Fast Confession – head pathologist Michal Palkovič: We’re surely in for a third wave
Pathologist Michal Palkovič is the director of the Department of Forensic Medicine and Pathological Anatomy at the Health Care Supervision Bureau in Bratislava. He also works at the Institute of Pathological Anatomy at the Faculty of Medicine of Charles University in Bratislava. In an interview with LP-Life.com, Michal opens up about what this insidious virus does to human lungs, why pathologists are afraid to perform autopsies, as well as about vaccination and COVID-related deaths. He also talks about the course of the disease he himself went through, or whether divers should be afraid of this disease.
How has the coronavirus affected your life?
During the last year very significantly, both in professional and family life, because the workload has been really "disproportionate" to the previous period.
Is there a key to why someone gets infected with the coronavirus, and another doesn't?
Basically, we only know certain statistically evaluated factors that we have identified as risk factors, but the direct mechanism - the marker that would reveal what a particular person's prognosis has not yet been discovered.
Do you think there will be a third wave of the pandemic?
It's definitely coming! We need to look at other countries around us that have experienced another wave after this - let's call it "loosening". The question is how critical it will be and how we will deal with it.
Mr. Palkovič, how's the situation at pathology looking right now? Are you still checking to make sure the body isn't infected with the virus?
We're still doing what we're legally required to do. The law requires us to order an autopsy if we suspect any dangerous transmissible disease. That means we continue to do what we have been doing. In all cases where coronavirus or any other infection is suspected, we order an autopsy. The difference is that we are now looking mainly at deaths of vaccinated patients where we identify mechanisms that confirm or exclude a vaccine link.
How have autopsies changed from the beginning of the COVID crisis to the present?
Very significantly. At the beginning of the pandemic, we performed autopsies on all patients that we had access to and where we had influence in ordering it. That was in about eighty percent of the cases. The remaining twenty percent were patients who were either tested for the virus after death, that is, the result came after death, when the body had already been buried, or there was no reason to order an autopsy because it was an obvious case. This changed during the second wave, when autopsies were carried out mainly on suspicious, unclear deaths or deaths of young people from causes that were not entirely clear. As for now, we are still focusing on this scope, plus deaths of vaccinated patients.
Why do you think some pathologists are afraid to perform autopsies?
That was more during the first wave, when there was kind of an exaggerated respect for the virus. Our knowledge of the virus was minimal, and the social pressure was transferring to pathologists. As our knowledge and experience grew, our attitude changed with it. Nowadays, I don't think we could find a colleague feeling this way.
During the first wave, Slovakia was talked about as a country with a very strict assessment of COVID-19 deaths and reporting of casualty statistics compared to other EU countries... is this still the case?
Yes. As of 15 March 2020, we started to use an adapted methodology, based on the existing infectious (non-coronavirus) disease assessment methodology. After that, the WHO issued basically exactly the same rules as recommendations for all member countries. We followed exactly the criteria for the evaluation of viral infections, and we are still doing so today. That is why we have very accurate statistics.
How do you remember your first autopsy on a patient with suspected COVID-19? It was said that doctors performed the first autopsies in protective suits, not even using water or removing the bodies from transport bags.
I performed the first-ever examination of a suspected coronavirus patient in Slovakia. It was on 10 March 2020. I went there because everyone else was afraid. I took protective suits from the hospital in Revúce, both for myself and for the funeral service staff, and we carried out the examination. In the end, the patient turned out to be negative. Three weeks later we performed an autopsy on an actual coronavirus patient. We were in full protective gear, looking like astronauts, and no water was used (only chloramine) because we were afraid of groundwater contamination. The information from foreign sources was quite dramatic, so we approached it with great respect.
And now?
Now we treat it like any other respiratory viral infection. We have disposable protective work equipment. We already know from the evidence that the dead human body is no longer infectious, so we don't have to isolate ourselves as much when we come into contact with it.
You've been nicknamed "the one who dissected the most COVID casualties" by the press. We wonder, how many were there in total?
One hundred and twenty autopsies last year and over thirty this year. And yes, I've had a lot of nicknames from journalists, this is just one of many. Some call me the chief coroner or the chief forensic pathologist, even though there is no such position. I'm delighted that people are so imaginative.
How does COVID-19 change the lungs and other human organs? How does lung capacity change?
It all depends on the course of the disease. In 99% of infections, lung inflammation does not cause significant changes. But in the one per cent where it causes severe pneumonia, it has very severe consequences. It causes fibrosis, limits vital lung capacity and respiratory comfort.
Many people on artificial lung ventilation ultimately suffocate, why is this?
Inflammation takes place in the cells that are responsible for exchanging respiratory gases. The more dramatic the lung infection, the fewer of these cells there are left. And since the gas exchange is not performed by the cells themselves then, oxygen must be supplied artificially so that at least a small fraction of cells that are still functioning have 100 percent oxygen in the system. It follows that these patients will not survive, because they have very few cells that are able to oxygenate the organism, so they suffocate.
However, it's not just confirmed COVID deaths that end up on the autopsy table, but the suspected cases as well...
First and foremost we need information about the patient's temperature or suspected infection. If there’s a suspected infection, we run tests. We have three levels of tests, the first being the antigen tests - even if these come out negative, we perform antibody tests. These will determine whether the patient has had an infection that might have been the cause of death, and finally PCR tests.
How can we differentiate between deaths from- and with COVID?
Deaths from COVID are those in which dramatic pneumonia has taken place. This means that the patient died as a result of significant viral destruction of the lungs. Deaths with COVID are deaths in which the patient was infected with the virus, but did not have pneumonia and died from decompensation or another illness, such as cancer or cardiac decompensation. There is no dominant viral effect on the tissues of the body.
Is there any evidence of full lung recovery from the COVID?
Sure. Most patients recover without significant sequelae. However, patients prone to severe course of the disease get severe pneumonia and the effects are long-lasting. Long-term consequences of coronavirus infection are being reported more and more frequently (these will manifest themselves in 2-3 months). Recovery of lung tissue does happen, but depends on the extent of the damage. The initial information we had was that it is preferable to undergo infection rather than to acquire immunity artificially after vaccination.
Today we know that the immune response to the coronavirus is different. For example, the age of the patient is a factor - the higher the age, the lower the immune response. Another factor is the infectious dose. If it's small, the immune system doesn't have time to counteract the dramatic course with some larger immune response. Then there's the immunocompetence of the system, which we still, to this day, are not able to estimate. Many studies say that the immune response is lower – that after infection, the immune response is much lower than after vaccination.
I can illustrate this with my own case. I didn't have a very pleasant course; I even had mild pneumonia, but I didn't develop antibodies. My antibody value was 13.2, yet a month after the second dose of the vaccine I had 381 units.
What is the difference between the coronavirus and influenza virus? It used to be said that COVID-19 was "just another flu"...
Coronavirus is a respiratory virus. In principle, it's not a dangerous disease. However, it has serious public health implications. Influenza and COVID are both respiratory diseases, but the mechanism of action of the viruses is different. The coronavirus has special receptors to which it binds, while the influenza virus uses a unique mechanism to enter the cell through its surface. It's as if the coronavirus has a switch, and the flu virus sort of drills its way into the cell. Approximately 57 people died from influenza in Slovakia in 2019, while in 2020, a total of 4,006 people died of severe pneumonia. The influenza virus is not as infectious in person-to-person contact. It spreads because we underestimate the symptoms of infection. Even if we sneezed and coughed, we still automatically went to work, no reason for sick leave... and that's why the flu spread in the spring and fall. The coronavirus is not seasonal and is 10 times more infectious on contact than the flu virus.
The pathologists in Slovakia are not only investigating whether someone died of COVID, but also deaths following vaccination. As of now, Slovakia has three deaths that have been linked to adverse reactions after vaccination. How can we be sure in our assessments and say "yes, this death was due to vaccination"?
The Health Care Supervisory Bureau has investigated over 100 deaths of people who have been vaccinated. Out of these, three cases have been assessed as being linked, two cases as so-called possible linkages and one case as probable linkage. If we wanted to prove a direct effect, it would have to be due to anaphylactic shock or a dramatic shock-like state following the administration of the vaccine in a person with no history of previous disease. We have had no such deaths in Slovakia. However, there are reported cases of such reactions in patients who survived. This has been managed. There’s an investigation underway of two cases, where we are evaluating the concurrence with other diseases, because these persons had a history of many serious diseases. We are trying to find out how vaccination may have contributed to the decompensation of these diseases. If we suspect a possible link, we need to examine it. We also have a case of myocarditis, a heart muscle inflammation, where we are evaluating whether it was related to the vaccine or whether the cause was different. Unlike other countries, we are looking at this in great detail in three phases. We find out what diseases the person had before the vaccination, how the vaccination went, we study the period until death as well as the autopsy findings.
'Russia is the first country in the world to perform a post mortem on a body with COVID-19 and, after a thorough investigation, found that COVID-19 does not exist as a virus. It's a global hoax, people are dying because of amplified 5G electromagnetic radiation (poison)', says a FB post shared by a social network user on February 16, 2021. What do you think about this?
Information of this kind is shared quite intensely. The first reports on the conclusions of the autopsies came from China at the end of 2019. Subsequently, more reports came from Canada and the US, with comprehensive information that came to light in the autopsies. Russian medicine is, of course, at a very high level. But I think that the theory of radiation affecting the activity of the virus has no scientific basis. I think it is a bit embellished to make it interesting.
Should we downplay this disease or should we fear it?
Fear it — certainly not, respect it and understand what it is about — yes.
Summer is coming, the time of holidays when many people go to the seaside. COVID-19 has not only affected our lives, but also some hobbies, such as diving, which is becoming an increasingly popular sport. By the way, you yourself are a top scuba diver... Is there anything recreational divers should look out for?
This is where we divers have a huge advantage, as we don't seek out touristy places with beaches full of ladies baking in the sun, but, for example in my case, mountain caves, isolated from the rest of the world, or marvels under the sea surface. The risk is very small for divers.
For a healthy person, diving poses no significant risk. But is it advisable for people who have had COVID-19?
The rule of thumb is that at least one month after a symptomatic course of coronavirus infection, we should give our body time to recover. If the course has been asymptomatic, a period of two weeks is recommended.
What are the most common ways divers can become infected?
We know that coronavirus does not spread through bodies of water. The infectious dose that a diver could get, for example by drinking some water, is negligible and cannot cause infection. We also know that infection from surfaces is virtually impossible. So it's really just standard contact in unprotected conditions, or breaking the social distancing and not using a protective barrier of the nose and mouth. I don't even register any numbers of divers infecting each other in the Czech Republic and Slovakia. Mostly one gets infected by contact in a close group.
Do you agree with the opinion of epidemiologist Jiří Beran that in most coastal countries one can count on the fact that swimming in the sea most likely reduces the infectious dose, because the seawater is a hypertonic solution in which the virus cannot survive?
One must receive a certain infectious dose for the virus to manifest itself. In a large body of water, the virus gets rapidly distributed, so the infectious dose is minimal. Furthermore, chlorine in swimming pools, for example, has a certain neutralising capacity, so that swimming is not problematic as far as pool water is concerned. Rather, it is problematic if one breathes too strenuously during swimming and produces an aerosol containing the virus, so the infection can be spread through unprotected contact.
Where can divers encounter the virus?
Only in close-knit communities.
Mr. Palkovič, should divers be concerned about the virus?
Respect is always in order. We need to do everything in our power to minimize the possibility of infection. As for our behaviour, I’d always adapt it to the circumstances.
What about divers and vaccinations?
I think that should be a free choice. Just as vaccinated people have to bear the possible consequences of being vaccinated, so should the unvaccinated have to bear the consequences of not being vaccinated. If a diver is travelling and meeting different people, they need to protect themselves. Those who aren't vaccinated? They have to accept the fact that they pose a higher risk of spreading the infection and therefore that access to resorts, for example, may be somehow limited for them.
