccurate PCR test, social this represented the highest death rate in the history of distancing, and contact tracing had been shown previously insurance records, which does extensive data collections on to be of little or no use during previous pandemics, yet all death rates each year. Davidson also noted that this high of attempts to reject these methods were to no avail. Some states a death rate increase has never been seen in the history of ignored these draconian orders and had either the same or death data collection. Previous catastrophes of monumental fewer cases, as well as deaths, as the states with the most extent increased death rates no more than 10 percent, 40% is strictly enforced measures. Again, no amount of evidence or unprecedented. obvious demonstration along these lines had any effect on ending these socially destructive measures. Even when entire Dr. Lindsay Weaver, Indiana’s chief medical officer, stated countries, such as Sweden, which avoided all these measures, that hospitalizations in Indiana are higher than at any point demonstrated equal rates of infections and hospitalization as in the past five years. This is of critical importance since nations with the strictest, very draconian measures, no policy the vaccines were supposed to significantly reduce deaths, change by the controlling institutions occurred. No amount but the opposite has happened. Hospitals are being flooded of evidence changed anything. with vaccine complications and people in critical condition from medical neglect caused by the lockdowns and other Experts in the psychology of destructive events, such as pandemic measures.[46,56] economic collapses, major disasters and previous pandemics demonstrated that draconian measures come with an A dramatic number of these people are now dying, with enormous cost in the form of “deaths of despair” and in the spike occurring after the vaccines were introduced. The a dramatic increase in serious psychological disorders. lies flowing from those who have appointed themselves The effects of these pandemic measures on children’s as medical dictators are endless. First, we were told that neurodevelopment is catastrophic and to a large extent the lockdown would last only two weeks, they lasted over irreversible. a year. Then we were told that masks were ineffective and did not need to be worn. Quickly that was reversed. Then Over time tens of thousands could die as a result of this we were told the cloth mask was very effective, now it’s not damage. Even when these predictions began to appear, the and everyone should be wearing an N95 mask and before controllers of this “pandemic” continued full steam ahead. that that they should double mask. We were told there was Drastic increases in suicides, a rise in obesity, a rise in drug a severe shortage of respirators, then we discover they are and alcohol use, a worsening of many health measures sitting unused in warehouses and in city dumps, still in and a terrifying rise in psychiatric disorders, especially their packing crates. We were informed that the hospitals depression and anxiety, were ignored by the officials were filled mostly with the unvaccinated and later found the controlling this event. exact opposite was true the world over. We were told that We eventually learned that many of the deaths were a the vaccine was 95% effective, only to learn that in fact the result of medical neglect. Individuals with chronic medical vaccines cause a progressive erosion of innate immunity. conditions, diabetes, cancer, cardiovascular disease, and Upon release of the vaccines, women were told the vaccines neurological diseases were no longer being followed properly were safe during all states of pregnancy, only to find out no in their clinics and doctor’s offices. Non-emergency surgeries studies had been done on safety during pregnancy during the were put on hold. Many of these patients chose to die at home “safety tests” prior to release of the vaccine. We were told that rather than risk going to the hospitals and many considered careful testing on volunteers before the EUA approval for hospitals “death houses”. public use demonstrated extreme safety of the vaccines, only Records of deaths have shown that there was a rise in deaths to learn that these unfortunate subjects were not followed, among those aged 75 and older, mostly explained by Covid-19 medical complications caused by the vaccines were not paid infections, but for those between the ages of 65 to 74, deaths for and the media covered this all up.[67] We also learned had been increasing well before the pandemic onset.[69] that the pharmaceutical makers of the vaccines were told by Between ages of 18 and aged 65 years, records demonstrate a the FDA that further animal testing was unnecessary (the shocking hike in non-Covid-19 deaths. Some of these deaths general public would be the Guinea pigs.) Incredibly, we were were explained by a dramatic increase in drug-related deaths, told that the Pfizer’s new mRNA vaccines had been approved some 20,000 more than 2019. Alcohol related deaths also by the FDA, which was a cleaver deception, in that another increased substantially, and homicides increased almost 30% vaccine had approval (comirnaty) and not the one being in the 18 to 65-year group. used, the BioNTech vaccine. The approved comirnaty vaccine Surgical Neurology International • 2022 • 13(167) | 11 Blaylock: Update on Covid-19 pandemic events was not available in the United States. The national media We are the Prey. Lake Edge Press, Ithaca, NY, 2021. Pp285-292. told the public that the Pfizer vaccine had been approved and 13. Breggin, p133 [Last accessed on 2022 Feb 06]. was no longer classed as experimental, a blatant lie. These 14. Bulik BS, The top 10 ad spenders in Big Pharma for 2020. deadly lies continue. 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US Medical, Scientific, Patient and Civic Organization Funding How to cite this article: Blaylock RL. COVID UPDATE: What is the truth? Surg Neurol Int 2022;13:167. Report: Pfizer: Fourth Quarter 2010. https://cdn.pfizer.com/ Surgical Neurology International • 2022 • 13(167) | 14 Received: 19 January 2021 | Revised: 21 February 2021 | Accepted: 14 March 2021 DOI: 10.1111/eci.13554 REVIEW ARTICLE Reconciling estimates of global spread and infection fatality rates of COVID-19: An overview of systematic evaluations John P. A. Ioannidis Departments of Medicine, of Epidemiology and Population Health, of Biomedical Abstract Data Science, and of Statistics, and Meta- Background: Estimates of community spread and infection fatality rate (IFR) of Research Innovation Center at Stanford COVID-19 have varied across studies. Efforts to synthesize the evidence reach seem- (METRICS), Stanford University, Stanford, CA, USA ingly discrepant conclusions. Methods: Systematic evaluations of seroprevalence studies that had no restrictions Correspondence based on country and which estimated either total number of people infected and/or John P. A. Ioannidis, SPRC, 1265 Welch Road, Medical School Office Building aggregate IFRs were identified. Information was extracted and compared on eligibil- Room X306, Stanford, CA 94305, USA. ity criteria, searches, amount of evidence included, corrections/adjustments of sero- Email: jioannid@stanford.edu prevalence and death counts, quantitative syntheses and handling of heterogeneity, Funding information main estimates and global representativeness. None; the Meta-Research Innovation Center Results: Six systematic evaluations were eligible. Each combined data from 10 to at Stanford (METRICS) has been funded with grants from the Laura and John Arnold 338 studies (9-50 countries), because of different eligibility criteria. Two evaluations Foundation. had some overt flaws in data, violations of stated eligibility criteria and biased eligi- bility criteria (eg excluding studies with few deaths) that consistently inflated IFR es- timates. Perusal of quantitative synthesis methods also exhibited several challenges and biases. Global representativeness was low with 78%-100% of the evidence com- ing from Europe or the Americas; the two most problematic evaluations considered only one study from other continents. Allowing for these caveats, four evaluations largely agreed in their main final estimates for global spread of the pandemic and the other two evaluations would also agree after correcting overt flaws and biases. Conclusions: All systematic evaluations of seroprevalence data converge that SARS-CoV-2 infection is widely spread globally. Acknowledging residual uncer- tainties, the available evidence suggests average global IFR of ~0.15% and ~1.5-2.0 billion infections by February 2021 with substantial differences in IFR and in infec- tion spread across continents, countries and locations. KEYWORDS bias, COVID-19, global health, infection fatality rate, meta-analysis, seroprevalence This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2021 The Authors. European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for Clinical Investigation Journal Foundation Eur J Clin Invest. 2021;51:e13554. wileyonlinelibrary.com/journal/eci | 1 of 13 https://doi.org/10.1111/eci.13554 2 of 13 | IOANNIDIS Highlights • Six systematic evaluations have evaluated seroprevalence studies without restric- tions based on country and have estimated either total number of people infected or aggregate infection fatality rates for SARS-CoV-2. • These systematic evaluations have combined data from 10 to 338 studies (9-50 countries) each with partly overlapping evidence synthesis approaches. • Some eligibility, design and data synthesis choices are biased, while other differ- ing choices are defendable. • Most of the evidence (78%-100%) comes from Europe or the Americas. • All systematic evaluations of seroprevalence data converge that SARS-CoV-2 in- fection has been very widely spread globally. • Global infection fatality rate is approximately 0.15% with 1.5-2.0 billion infections as of February 2021. 1 | IN T ROD U C T ION 2.2 | Search strategy The extent of community spread of SARS-CoV-2 infec- Searches were updated until 14 January 2021 in PubMed, tion and the infection fatality rate (IFR) of COVID-19 are medRxiv and bioRxiv with ‘seroprevalence [ti] OR fatality hotly debated. Many seroprevalence studies have provided [ti] OR immunity [ti]’ For feasibility, the search in PubMed relevant estimates. These estimates feed into projections that was made more specific by adding ‘(systematic review OR influence decision-making. Single studies create confusion, meta-analysis OR analysis)’. Communication with experts since they leave large uncertainty and unclear generalizabil- sought potentially additional eligible analyses (eg unindexed ity across countries, locations, settings and time points. Some influential reports). overarching evaluations have systematically integrated data from multiple studies and countries.1-6 These synthetic ef- forts probe what are typical estimates of spread and IFR, how 2.3 | Extracted information heterogeneous they are, and what factors explain heterogene- ity. An overview of these systematic evaluations comparing From each eligible evaluation, the following information was their methods, biases and inferences may help reconcile their extracted: findings on these important parameters of the COVID-19 pandemic. 1. Types of information included (seroprevalence, other) 2. Date of last search, search sources and types of publica- tions included (peer-reviewed, preprints, reports/other) 2 | M ET H OD S 3. Types of seroprevalence designs/studies included 4. Number of studies, countries, locations included 2.1 | Eligible articles 5. Seroprevalence calculations: adjustment/correction for test performance, covariates, type of antibodies measured, Articles were eligible if they included a systematic review seroreversion (loss of antibodies over time) of studies aiming to assess SARS-CoV-2 seroprevalence; 6. Death count calculations: done or not; adjustments there were no restrictions based on country; and an effort was for over- or under-counting, time window for count- made to estimate either a total number of people infected or ing COVID-19 deaths in relationship to seroprevalence aggregate IFRs. Articles were excluded if they considered measurements exclusively studies of particular populations at different risks 7. Quantitative synthesis: whether data were first synthesized of infection than the general population (eg only healthcare from seroprevalence studies in the same location/country/ workers), if they focused on specific countries (by eligibility other level; whether meta-analyses were performed across criteria, not by data availability), and if they made no effort locations/countries and methods used; handling of hetero- to estimate total numbers of people infected and/or aggregate geneity, stratification and/or regression analyses, includ- IFRs. ing subgroups IOANNIDIS | 3 of 13 8. Reported estimates of infection spread, under- 3.2 | Information used ascertainment ratios (total/documented infections) and/or IFR Five evaluations included only seroprevalence studies 9. Global representativeness of the evidence: proportion (Table 1). Meyerowitz-Katz also included non-serological of the evidence (weight, countries, studies or locations, and modelling papers; summary IFR was smaller in the se- depending on how data synthesis had been done) from roprevalence studies (0.60% vs 0.84% in others). The six Europe and North America (sensitivity analysis: Europe evaluations differed modestly in dates of last search (range, and America) 6/16/2020-9/9/2020) and in sources searched. Given that few studies outside of Europe and Americas were released early, evaluations with earlier searches have a more promi- 2.4 | Comparative assessment nent dearth of low-IFR studies from countries with younger populations and fewer nursing home residents. Based on the above, the eligible evaluations were compared Eligibility criteria varied and were sometimes unclear or against each other with focus on features that may lead to left room for subjectivity. Consequently, eligible studies var- bias and trying to decipher the direction of each bias. ied from 10 to 348 and countries covered with eligible data varied from 9 to 50. Two evaluations1,4 excluded studies in overtly biased ways, leading to inflated IFR estimates. 3 | R E S U LTS Specifically, Meyerowitz-Katz excluded one study with low-IFR5 alluding that the study itself ‘explicitly warned 3.1 | Eligible evaluations against using its data to obtain an IFR’1; as co-investigator of the study, both myself and my colleagues are intrigued Nine potentially eligible articles were retrieved1-3,5-10 And at this claim. They also excluded two more studies with four were rejected (Figure 1).7-10 One more eligible report4 low-IFR alluding that it ‘was difficult to determine the nu- was identified from communication with experts. The six eli- merator (ie number of deaths) associated with the seroprev- gible evaluations are named after their first authors or team alence estimate or the denominator (ie population) was not throughout the manuscript. well defined’,1 while one even presented IFR estimates in its published paper. Another excluded paper11 tabulated several seroprevalence studies with median IFR = 0.31%, half the Meyerowitz-Katz estimate. The Imperial College COVID-19 Response Team 1084 items retrieved by searches (ICCRT) excluded studies with <100 deaths at the sero- (249 from PubMed, 359 from survey mid-point.4 This exclusion criterion introduces bias medRxiv, 476 from bioRxiv) since number of deaths is the numerator in calculating IFR. Exclusion of studies with low numerator excludes studies 1075 items excluded a!er likely to have low IFR. Indeed, five of six excluded studies screening "tles and abstracts with <100 deaths (Kenya, LA County, Rio Grande do Sul, 9 poten"ally eligible ar"cles Gangelt, Scotland)12-16 have lower IFR than the 10 ICCRT- included studies; the sixth (Luxembourg)17 is in the lower Four ar"cles excluded upon full- range of the 10 ICCRT-included studies. text scru"ny (three [refs. 7-9] The six evaluations varied on types of populations con- had not obtained any total es"mates of infected people or sidered eligible. Table 2 summarizes biases involved in each IFR and one [ref. 10] had study population type. General population studies are proba- focused only on countries with advanced economies. bly less biased, provided they recruit their intended sample. Conversely, studies of healthcare workers,18 other high-risk 5 eligible ar"cles exposure workers and closed/confined communities may overestimate seroprevalence; these studies were generally One addi"onal report excluded, either upfront (5/6 evaluations) or when calculat- obtained from communica"on with experts ing key estimates (Bobrovitz). Other designs/populations may be biased in either direction, more frequently towards 6 total eligible evalua"ons underestimating seroprevalence.19-26 Three evaluations (Meyerowitz-Katz, ICCRT, O’Driscoll) were very aggressive FIGURE 1 Flow diagram with exclusions. TABLE 1 Key features for eligible systematic data syntheses 4 of 13 | Features Meyerowitz-Katz Rostami Bobrovitz Imperial college COVID-19 response team Ioannidis O’Driscoll Types of information SP, non-serological SP studies SP studies SP studies SP studies SP studies included and modelling studies Last search 16 June 14 August 28 August Unclear 9 September Unclear (1 September?) Search sources PubMed, preprints PubMed, Scopus, MEDLINE, EMBASE, SeroTracker searches (see Bobrovitz) PubMed (LitCOVID), Unclear (medRxiv, SSRN), EMBASE, Web of Science, and medRxiv, bioRxiv, Research Google, Twitter medRxiv, Europe PMC, Google, Square, national reports, searches, government bioRxiv, communication with communication with experts agency reports research reports experts for additional studies eligible eligible Types of SP studies Excluded targeted Excluded at-risk All studies included if they Studies with defined sampling framework, General population or Unclear, but eventually it included populations with populations (eg reported on sample, date, defined geographic area, with availability of approximations (including includes some general selection bias, also HCW), known region and SP estimate test performance, preferentially validation blood donors, excluding population studies, four other studiesa diseases (eg done as part of the study (not just by high risk, eg HCW, some blood donors and dialysis, cancer) manufacturers), >100 deaths at SP study communities), sample size some hospital samples mid-pointb ; excluded healthcare workers, >500, area with population symptoms of COVID-19, self-referral or self- >5000 selection, narrow age range, confined settings, clinical samples Number of studies, 24-27 studiesc , of 107 data sets 338 studies (184 from 10 studies (six national, four subnational), nine 82 estimates, 69 studies, 51 25 studies from 20 countries, locations which 16 serological from 47 studies general population) from countriese locations, 36 countries (main countries (only 22 from 14 countries from 23 50 countries (36 from analysis at the location level) national representing countries general population)d 16 countries used in the ensemble model) Studies published in 1/16 61/107 4/40 included in final 5/10 35/82 6/20 countries peer-review journals analysis of under- at the time of the ascertainment ratio evaluation Abbreviations: HCW, healthcare workers; IFR, infection fatality rate; SP, seroprevalence. a One study (LA County)12 with very low IFR was excluded with the justification that it ‘explicitly warned against using its data to obtain an IFR’; as a co-investigator of the study, both myself and my colleagues are intrigued at the rationale for exclusion; in the publication of the study in JAMA,12 we did list limitations and caveats, as it is appropriate for any seroprevalence study to do; excluding studies that are honest to discuss limitations would keep only the worst studies that discuss no limitations. Two other studies with low IFR were excluded as well. One was done in Rio Grande do Sul13 where its authors even report IFR estimates in their paper (0.29%, 0.23%, 0.38% in the three rounds of the serosurvey); the other was done in Boise,85 where its authors properly discuss limitations but an approximation of IFR is possible; even if not perfectly accurate, it is certainly lower than the IFR estimates included in the Meyerowitz-Katz meta-analysis. For the fourth excluded study,11 the justification offered for its exclusion is that it ‘calculated an IFR, but did not allow for an estimate of confidence bounds’.1 However, this study presents results of a New York study that Meyerowitz-Katz did include in their meta-analysis. Of note, that fourth study11 also presents a cursory review of seroprevalence studies arriving at a median IFR = 0.31%, half of the summary estimate of Meyerowitz-Katz.; bClear bias introduced since number of deaths is the numerator itself in the calculation of IFR, and exclusion of studies with low numerator is thus excluding studies likely to have low IFR; cDifferent numbers provided by the authors for total studies in abstract (n = 24), text of the paper (n = 25), tabulated studies (n = 27) and forest plot studies (n = 26); d39 estimates from 17 countries used in main calculation of median under-ascertainment ratio (N. Bobrovitz, personal communication); eOne of the 10 included studies violates the eligibility criterion of the investigators having validated themselves the antibody test used; the ICCRT included this study invoking validation data for the same antibody kit done by a different team in a study in a completely different setting and continent (San Francisco); based on this rationale, perhaps many other studies could have been included, if the same violation of the eligibility criteria was tolerated. The included study was an Italian survey30 which had only been released in the press with a preliminary report at the time of the ICCRT evaluation and which included crude results on only 64 660 of the intended 150 000 participants (missingness 57%). Its inferred IFR estimate (2.5%) is an extreme outlier, as it is 2- to 20-fold larger than other typical estimates reported from numerous European countries. Moreover, that IFR estimate even matches/exceeds case fatality rates, and thus, it is simply impossible. It is widely accepted that IFR must be several times smaller than case fatality rate, even in locations with substantial testing. Italy had very limited testing in the first wave and modest testing in the second wave. One estimate suggests that the number of infections in Italy at the peak of the first wave was 12 times IOANNIDIS more than the number of documented cases; that is, the IFR would be more than an order of magnitude lower than the case fatality rate.31 IOANNIDIS | 5 of 13 TABLE 2 Direction of potential bias in studies with different types of populations Type of sampling Direction of bias General population (entire Depends on characteristics of individuals who cannot be reached and/or decline participation. If they are more population or design for likely to be more disadvantaged (eg have no address/phone/e-mail) and thus also at higher risk of infection, SP representative sample) may be underestimated. Potential for bias is more prominent when non-response/non-participation is larger. Institutionalized populations and homeless people are typically not included, and these populations often have very high infection rates19,20 ; thus, SP is underestimated Convenience sample Bias could be in either direction. Volunteer bias is common and would tend to recruit more health-conscious, (including self-referral and low-risk individuals,21 leading to SP underestimation. Conversely, interest to get tested because of worrying in response to adverts) the presence of symptoms may lead to SP overestimation Blood donors Bias could be in either direction, but SP underestimation is more likely, since blood donors tend to be more health-conscious and thus more likely to avoid also risky exposures. An early classic assessment22 described blood donors as ‘low-risk takers, very concerned with health, better educated, religious, and quite conservative’—characteristics that would lead to lower infection risk. In countries with large shares of minorities (eg USA and UK), minorities are markedly under-represented among blood donors.23,24 For example, in the USA, donation rates are 37%-40% lower in blacks and Hispanics versus whites23 and in the UK, donation rates range from 1.59 per 1000 among Asian Bangladeshi origin, compared to 22.1 per 1000 among white British origin.24 These minorities were hit the most by COVID-19. In European countries, donations are lower in low-income and low-education individuals25,26 ; these are also risk factors for COVID-19 infection. Bobrovitz3 found median seroprevalence of 3.2% in blood donor studies versus 4.1% in general community/household samples (risk ratio 0.80 in meta-regression). SP may be overestimated if blood donation is coupled to a free COVID-19 test in a poor population (as in the case of a study in Manaus, Brazil) Clinical residual samples and Bias could be in either direction, but SP underestimation is more likely since patients with known health patients (eg dialysis, cancer, problems may be more likely to protect themselves in a setting of a pandemic that poses them at high risk. other) Conversely, repeated exposure to medical facilities may increase risk. Demographic features and socio- economic status may also affect the size and direction of bias. Bobrovitz3 found median seroprevalence of 2.9% in studies of residual samples versus 4.1% in general community/household samples (risk ratio 0.63 in meta-regression). Hospital visitors’ studies had even lower seroprevalence (median 1.4%) Healthcare workers, Bias very likely to lead to SP overestimation compared with the general population, because of work-related emergency response, other contagion hazard; however, this may not always be the case (eg most infections may not happen at work) and workers with obvious high any increased risk due to work exposure sometimes may be counterbalanced by favourable socio-economic risk of exposure profile for some healthcare workers (eg wealthy physicians). Bias may have been more prominent in early days of the pandemic, especially in places lacking protective gear. Across eight studies with data on healthcare workers and other participants, seroprevalence was 1.74-fold in the former.3 Other workers Bias could be in either direction and depends on work experience during the pandemic period and socio- economic background; for example, SP may be underestimated compared with the general population for workers who are wealthy and work from home during the pandemic and overestimated for essential workers Communities (shelters, Likely very strong bias due to high exposure risk leading to SP overestimation compared with the general religious, other population. Some of these communities were saturated with very high levels of infection very early.19,20 shared-living) Note: Abbreviations: SP, seroprevalence. ICCRT had the most draconian exclusion criteria, ex- test validation; ICCRT ‘salvaged’ the Italian study by trans- cluding 165/175 identified seroprevalence studies. However, porting validation data from another study in San Francisco. ICCRT actually dropped many general population studies (for The Italian study report30 showed data on only 64 660 of the various reasons), but included two blood donor studies27,28 intended 150 000 participants (missingness 57%). Its inferred (out of many such) and one New York study29 with conve- IFR estimate (2.5%) is an extreme outlier (2- to 20-fold larger nience samples of volunteers recruited while entering gro- than other reported European estimates) and simply impos- cery stores and through an in-store flyer. The latter inclusion sible: it matches/exceeds case fatality rates despite probably goes against the stated ICCRT eligibility criteria where self- major under-ascertainment of infections in Italy.31 selection is reason for exclusion. The New York study29 had Finally, the six evaluations differed markedly on how many high IFR (from the worst-hit state in the first wave). The pre- included seroprevalence estimates came from peer-reviewed liminary press-released report from an Italian general popu- publications (journal articles listed in the references) at the lation survey30 was included in violation of ICCRT eligibility time of the evaluation: from only one peer-reviewed esti- criteria4 that a study should have performed its own antibody mate in Meyerowitz-Katz to 61 in Rostami. Some included 6 of 13 | IOANNIDIS seroprevalence estimates that came from preprints/reports published in peer-reviewed journals by 2/2021; final publica- to seroconversion, 20 d Distributional (gamma), mean 10 d from onset Unclear selection rule tions could have minor/modest differences versus preprints/ from onset to death secondary analysis Yes (24/25 studies) reports. Even journal-published estimates may get revised; Seroreversion, in No adjustments for example, a re-analysis increased Indiana seroprevalence O’Driscoll estimates by a third.32 3.3 | Seroprevalence and death calculations Selecting most fully adjusted SP 7 d after mid-point of SP survey Yes, when done by authors of or as chosen by its authors Three evaluations3,4,6 routinely adjusted for test perfor- mance, one5 adjusted for test performance when the authors Type of antibodiesa of the studies had done so, and two were unclear (Table 3). No adjustments Depending on test sensitivity/specificity, lack of adjustment may inflate or deflate seroprevalence. Ioannidis selected the estimated Ioannidis SP study most fully adjusted seroprevalence estimate, when both ad- justed and unadjusted estimates existed; other evaluations were unclear on this issue. Ioannidis corrected the seropreva- and beta), mean 18.3 d from onset lence upward when not all three types of antibodies (IgG, Distributional (truncated Gaussian to seroconversion, 19.8 d from IgM, and IgA) were assessed. ICCRT and O’Driscoll consid- Imperial College COVID-19 ered seroreversion adjustments. Rostami and Bobrovitz did not collect death counts to Unclear selection rule estimate IFR. The other four evaluations did not systemati- cally adjust death counts for under- or over-counting. Finally, No adjustments response team onset to death Seroreversion ICCRT and O’Driscoll used distributional approaches on the time window for counting deaths (with means between sero- conversion and death differing by 1.5 and 10 days, respec- Yes tively), Ioannidis counted deaths until 7 days after the survey mid-point (or the date survey authors made a strong case for), Unclear selection Yes (Bayesian) and Meyerowitz-Katz counted deaths up until 10 days after Deaths not Deaths not Bobrovitz survey end. assessed assessed rule Adjustments and corrections for seroprevalence and death counts No 3.4 | Quantitative synthesis, heterogeneity and main estimates selection rule selection rule Deaths not Deaths not assessed assessed Rostami Unclear Unclear The six evaluations differed in quantitative synthesis ap- Abbreviations: d, days; IFR, infection fatality rate; SP, seroprevalence. proaches with implications for the main results (Table 4). one-tenth adjustment per each not tested antibody (IgG, IgM, IgA). No Meyerowitz-Katz used random effects meta-analysis of Unclear selection rule Unclear selection rule 10 d after completion 26 IFRs calculating a summary estimate despite extreme Meyerowitz-Katz between-study heterogeneity (I2 = 99.2%). Such extreme No adjustments heterogeneity precludes obtaining meaningful summary es- of SP study timates. Estimates from the same country/location were not combined first, and two multiply-counted countries (Italy No and China) have high IFRs entered in calculations. Meta- analysis limited to seroprevalence studies yielded slightly Adjustment of SP for test Death count adjustments lower summary IFR (0.60% vs 0.68%), but extreme between- Time window for death Adjustment of SP for study heterogeneity persisted (I2 = 99.5%); thus, summary Other SP correction estimates remained meaningless. Extreme between-study performance confounders heterogeneity persisted also within three risk-of-bias cate- TABLE 3 gories (I2 = 99.6%, 98.8% and 94.8%, respectively), within Features counts Europe and within America. There was no between-study heterogeneity for four Asian estimates, but none came from a TABLE 4 Quantitative synthesis approaches, stratification and/or regression and main estimates Imperial College IOANNIDIS COVID-19 response Meyerowitz-Katz Rostami Bobrovitz team Ioannidis O’Driscoll Quantitative 26 IFR estimates First step 107 SP estimates Median SP calculated overall Log-linear model for First step, sample size- The ensemble model synthesis combined at one step combined separately for each and per subgroup of interest. pooling age-stratified weighted summary of SP eventually models age- with D-L RE model, country with D-L RE model, IFR, then age-stratified per location; then median stratified IFR in a total I2 = 99.4% then per region. Also D-L estimates extrapolated estimated across locations of 45 countries with RE for all 107 estimates, to the age structure of available age-stratified I2 = 99.7% populations of typical death counts, but data are countries used as input from only 16 countries that have IFR data with some age stratification Stratification Subgroup analyses per Subgroup analyses per age, Subgroup analyses per GBD Focus on age-strata, also Separate analyses for age Focus on age-strata; also and/or continent, month of gender, type of population, region, scope (national, IFR estimates with and <70 years; also subgroup per sex/gender and per regression publication, modelling serological method, race/ regional, local, sublocal), without seroreversion, analyses according to level country versus serological and ethnicity, income, human risk of bias, days since 100th and (for some countries) of overall mortality in the risk of bias development index, latitude/ case (also explored in meta- excluding nursing home location longitude, humidity, regressions); RE inverse deaths temperature, days from variance meta-analysis onset of pandemic; also RE of prevalence ratios for meta-regressions demographics (age, sex, race, close contact, HCW status) with I2 = 85.1%-99.4% per grouping factor Main Summary IFR 0.68 (95% 263.5 million exposed/infected 643 million infected as of Overall IFR: LIC 0.22 Over 500 million infected 5.27% of the population estimates CI-0.53%-0.82%), at the time of the study based 17 November, based on (0.14, 0.39), LMIC) 0.37 as of September 12 (vs of the 45 modelled 0.60 when limited to on the pooled SP from all estimated median under- (0.25, 0.61), UMIC 0.57 29 million documented countries had been serological studies 107 data sets; when estimated ascertainment factor of 11.9 (0.38, 0.92), HIC 1.06 cases) globally; median infected by 1 September per region the total is 641 (using 9 d before study end (0.73, 1.64) IFR 0.23% in the available milliona date for PCR counts)b studies (0.09% in locations with <118 deaths/million), 0.20% in locations with 118-500 deaths/million, 0.57% in locations with >500 deaths/million Abbreviations: IFR, infection fatality rate; RE, random effects; SP, seroprevalence. a In millions: Europe+North America 47, East+South-East Asia 47, Latin America 9, South America 6, Sub Saharan Africa 62, Central and South Asia 446, North Africa and West Asia 24; bMedian under-ascertainment was 14.5 | overall based on 125 study estimates and 11.9 in national estimates, 15.7 in regional estimates and 24.0 in local estimates. 7 of 13 8 of 13 | IOANNIDIS seroprevalence data and their IFR estimate (0.46%) is far 87% of countries 94% of countries higher than many subsequent Asian studies (outside Wuhan) Geographic location of estimates (countries) included in main calculations.; bThe extrapolated 45 countries on which age-stratified IFR estimates are obtained also include countries outside the regions that have at least one using seroprevalence data5 instead of modelling. O’Driscollb Rostami also performed random effects meta-analyses 13 (13) 1 (1) 1 (1) 0 (0) 1 (1) 0 (0) but more appropriately combined at a first step seropreva- lence data from studies in the same country, and in the same region, a summary estimate across all 107 estimates in all countries was also obtained. The step-wise approach avoids the Meyerowitz-Katz analysis flaw. However, seroprevalence 73% of location 78% of location estimates may still vary extremely even within the same lo- estimates estimates Ioannidis cation, for example if done at different times. Moreover, the 22 (21) 15 (2) 10 (9) 3 (3) 1 (1) 0 (0) main estimate of the evaluation (‘263.5 million exposed/in- fected at the time of the study’) extrapolated to the global population the pooled estimate from all 107 data sets. The more appropriate estimate is a sum of the infected per coun- Imperial College COVID-19 try, or at least per region. Actually, the authors did calcu- late numbers of people exposed/infected per world region. country represented (Pakistan, Philippines, Bangladesh, Indonesia, China, Thailand, South Korea, Japan) even though not directly measured in any of them. The sum was 641 million, 2.5-fold larger. Moreover, these 100% of data sets 90% of data sets numbers did not reflect ‘the time of the study’: the 107 sero- response team prevalence studies were done 2-6 months before the Rostami evaluation was written. 8 (7) 1 (1) 1 (1) 0 (0) 0 (0) 0 (0) Bobrovitz calculated medians (overall and across several subgroups of studies), and Ioannidis calculated sample size- weighted means per location and then medians across loca- 85% of data sets (82% of 93% of data sets (87% of tions. Their approaches avoid multiple counting of locations with many estimates available. Bobrovitz also performed random effects inverse variance meta-analysis of prevalence countries) countries) ratios for diverse demographics (age, sex, race, close contact, Bobrovitz 33 (13) healthcare workers). The approach is defendable, since prev- 1 (1) 3 (1) 2 (1) 1 (1) 0 (0) alence ratios were calculated within each study, but still very large between-study heterogeneity existed (I2 = 85.1%-99.4% per grouping factor) making results tenuous. Bobrovitz and Ioannidis reach congruent estimates for total number infected 72% of data sets 85% of data sets globally (643 million by November 17 and at least 500 mil- lion by September 12, respectively) with under-ascertainment Rostami 52 (13) ratios of 11.9 in November and 17.2 in September. Only the 22 (1) 17 (2) 14 (5) 2 (2) 0 (0) latter evaluation calculated IFRs (0.23% overall; 0.05% for those <70 years old). ICCRT and O’Driscoll focused on age-stratified esti- Meyerowitz-Katz mates. ICCRT extrapolated age-stratified estimates to the 91% of weight 98% of weight age structure of populations of typical countries, obtaining separate overall IFR estimates for low-income countries 11 (11) 3 (1) 1 (1) 1 (1) 0 (0) 0 (0) Global representativeness (0.22%), lower-middle–income countries (0.37%), upper- middle–income countries (0.57%) and high-income countries (1.06%). O’Driscoll made extrapolations to 45 countries es- Information from Europe and Information from Europe and timating 5.27% of their population infected by 1 September. Estimates (countries)a 3.5 | Global representativeness North America Latin America North America TABLE 5 Oceania America Europe Seroprevalence data lacked global representativeness. 72%- Africa Asia 91% of the seroprevalence evidence came from Europe and North America (78%-100% from Europe or Americas) a IOANNIDIS | 9 of 13 (Table 5). Lack of representativeness was most prominent not all types of antibodies are assessed, a correction may also in Meyerowitz-Katz (only one estimate from Asia, none be useful. Adjustment for test performance may seemingly from Africa), ICCRT (no estimates from Asia or Africa) and suffice. However, control samples used to estimate test sensi- O’Driscoll (only one estimate from Africa, no estimate from tivity come from PCR-tested diagnosed patients, while missed Asia). However, ICCRT extrapolated to all countries glob- diagnoses typically reflect asymptomatic or less symptom- ally and O’Driscoll extrapolated to 45 countries including atic patients not seeking testing. Sensitivity may be much eight in Asia. lower in these people, as many develop no or low-titre anti- bodies.40,41 Seroreversion has a similar impact. Preliminary evidence suggests substantial seroreversion.29,42-45 For ex- 4 | D IS C U SSION ample, among healthcare personnel, 28.2% seroreverted in 2 months (64.9% in those with low titres originally).45 Only This overview of six systematic evaluations of global spread ICCRT and O’Driscoll considered corrections for serorever- and/or IFR of SARS-CoV-2 utilizing seroprevalence data sion, but still did not allow for high seroreversion. All these highlights differences in methods, calculations and infer- factors would result in underestimating seroprevalence (over- ences. Several choices made by some evaluations led to bias. estimating IFR). Other choices are defendable and reveal some unavoidable Both over- and under-counting of COVID-19 deaths (the variability on how evidence on these important questions IFR numerator) may exist,46,47 varying across countries with should be handled. different testing and death coding. Correction of COVID-19 Choices that led to biased inflated IFR estimates are the death counts through excess deaths is problematic. Excess inclusion of modelling estimates, inappropriate exclusion of reflects both COVID-19 deaths and deaths from measures low-IFR studies despite fitting stated inclusion criteria of the taken.46-49 Year-to-year variability is substantial, even more evaluators, inappropriate inclusion of high-IFR studies de- so within age-strata. Comparison against averages of multi- spite not fitting stated inclusion criteria, and using low death ple previous years is naïve, worse in countries with substan- counts as exclusion criterion. Two evaluations (Meyerowitz- tial demographic changes. For example, in the first wave, Katz and ICCRT) suffered multiple such problems each. an excess of 8071 deaths (SMR 1.03, 95% CI 1.03-1.04) in These biases contributed to generate inflated and, sometimes, Germany became a deficit of 4926 deaths (SMR 0.98, 95% overtly implausible results. These two evaluations also nar- CI 0.98-0.99) after accounting for demographic changes.50 rowly selected very scant evidence (16 and 10 studies, includ- The exact timepoint when deaths are counted may affect IFR ing only one and five peer‐reviewed articles, respectively), calculations when surveys happen while many deaths are while hundreds of seroprevalence estimates are available. still accruing. All evaluations that counted deaths allowed Differences in types of study designs and populations for greater time for death to occur than for seroconversion, considered eligible may be defended with various arguments but Meyerowitz-Katz used a most extreme delay, considering by each evaluator. Studies of healthcare workers were con- deaths until 10 days after survey end. Surveys take from one sistently excluded. No consensus existed on studies of blood day to over a month; thus, inferred sampling-to-death delay donors, clinical samples, workers at no obvious high-risk may occasionally exceed 6 weeks. Meyerowitz-Katz defends occupations and various convenience samples; these designs this choice also in another paper10 choosing 4 weeks after have variable reliability. Reliability increases with careful ad- the serosurvey mid-point. However, the argument (account- justment for sampling, demographics and other key factors ing for death reporting delays) is weak. Several situational re- and when missing data are limited. General population sam- ports plot deaths according to date of occurrence rather than pling is theoretically best, but general population studies may date of reporting anyhow.51 Moreover, infection-to-death still suffer large bias from selective missingness. Unreachable time varies substantially and may be shorter in developing individuals, institutionalized people and non-participating in- countries where fewer people are long-sustained by medical vitees are typically at higher infection risk; if so, some general support. population studies may substantially underestimate seroprev- Some quantitative synthesis approaches were problem- alence (overestimate IFR). For example, Meyerowitz-Katz atic, for example calculating summary estimates despite included a Danish government survey press release33 where I2 > 99% or no data combination within the same country/ only 1071 of 2600 randomly selected invitees participated location before synthesis across countries/locations. Another (missingness 59%); the estimated IFR (0.79%) is probably generic problem with meta-analysis of such data is that it pe- substantially inflated.6,28 nalizes better studies that allow more appropriately for uncer- Differences may also ensue from seroprevalence adjust- tainty in estimates (eg by accounting for test performance and ments for test performance and other factors.34,35 Sometimes adjusting for important covariates). Studies with less rigorous the change in estimated seroprevalence is substantial.36-38 or no adjustments may have narrower CIs (smaller variance, Special caution is needed with low seroprevalence.39 When thus larger weight).5 Finally, for IFR meta-analysis, studies 10 of 13 | IOANNIDIS with few deaths may have higher variance (lower weight) and as of 12 September) and Rostami (641 million infected by these studies may have the lowest IFR. summer, when numbers are added per region) estimates. The Age stratification for IFR estimation and synthesis is a rea- Bobrovitz estimate (643 million infected as of 17 November) sonable choice to reduce between-study heterogeneity driven should be increased substantially given that only 2 of 17 by steep COVID-19 death risk age gradient.52 However, both countries informing the calculated under-ascertainment ratio analyses4,6 that capitalized on granular age stratification made were in Asia or Africa, continents with much larger under- tenuous extrapolations to additional countries from thin or no ascertainment ratios. National surveys in India actually es- data. ICCRT lacked seroprevalence data on low-income and timated 60% seroprevalence in November in urban areas.66 lower-middle–income countries (~half the global popula- Therefore, probably infected people globally were ~1 billion tion); upper-middle–income countries (~35% of global pop- (if not more) by 17 November (compared with 54 million ulation) were only represented by one estimate from Brazil documented cases). By extrapolation, one may cautiously assuming IFR = 1%, exceeding twofold to fivefold other estimate ~1.5-2.0 billion infections as of 21 February 2021 peer-reviewed estimates from Brazil.13,53 Estimates used (compared with 112 million documented cases). This cor- from high-income countries included an impossible Italian responds to global IFR ~0.15%—a figure open to adjust- estimate (IFR = 2.5%)30 and mostly non–peer-reviewed data. ment for any over- and under-counting of COVID-19 deaths O’Driscoll was more careful, but still some IFR extrapola- (Appendix S2). tions appear highly inflated versus data from subsequently Meyerowitz-Katz and ICCRT reach higher estimates of accrued seroprevalence studies. Their ensemble model as- IFR, but, as discussed above, these are largely due to en- sumed highest IFR in Japan (1.09%) and lowest in Kenya dorsing selection criteria focusing on high-IFR countries, (0.09%) and Pakistan (0.16%). Currently, available seroprev- violations of chosen selection criteria and obvious flaws alence studies from these countries show markedly lower IFR that consistently cause IFR overestimation. Similar concerns estimates: =<0.03%,54-56 =<0.01%14 and 0.04%-0.07%,57,58 apply to another publication with implausibly high age- respectively. In Japan, infections apparently spread widely stratified IFRs by Meyerowitz-Katz limited to countries with without causing detectable excess mortality.54 In Kenya, advanced economies, again narrowly selected some of the under-ascertainment compared with documented cases was highest IFR locations and estimates.12 ~1000-fold.14 While some COVID-19 deaths are certainly Even correcting inappropriate exclusions/inclusion of missed in Africa, containment measures are more deadly.59 studies, errors and seroreversion, IFR still varies substan- All six evaluations greatly over-represented Europe and tially across continents and countries. Overall average IFR America. Only two (Rostami and Ioannidis) included mean- may be ~0.3%-0.4% in Europe and the Americas (~0.2% ingful amounts of data from Asia and Africa (still less than among community-dwelling non-institutionalized people) their global population share) in main estimate calculations. and ~0.05% in Africa14 and Asia (excluding Wuhan). Within Currently, extensive data suggest high under-ascertainment Europe, IFR estimates were probably substantially higher in ratios in Africa and many Asian countries5,14,54-61 and thus the first wave in countries like Spain,67 UK68 and Belgium69 much lower IFR in Asia (outside Wuhan) and Africa than and lower in countries such as Cyprus or Faroe Islands elsewhere. (~0.15%, even case fatality rate is very low),70 Finland Quality of seroprevalence studies varies. Risk-of-bias as- (~0.15%)71 and Iceland (~0.3%).72 One European coun- sessments in prevalence studies are difficult. There are mul- try (Andorra) tested for antibodies 91% of its population.73 tiple risk-of-bias scales/checklists,62-65 but bias scores do not Results73 suggest an IFR less than half of what sampling translate necessarily to higher or lower IFR estimates, while surveys with greater missingness have inferred in neighbour- assessors often disagree in scoring (Appendix S1). ing Spain. Moreover, high seroreversion was noted, even a Acknowledging these caveats, four of the six evaluations few weeks apart73; thus, IFR may be even lower. Differences largely reach congruent estimates of global pandemic spread. exist also within a country; for example within the USA, IFR O’Driscoll estimated 5.27% of the population of 45 countries differs markedly in disadvantaged New Orleans districts ver- had been infected by 1 September 2020, that is 180 million sus affluent Silicon Valley areas. Differences are driven by infected among 3.4 billion. Excluding China, the proportion population age structure, nursing home populations, effective of population infected among the remaining 44 countries sheltering of vulnerable people,74 medical care, use of effec- would be ~9%, likely >10% after accounting for serorev- tive (eg dexamethasone)75 or detrimental (eg hydroxychloro- ersion. Countries not included among the 45 include some quine)76 treatments, host genetics,77 viral genetics and other of the most populous ones with high infection rates (India, factors. Mexico, Brazil, most African countries). Therefore, arguably Infection fatality rate may change over time locally78 and at least 10% of the non-China global population (ie at least globally. If new vaccines and treatments pragmatically prevent 630 million) would be infected as of 1 September. This is deaths among the most vulnerable, theoretically global IFR may very similar to the Ioannidis (at least 500 million infected decrease even below 0.1%. However, there are still uncertainties IOANNIDIS | 11 of 13 both about the real-world effectiveness of new options, as well Nature. 2021;590(7844):140-145. https://doi.org/10.1038/s4158 as the pandemic course and post-pandemic SARS-CoV-2 out- 6-020-2918-0 7. Franceschi VB, Santos AS, Glaeser AB, et al. Population-based breaks or seasonal re-occurrence. IFR will depend on settings prevalence surveys during the Covid-19 pandemic: a system- and populations involved. For example, even ‘common cold’ atic review. Rev Med Virol. 2020;e2200. https://doi.org/10.1002/ coronaviruses have IFR~10% in nursing home outbreaks.79 rmv.2200 Admittedly, primary studies, their overviews and the cur- 8. Chen X, Chen Z, Azman AS, et al. Serological evidence of human rent overview of overviews have limitations. All estimates infection with SARS-CoV-2: a systematic review and meta-analysis. have uncertainty. Interpretation unavoidably has subjective medRxiv. 2020:2020.09.11.20192773. elements. This challenge is well-known in the literature of 9. Arora RK, Joseph A, Van Wyk J, et al. SeroTracker: A global SARS-CoV-2 seroprevalence dashboard. Lancet Infect Dis. discrepant systematic reviews.80-84 Cross-linking diverse 2021;(21):e76-e77. types of evidence generates even more diverse eligibility/ 10. Levin AT, Hanage WP, Owusu-Boaitey N, Cochran KB, Walsh design/analytical options. Nevertheless, one should separate SP, Meyerowitz-Katz G. Assessing the age specificity of in- clear errors and directional biases from defendable eligibil- fection fatality rates for COVID-19: systematic review, meta- ity/design/analytical diversity. analysis, and public policy implications. Eur J Epidemiol. Allowing for such residual uncertainties, reassuringly the 2020;35(12):1123-1138. picture from the six evaluations assessed here is relatively 11. Wilson L. SARS-CoV2 COVID-19 infection fatality rate implied by congruent: SARS-CoV-2 is widely spread and has lower av- the serology antibody testing in New York City. SSRN 2020; http:// refhub.elsevier.com/S1201-9712(20)32180-9/sbref0350 erage IFR than originally feared, and substantial global and 12. Sood N, Simon P, Ebner P, et al. Seroprevalence of local heterogeneity. Using more accurate estimates of IFR SARS-CoV-2-specific antibodies among adults in Los may yield more appropriate planning, predictions and eval- Angeles County, California, on April 10–11, 2020. JAMA. uation of measures. 2020;323(23):2425-2427. 13. Silveira MF, Barros AJD, Horta BL, et al. Population-based sur- ACKNOWLEDGEMENTS veys of antibodies against SARS-CoV-2 in Southern Brazil. Nat I am grateful to Niklas Bobrovitz and Rahul Arora for offer- Med. 2020;26(8):1196-1199. ing clarifications on their important study. 14. Uyoga S, Adetifa IMO, Karanja HK, et al. 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Research J Clin Invest. 2021;51:e13554. https://doi.org/10.1111/ Square. 2020. eci.13554 74. Ioannidis JPA. Precision shielding for COVID-19: Metrics of assessment and feasibility of deployment. BMJ Glob Health. 2021;6:e004614. The Evidence-Based Medicine Consultancy Ltd EbMC Squared CiC Research for Impact 9 June 2021 Medicines and Healthcare Products Regulatory Agency Dear Dr. Raine, RE: Urgent preliminary report of Yellow Card data up to 26th May 2021 As the Director of the Evidence-based Medicine Consultancy Ltd and EbMC Squared CiC, I am writing to share with you this urgent preliminary report on the Yellow Card data up to 26th May 2021. Please note that EbMC Squared CiC is a Community Interest Company that conducts research mandated by the public and funded by public donations. We have no conflicts of interest and do not engage in industry-funded work. The MHRA describes the purpose of its Yellow Card system as providing “an early warning that the safety of a medicine or a medical device may require further investigation. It is important for people to report problems experienced with medicines or medical devices as these are used to identify issues which might not have been previously known about.”1 Furthermore, the MHRA recognises that the conditions under which medicines are studied in clinical trials do not reflect how the medicines will be used in hospitals or clinical practice once they are rolled out. This means that some adverse drug reactions “may not be seen until a very large number of people have received the medicine.” The Covid-19 vaccines were rolled out in the UK on the 8th of December 2020. As of the 6th May 2021 nearly 39 million people have received their first dose of the Covid-19 vaccine, and 24 million both doses. Sufficient data have now accumulated to get a good overview of adverse 1 https://yellowcard.mhra.gov.uk/the-yellow-card-scheme/ The Evidence-Based Medicine Consultancy Ltd drug reactions (ADRs). I would, therefore, like to draw your attention to the high number of covid-19 vaccine-attributed deaths and ADRs that have been reported via the Yellow Card system between the 4th January 2021 and the 26th May 2021. In total, 1,253 deaths and 888,196 ADRs (256,224 individual reports) were reported during this period. To facilitate a better clinical understanding of the nature of the adverse events occurring, primarily to inform doctors at the frontline, we have searched the Yellow Card reports using pathology-specific key words to group the data according to the following five broad, clinically relevant categories: A. Bleeding, Clotting and Ischaemic ADRs B. Immune System ADRs C. ‘Pain’ ADRs D. Neurological ADRs E. ADRs involving loss of Sight, Hearing, Speech or Smell F. Pregnancy ADRs After running each search, we entered the results into an Excel spreadsheet, excluding ADRs that were clearly irrelevant or appeared in duplicate. These spreadsheets will be used going forward to facilitate the weekly monitoring of Yellow Card data. We recognise that keywords may need expanding to capture category relevant ADRs that may have been missed in this preliminary ADR scope and analysis. A. Bleeding, Clotting and Ischaemic Adverse Drug Reactions (Table 1) We used the following SEARCH TERMS to identify bleeding, clotting and ischaemic ADRs: bleed, haemo*, thrombo*, emboli*, coag*, death, ischaem*, infarct*, angina, stroke, cerebrovascular, CVA. We included the term ‘death’ in this search group, as this term accounted for many reported fatalities (438) without specific details. Given the large number of fatalities without a specific cause of death, we considered that ADRs reported in this way, in particular as ‘sudden death’, would be most likely to occur from haemorrhagic, thrombo-embolic or ischaemic events. Given the seriousness of this ADR, we considered it justifiable to do this pending a Freedom of Information (FOI) request to clarify the cause of death in these 438 people. The Evidence-Based Medicine Consultancy Ltd Using these search terms, 13,766 bleeding, clotting and ischaemic ADRs were identified – 856 of which were fatal. Government reports have highlighted the occurrence of cerebral venous sinus thrombosis, apparently accounting for 24 fatalities and 226 ADRs up to the 26th May 2021. However, our analysis indicates that thromboembolic ADRs have been reported in almost every vein and artery, including large vessels like the aorta, and in every organ including other parts of the brain, lungs, heart, spleen, kidneys, ovaries and liver, with life-threatening and life-changing consequences. The most common Yellow Card categories affected by these sorts of ADRs were the nervous system (152 fatalities, mainly from brain bleeds and clots), respiratory (with 103 fatalities, mainly from pulmonary thromboembolism) and cardiac categories (81 fatalities). B. Immune System Adverse Drug Reactions (Infection, Inflammation, Autoimmune, Allergic) (Table 2) We used the following SEARCH TERMS to identify immune system ADRs: INFECTION (category), IMMUNE DISORDERS (category), -itis; immun, multiple sclerosis, lupus, myasthenia, pernicious, diabetes, Addison, Crohn’s, Coeliac, Graves, alopecia, amyloidosis, antiphospholipid, angioedema, Behcet's, pemphigoid, psoriasis, aplasia, sarcoidosis, scleroderma, thrombocytopenia, vitiligo, Miller Fisher, Guillain-Barre; allerg*, urticaria, rash, eczema, asthma To the 26th May, a total of 54,870 ADRs and 171 fatalities fell into this category, which comprised the second most common cause of post-vaccination fatalities after ‘Bleeding, Clotting and Ischaemic ADRs’. However, only 4 associated fatalities were reported under the Yellow card ‘IMMUNE DISORDERS’ category, with the majority (141 fatalities associated with 19,474 ADRs) reported under the ‘INFECTIONS’ category. Among 1,187 people for whom post-vaccination COVID infection was reported, there were 72 fatalities (6% of reported COVID infection ADRs). Many ‘INFECTION’ category ADRs indicated the occurrence of re-activation of latent viruses, including Herpes Zoster or shingles (1,827 ADRs), Herpes Simplex (943 ADRs, 1 fatal), and Rabies (1 fatal ADR) infections. This is strongly suggestive of vaccine-induced immune-compromise. Bell’s palsy, also associated with latent virus re-activation, is reported in the Neurological ADRs section of this report (D). Also suggestive of vaccine-induced immunocompromise was the high number of immune-mediated conditions reported, including Guillain-Barré Syndrome (280 ADRs, 6 deaths), Crohn’s and non-infective colitis (231 ADRs, 2 deaths) and Multiple Sclerosis (113 ADRs). The Evidence-Based Medicine Consultancy Ltd Allergic responses to the vaccines comprised 25,270 reported ADRs, with 4 fatalities occurring among 1,001 people experiencing anaphylactic reactions. C. ‘Pain’ Adverse Drug Reactions We used the following SEARCH TERMS to identify pain ADRs: pain, -algia. Pain ADRs accounted for at least 157,579 ADRs (18%) in total. A large number of these were arthralgias (joint pains – 24,902 ADRs) and myalgias (muscle pains – 31,168 ADRs), including fibromyalgia (270 ADRs), a long-term condition that causes pain all over the body. Among Congenital Disorders (usually conditions present from birth) there were 11 reports of Paroxysmal Extreme Pain Disorder (PEPD), which is an extremely rare inherited disease caused by a genetic mutation leading to dysfunction of voltage-gated sodium channels. The head was the most common location for pain, but abdominal pain, eye pain, chest pain, pain in extremities, and anywhere else that pain can be imagined was reported. Headaches were reported more than 90,000 times and were associated with death in four people (excluding deaths reported to be from other causes, that may also have involved headache). D. Neurological Adverse Drug Reactions In addition to examining ADRs in the NERVOUS SYSTEM DISORDERS (category), we used the following SEARCH TERMS to identify neurological ADRS specifically involving paralysis, neurological degeneration, and convulsive ADRs as follows: (paralysis), palsy, paresis, neuropathy, incontinence, Guillain-Barre, Miller Fisher, multiple sclerosis; (neurodegeneration) encephalopathy, dementia, ataxia, spinal muscular atrophy, delirium, Parkinson; (seizure), convuls, seizure, fit, -lepsy Twenty-one percent (185,474) of ADRs were categorized as Nervous System Disorders in the Yellow Card system. A wide variety of neurological ADRs were noted, including 1,992 ADRs involving seizures and 2,357 ADRs involving some form of paralysis, including Bell’s palsy (626 ADRs). Other ADRs involving encephalopathy (18), dementia (33), ataxia (34), spinal muscular atrophy (1), Parkinson’s (18) and delirium (504) may reflect post-vaccination neurodegenerative pathology. The majority of fatalities associated with Nervous System ADRs occurred as a result of central nervous system haemorrhages – 127 fatalities out of the 186 fatalities reported as Nervous
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