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mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/5/20 1:39 p.m.

Posting future updates here until we fill up page 3. Read the first posts on page 1 and 2 for "instructions". Warning: Wall of text. I will be updating this first post of the page every time I get a new update until we fill the page with posts. Each update, I will put “X Y Z” without the spaces before the new post, and “Z Y X” at the end (and remove it from the prior post) so you can CTRL+F it and won’t have to scroll for 6 hours to get to the end.

 

 

Covid-19  Update #50-Part 1  
May 6, 2020

 

It is clear from the outset, that today will be in two parts. I'm not quite sure how to divide it up. I slept in until 7 A.M., so both will be a bit later than usual.

 

There are several hard science papers I think I'll review first. They are, to say the least, difficult reads. Thanks to all of you, who have been sending me links and articles to review. It has been very helpful.

 

  • The first is a 33-page report posted on BioRxiv. As you may recall from prior posts, this is a site that allows biology postings of as yet unpublished, non-peer reviewed articles. The report is from a group out of Los Alamos, that monitors the HIV virus for mutations that might be meaningful. They draw samples for testing from GISAID (global initiative for sharing all influenza data).
    • Their goal is to help form a data analysis pipeline, regarding mutations in SARS-CoV-2. HIV mutated so frequently, that we can often tell where a patient contracted the virus based on its genetic signature.
    • They have identified 14 mutations in the spike protein thus far. They are looking for mutations that affect how the virus affects us. Many of the vaccines are targeting a single spike protein, mutations to that particular protein could render a vaccine ineffective.
    • They have identified one mutation, D614G, which appears to have evolved in Europe in February. They believe that this mutation made the virus more contagious, and possibly more harmful. The rest of the report is speculation on the triggered mechanism for this. I, for one, am glad these scientists have our backs. I'm sure the vaccine developers are as well.
  • There continue to be more and more articles and case reports on blood clots and Covid-19. I have seen repetitively a number of 30%, mentioned on autopsies of those who have died from the virus, regarding blood clots in the lungs. This is likely what kills at least some of these patients.
    • A study out of the U.K. showed that a measure of blood clotting capability was abnormal in 20% of severely ill patients. Of those who were further tested for lupus anticoagulant, 91% were positive (this has nothing to do with having lupus). Their recommendation was not to withhold either anticoagulation (blood thinners) or thrombolytic therapy (clot busters) in these patients.
  • Regeneron is to begin human testing of a monoclonal antibody cocktail in June. They hope to have useful data by September.
  • The CDC has made a change of recommendation for recovery. They now state that recovered patients should isolate for 10 days after the onset of symptoms. They should isolate for three days after their fevers are gone, in the absence of fever reducing drugs, and showing progressive improvement or resolution of other symptoms. In my opinion this is still too short. I’m looking for more data on this.

 

Stay safe, isolate, wear a mask in public. The economy you save may be your own.

 

 

 

Update from the Professor – May 6, 2020

Timeline III – Catastrophe

 

We are now living in the world of shelter-in-place as the pandemic overwhelms our ability to comprehend the plague and its consequences. I watch with horror the scenes of Emergency Department and ICU life in NYC as clinicians, nurses, technicians, respiratory therapists and the myriad of hospital support personnel perform their assigned tasks with inadequate protective gear. They literally risk their life and their family’s lives to care for the helpless and ill. We see physicians, RNs, EMTs coming out of retirement and flying to New York to contribute to the common good. I watch first responders work endless exhausting shifts, without appropriate PPE to serve their communities and tearfully begging for the tools to do their job. I know the personal burden of these dedicated people caring for critically ill patients and watching the relentless march of disease. They know that 60-70% of the patients that go to the ICU will perish – alone and without family. The mental health burden is hard to conceive. Yet they show up to work each day and carry on. I also know that many are contracting Covid-19 while serving others and not a small number have paid the ultimate price. Truly they are heroes.

 

Parents now tasked with home schooling are beginning to realize the enormity of the task their children’s teachers routinely perform. We begin to appreciate the role of public schools and teachers as the critical backbone of our communities. We recognize them as dedicated servants, vastly underpaid, and their calling not receiving the respect they deserve. Our society is utterly dependent on educating all our children equally and to the highest standard.

 

We now recognize and appreciate the invisible, forgotten, and often taken for granted service workers who drive the trucks, stock our grocery stores, check us out, deliver our packages, process the mail, clean our public facilities and provide the myriad of services necessary to keep us alive. We learn the true meaning of “essential labor.” Recognizing the value of their labor and reducing structural wage differences in our economy after this is over may reduce the interminable and unnecessary friction in our society. We really do need a functioning, thriving “middle class” if we are to survive as a democratic institution.

 

Physical and social isolation is increasingly frustrating and wearing. We tune into the 24-hour news cycle much too often looking for positive signs of hope. We search for reporters and government spokesmen/spokeswomen who we trust to believe and frankly not lie to us. We look for action not plaudits. My personal favorites are Nicole Wallace (MSNBC), President Bush’s communications director; Michael Steele, former RNC chairman; Brian Williams (MSNBC) 11th Hour, and Anderson Cooper (CNN) for political and hard news reporting. Meet the Press has become a Sunday morning ritual. Dr Fauci continues to amaze, fascinate and educate us with his consistent and calm science-based reasoning. Dr. Birx, once a student of Dr Fauci; served President Bush and appointed as U.S. Global AIDS Coordinator by President Obama. She is a widely respected clinician with experience in epidemic control and vaccine technology. She is a colonel in the U.S. Army Reserve. Dr. Birx provides a second, balanced, medically based commentary.

 

Unfortunately the politics of an election year with the long-standing legacy of political stalemate are highlighted by the crisis. Stress reveals longstanding dysfunction in our institutions. We watch the Governors fill a leadership vacuum and make the hard decisions necessary to insure the welfare of their citizens. Two major forums emerge. The daily White House Covid-19 briefing becomes a political side show with 6% of briefing time by Dr. Fauci, 12% by Dr. Birx and 80 % a personal forum for the President. Governors Cuomo (D) New York and Governor Hogan (R) Maryland emerge as information channels focused on the immediate needs and concerns of the states.

 

  • March 31: U.S. with 164,620 confirmed cases and 3170 deaths. Projected deaths 40,000.
  • April 2: More than one million cases confirmed worldwide with many more suspected due to lack of testing and an increasing awareness of asymptomatic infection. U.S. jobless claims hit 6.86 million. The President blames state governors for supply shortages in their states. Jared Kushner says the national stockpile is not for states.
  • April 3: CDC recommends use of face masks in public. Some governors ask for temporary, local school closings to continue into summer. White House announces use of Defense Production Act (DPA) for N95 masks and ventilators
  • April 6: Increasing caseloads in Michigan, Ohio, Indiana, Pennsylvania. Hospital and ICU admissions in NYC threaten to overwhelm hospitals and Emergency Departments. Military field hospitals, the Javits Center are pressed into operation. Covid-19 becomes the leading cause of death in the U.S.
  • April 7: The President removes Inspector Glen Fine of the Pandemic Response Accountability Committee citing leftover status from the Obama administration. Mr. Fine was appointed by President Clinton and served through the Bush and Obama administrations. The President states WHO mishandled the pandemic and was “China-centric” and threatens to withhold funds.
  • April 8: WHO Director General states: “the goal of all countries should be to save their people. Don’t politicize this virus. No need to use Covid to score political points. You have many other ways to prove yourself.” State governors consider creating a multi-state consortium to supply PPE.
  • April 9: House Oversight Committee releases documents showing national stockpile of PPE almost empty.
  • April 10: One year has passed without a Secretary of Homeland Security. Detroit opens field hospitals as established hospitals overwhelmed. More than 2000 people die on Good Friday. Dr. Birx said the U.S has not “reached the peak” of the pandemic but there were “encouraging” signs of flattening the curves. Hospitals close down elective surgery and routine admissions and procedures. Rural hospital survival is threatened by restrictions on elective care and need to reserve space for potential Covid patients. People are reluctant to seek Emergency and Urgent Care for routine major illness with resultant increase in morbidity and mortality.
  • April 12: Dr Fauci states “no one is going to deny” that earlier mitigation efforts would have saved lives.
  • April 14: Governors on the west coast and the northeast announce interstate coalitions to coordinate opening their economies, Justice Department intervenes on behalf of a small Mississippi church in a lawsuit challenging the city of Greenville’s public health order that restricts church gatherings. Ohio nursing homes now required to notify families of Covid cases within 24 hours. The President halts WHO funding. Internal State Department memo circulates urging the President not to halt funding the WHO because doing so undermines the U.S. ability to address global urgent needs and the U.S. role as a global health leader.
  • April 15: Dr Fauci says we do not have the critical testing and tracing to be begin reopening the nation’s economy. May 1 target a bit overly optimistic. All states now have recorded deaths from the virus.
  • April 16: 639,664 confirmed Covid cases with 30,985 fatalities. Projected death toll now 60,000. The administration unveils federal guidelines outlining a three-phased approach to gradually restoring normal commerce and services. Each phase will last at least 14 days. Progressive phases should only be implemented in areas with strong testing capability and having a consistent decrease in Covid-19 cases.
  • April 20: Multiple states see small angry demonstrations protesting social isolation guidelines. Some commentators encourage this behavior. Dr. Rick Bright, Director of Biomedical Advanced Research and Development Authority (BARDA), is removed. He states this happened because he “resisted efforts to fund potentially dangerous drugs promoted with political connections”
  • April 21: FDA approves LabCorp home testing kit.
  • April 22: The President suspends immigration into the United States. Steven Miller, senior presidential advisor, tells conservative allies this proclamation will reduce immigration beyond Coronavirus. He states: “the most important thing is to turn off the faucet of new immigrant labor”. Veterans Administration (VA) publishes a study indicating there is no benefit and a higher mortality rate with the use of Hydroxychloroquine with or without concomitant Azithromycin.
  • April 23: House approved a $484 billion appropriation bill including funding for hospitals overwhelmed by the pandemic. $320 billion is to go to the Paycheck Protection Program for small businesses. Frustrated by Secretary Azar’s lack of agency coordination, the White House Domestic Policy Council convenes its own meetings with HHS agency leaders. The President suggests checking whether the ingestion/injection of disinfectants and intense UV light could help treat the virus.
  • April 24: Georgia reopens some businesses while hospitalizations in Atlanta are rising. Some businesses open to capacity demand, others remain dark. Georgia Governor is at odds with the President on the date and speed of reopening.
  • April 28: U.S. confirmed cases top one million. There have been 57,000 deaths and projections now suggest 72,000 total deaths
  • April 29: White House announces a program, Operation Warp Speed, with universities, private business and the government in partnership to speed the development of a vaccine. Remdesivir in early studies clears the virus and shortens hospital stay in severe patients. Emergency approval by the FDA for compassionate use is expected.
  • April 30: Office of the Director of National Intelligence (ODNI) announces that there is “wide scientific consensus that the Covid-19 virus was not manmade or genetically modified.”
  • The advent of May signals the expiration of many early stay-at-home declarations and guidelines. With the apparent leveling of the mortality curve in several high visibility locales a genuine groundswell of optimism appears in the public. There is decreasing patience for restrictions and a genuine desire to normalize our lives. This optimism has been carefully nurtured and encouraged by the White House.

 

The optimism ignores the unpleasant data that deaths and infections are increasing in 14 of the states most aggressively reopening their economies. There is recognition of the difficult tradeoff between infections and death versus liberalizing mitigation efforts. It is a zero-sum game. It is an unpleasant concept but you cannot liberalize the economy without increasing virus mortality.

 

The societal and political momentum is well established, and we appear to be moving to a modified Swedish model where the older and more vulnerable continue to shelter-in-place and younger citizens seek a return to a pre-pandemic life scenario. They will look to recover their jobs, their incomes, and their future. They will ignore the significant number of younger people adversely affected by the virus. They will ignore the risk they place on their parents, grandparents, and the vulnerable in our population. There will be a tradeoff between necessary economic activity and human lives.

 

As we move in fits and starts to open the economy the optimism is crushed by new projections validated with the University of Washington model and echoed by the President and his advisors. They revise the projected death total from72,000 to 134,000 by August. The daily death total will likely to double to 3000/day by June 1. Their will 25,000 new cases daily. This is just a model as Dr. Fauci often states. The prediction may not be precise but our models have consistently underestimated the extent of Covid-19 infection and consequence.

 

Our next post will highlight conclusions and policy recommendations. International trends will be addressed at a future post.

 

 


Covid-19  Update #50/Part 2  
May 6, 2020

 

  • One-fifth of Wendy's restaurants are out of beef. "Clara Peller would know what to say."
  • Disney just reported, their profits were down 91% for the first quarter. They are planning on opening their Shanghai Park next week.
  • The U.S. had 23,076 new cases yesterday. Looking at the graphs of how other countries are doing, we seem to be the worst. Even Iran is doing better than we are at containment.
  • The U.K. now has more Covid-19 deaths than any country in Europe, ahead of both Italy and Spain. In my opinion, this is directly related to their initial policy of allowing the virus to go, trying for herd immunity.
  • The earliest case in Paris is now that of a fishmonger whose sputum tested positive from Dec. 27, 2019.
  • G.E. is permanently cutting 25% of its global workforce.
  • The Gap is in financial distress and has stopped paying rent.
  • Tyson Foods is shutting down more plants.
  • Gold's Gym has filed for bankruptcy.
  • Lufthansa is losing one million dollars an hour.
  • Boeing has laid off 16,000 workers.
  • Ford has told its investors, it will lose 5 billion dollars next quarter.
  • Amazon has $10,000 in sales every second.
  • Blaine County, Idaho, once a hot spot, has only had two new cases in the last week. How will they handle the summer tourist trade?
  • Boston, Dallas, and Indianapolis all are showing an increased number of deaths.
  • Germany has had an increase in cases for the first time in six days. they reported 855 new cases. up from 488 the previous day. Let's hope this is an anomaly.
  • I took a look at all the curves for all the states.
    • Illinois curve looks bad.
    • D.C. looks worse.
    • Georgia and Oregon are trending up.
    • Idaho is decreasing.
    • New York and New Jersey are declining, but are still bad.
    • Hawaii and Montana continue to be the best.

 

As I have stated previously, there is no right answer. Reopening the economy will kill a lot of people. Failing to reopen the economy will kill a lot of people as well. It will also ruin a lot of people financially. It is true no-win decision either way. I wouldn't want to be a governor of any state.

 

Am still waiting to hear that the Whitehouse has released the CDC's new guidelines for states.

 

Stay safe, isolate, wear a mask in public.

 

 


Covid-19  Update #51  Part 1
May 7, 2020

 

More than 17% of the nations young children lack sufficient food.  I talked about this in a prior post. The most at risk depended heavily on school programs for the bulk of their nutritional needs. At the time of that post, my wife and I made a contribution to our local food bank, "The Hunger Coalition". Check out their website. We received a thank you note from them. In it they stated, "In two weeks, the number of families seeking food doubled. In three weeks, that number tripled. By the end of week four, we had served more people than we did in an entire year through our food pantry in 2019."

 

Many are suffering, you can help. Make a gift to your local foodbank, be part of the solution.

 

The quote of the day, "The economy had a heart attack. Today it's on life support." The disconnect between the stock market and what is happening to our economy continues to amaze me. I have been looking at what happened during the great depression.  After the initial plunge in stock prices, buying the dip is what ruined most people. Disney is a ruined company, it will never be the same. I hope it can survive.

 

  • Over 50 children in the greater New York area have become ill with a SARS related illness. It is being called pediatric multisystem inflammatory syndrome. The children have persistent fever, and show features of Kawasaki disease and toxic shock. Some feel this is an autoimmune problem, much like the cytokine storm we have seen in adults. I look for The Professor to weigh in on this. He recently retired as a full professor of pediatrics at the University of Washington.
  • Antibodies from a llama named Winter, who had been immunized with coronavirus proteins, Neutralizes SARS in culture. They appear to block receptor binding of the virus. It appears to work in MERS, SARS-1 and SARS-CoV-2.
    • The article was published in "Cell". As I read that article, I marveled at how incredibly bright the researchers in many of the articles I've read truly are.
    • The researchers concluded that these results, "suggest that these molecules may serve as useful therapeutics during coronavirus outbreaks."
  • Mr. Trump has reversed course on the Covid-19 task force and now states it will go on indefinitely.
  • Russia reported 11,231 new cases yesterday, a new high and clear an uptrend. I am taking all numbers and data from China and Russia with a grain of salt. It may be much higher.
  • I read an interesting piece comparing California and Texas in terms of approach. Time will tell whose is the better plan. Again, there is no right answer. There may be a wrong answer.
  • It is clear, however, that sustained exposure in a closed space is the worst possible thing in terms of transmission of the virus, i.e. movies and indoor concerts.
  • Neiman Marcus has filed for bankruptcy.
  • The WHO states if we are to fast track vaccines, it may be necessary to expose healthy volunteers to the virus to see if they are effective. This would pose all sorts of ethical questions.
  • U.S. beef and pork supplies shrank 40% in April. Wholesale beef prices hit an all-time high on May 4th. They were double the February low. Look for 30% less meat in stores by Memorial Day, and a 20% price increase.
  • As promised, I did try to look at the reasons why the meatpacking industry was hit so hard. It appears they used denial as a business plan, which blew up in their collective faces. The fact that the workplaces are cold, damp, and crowded didn't help. That being the case, they should be able to clean their facilities, institute proper safety measures, and reopen.

 

Stay safe, isolate, wear a mask in public.

 

 

Covid -19  Update #51, Part 2  
May 7, 2020

This is a brief comment, and highly political. Just skip over it if politics and criticism upset you. That is not my intent.

As you may recall, I obtained a copy of the CDC's outline for states. It was 16 pages long, and I thought, very well done. You may be able to access it through the New York Times. Taken in congress with the White House Guidelines, it provided an excellent frame work for reopening. It was sent to the White House, they have been sitting on it.

They have sent it back to the CDC for revision, as it did not meet the aggressive position the administration has been taking. This, in my opinion, is ill-considered... political hacks telling the top scientists to revise recommendations to fit a political agenda. I am just speechless.

In the long run, it probably won't make any difference, as many states are not following the White House guidelines either. At the same time, there are many states who would have appreciated the guidance.

If ever published, it will not be the CDC's recommendation.

 

Until tomorrow, stay safe, isolate, wear a mask in public. Don't go to the movies.

 

 

 

Update from the Professor May 7, 2020

Children with Covid-19
 

Epidemiologists and Pediatric Infectious Disease specialists have long pondered the minimal incidence of Covid-19 in children and the relative lack of serious consequences in the infected. It now appears the low incidence is an artifact of testing. The children were either asymptomatic or minimally ill and in the absence of available testing simply were not counted. Infants under one year had significant severe disease. Adolescents had the disease spectrum of young adults.

 

The lack of serious consequence for pre-adolescent children remains a puzzle. With many viral illnesses, children suffer the most. This also may be artifact as with conventional established viral illnesses, older generations have seen the virus and have partial or complete immunity. Covid-19 is a “novel” virus not identified in human populations before this current pandemic and no one has immunity.

 

There have been reports from Britain, Italy, and Spain of a rare life-threatening inflammatory syndrome associated with exposure to Covid-19. Physicians in the United States are now seeing clusters of cases with 64 in New York alone. Incidence appear to be rising. Several children in Britain has died. Long term consequence in the other cases will be observed.

 

It is now labeled Pediatric Multi-System Inflammatory Syndrome Potentially Associated with Covid-19. It is a severe illness of rapid onset with elevated temperature, inflammation with organ system failure and shock. Most are hospitalized and many are admitted to the ICU.

 

The symptoms and course are closely linked to Kawasaki Disease, a rare (20,000 cases annually) multisystem inflammatory disease of unknown origin. It has a predilection for affecting the coronary arteries. Children have swollen lymph nodes, rashes, peeling of the skin on the hands, inflamed tongue and throat with suggestive specific blood test results. It is treated with anti-inflammatories and intravenous gamma globulin. The course of Kawasaki Disease is less aggressive than these observed clusters. Dr. Sean O’Leary, pediatric infectious disease specialist at Children’s Hospital Colorado, is one of the lead investigators coordinating the clinical investigation of this syndrome.

 

The identification of new symptom complexes highlights the novel (new) nature of this virus. We are still learning. We have had only four months to study the virus and its pathophysiology -how it causes human injury. We have learned a phenomenal amount in a short amount of time. It is as if the pandemic emerged at place in time that we have the bioscience to evaluate the virus and learn to combat it. There is still a lot to learn! We have just learned of micro blood clots and the role of blood thinner therapy in adults. We continue to evaluate potential antiviral and anti-inflammatory therapies. We are just determining the antibodies which may control or prevent the infection. We have yet to determine the antibody level which may confer immunity and how long it may last. There is a lot to learn. Stay tuned.

 

I would like to speak clearly on the need to re-open the economic, educational and social life of this great country. The opening needs to proceed in a careful and thoughtful way such that we do not lose the precious, hard-fought progress we have recorded against Covid-19 to this date. The Centers for Disease Control (CDC) generated a 16-page document outlining the way to proceed. It was rejected by the White House as it did not meet the needs of the president. It was to be confidential and not to be released. Like many confidential memos in Washington D.C., it was “leaked” and published by the New York Times. It is a pragmatic discussion of the steps involved, the intended time schedule, and resources needed to implement the design. It contains nothing new or radical. It frankly mirrors the plans and intent of many governors, red and blue. It is clearly these governor’s intent to implement the plan as prescribed by science. They prefer not to reject the science and implement the politically motivated.

 

Once again timeline conclusions and recommendations are on the way.

 

 

Covid-19  Update # 52 
May 8, 2020

 

First, the hard science:

  • For those who live in Blaine County, The COVID-19 Response Group, has carefully vetted their antibody testing, and is working with Stanford to gather data. The test will be offered free of charge to the public. Donations will be gratefully accepted to help fund their work. The group is composed of many highly regarded local healthcare professionals. I highly recommend those who think they have had the virus, sign up and get tested. It is first come first served. You may make an appointment on their website. You must fill in your intake data prior to coming in. You must wear a mask.
  • Anakirna, a recombinant interleukin-1 receptor antagonist,  (very simply put, blocks inflammation by preventing Interleukin-1  from acting) was shown in a small retrospective study from Italy, to have reduced the death rate. It only was studied in 29 patients and compared to 16 untreated. Survival was 90% vs. 56% respectively. The numbers are too small for any conclusions other than this might be worth a better look.
  • A study from the Annals of Internal Medicine reviewed the autopsies of the first 12 Covid -19 deaths in Germany. They found that 58% had DVT (blood clots in the deep veins of the legs). In 4 patients, the cause of death was listed as massive P.E. (blood clots breaking off from the veins, going upstream and lodging in the lungs.). Looking at all the data, it seems likely all patients sick enough to be in the hospital should have preventative doses of anti-coagulation given to them.

 

Second, another look at the reopening:

  • As of this Sunday, 44 states will have partially reopened. Virtually none of them meet the opening criteria set by the White House.
  • Pew research has found that 68% of those surveyed are worried that their state is opening prematurely. In my opinion, most of them will be right.

o That being said, there is no right answer here. The unemployment numbers have risen to 14.7%, the highest since the great depression.

  • My greatest worry is that if some states are too bold, they will end up going back into lockdown and starting all over again. That would indeed be catastrophic for their economies and state revenues. I think, two incubation periods should tell the tale. In 28 days from a change in policy, we should be able to see what is happening. My fear is a second wave in mid June. Go to Jail, go directly to jail, do not pass go.
  • One of my favorite movies in the past few years was, "The Martian" with Matt Damon. A paraphrase of one of my favorite lines, when he was presented with a seemingly insurmountable set of problems, "I am going to have to science the sh-- out of it."  We are as well. Fantasy thinking is not going to help us.
  • Governor Cuomo made an interesting point regarding statistics yesterday in his press conference. If you take New York out, then look at the U.S. curve, it is going up. He was right. The cases in both N.Y. and New Jersey, while still high, are dropping quite dramatically. If you pull them both out, the curve is anything but flat, it's quite dramatically worsening. Reopening into this curve is frightening.
  • If you look at CNN, "Tracking Covid-19", they are using the Johns Hopkins numbers. They have a set of graphs for all states. It shows the new cases over the last 14 days with a dotted line reflecting the 5 day moving average. Quite useful for those of us who are visual learners.
  • Montana continues to be the best in the nation, Hawaii looks worse, but that is going from one case to two. Tennessee and Massachusetts look really good. Minnesota looks terrible.
  • They did have a U.S. graph without N.Y., but including N.J., it looked pretty grim. We have not plateaued, much less shown a sustained down curve.
  • I think the hidden numbers going forward will include suicide and depression. Many will see no way out, and financial ruin.

 

Third, the world:

  • Russia continues on the uptrend. we will never know the real numbers.
  • Africa is a powder keg. In 47 countries, they have 9 ICU beds for each million people. The WHO estimates 29 to 44 million infections, and up to 190,000 deaths this year alone. Africa has been devastated by the HIV epidemic, now this. My heart goes out to them.
  • What is happening in Brazil is disturbingly familiar. This is a country of 209 million people. Their president, Bolsonaro, is dismissive of the virus. He has said Brazilians don't catch anything, they are already immune. He has said the worst is already over. He is anti-lockdown and quarantine.
  • Brazil now has 135,106 cases and 9,146 deaths, I feel both are under reported, the country undertested. On Thursday they had 20,000 new cases and 610 deaths.
  • Bolsonaro's spokesperson has tested positive.
  • The former health minister predicts that the months of May and June will be the worst. He was fired for having a different view than the president.
  • In Sao Paulo, they will require face masks in public places. This is their financial capital, much like our NYC.
  • They don't have anywhere near our resources.

 

Stay safe, isolate, wear a mask in public places.

 

 

 

Covid-19  Update #53  
May 9, 2020

On the bright side:

  • The FDA has issued another EUA for at home sputum testing for SARS-CoV-2. This is the Rutgers based test. While their lab has a lot of capability, they have yet to scale the test kits. Hopefully one of the big boys will step up with manufacturing capability. The test is touted to be as sensitive as a nasopharyngeal swab. As you may recall, PCR testing is only 67% accurate on its best day.
  • Yesterday, a study out of Hong Kong was printed online by the Lancet (the leading British medical journal). The bottom line, a four drug cocktail, when given early, within 7 days of testing positive, in patients with mild to moderate Covid-19, decreases length of viral positivity, shortens the time to being symptom free, and shortens hospital stay. The details, if you want them, are given below.
    • The study was a phase-2 open label trial. It was not placebo controlled, it was not blinded. It was randomized. The number of patients was small. It ran from February 10th through March 20th. There were 86 in the treatment group and 41 in the control group.
    • The treatment group was given ritonavir and lopanivir (an AIDS combo), ribaviran (a broad anti-viral),  and beta 1-B interferon (a drug used for many problems including MS). The control group was given only the two AIDS drugs. These drugs are readily available, and have a proven track record for safety.
    • The treatment group felt better in 4 days. The time to viral clearing was 7 days in the treatment group vs.12 days in the control group. Patients in Hong Kong are kept in the hospital until they are PCR negative on two consecutive samples. the p value was 0.0010.
    • It took 4 days to symptom resolution in the treatment group vs. 8 days in the control group. p 0.05
    • The treatment group spent 9 days in the hospital vs.14.5 in the control group. p 0.016
    • IL-6 a surrogate for the cytokine storm was significantly lower in the treatment group.
    • The authors suggested a phase 3, placebo controlled, double blind study with Beta interferon as the backbone. The p values, despite the small numbers, are highly significant.
    • I believe this study would be very worthwhile. The good news is all these drugs are already approved by the FDA for other uses. This means any clinician could use them on their patients right now. If I couldn't get Remdesivir, this is what I would go with, as early as possible. The viral load in this illness peaks early, around the time of symptom onset.
  • In Seoul, South Korea, all bars have been ordered closed. An outbreak of 40 new cases has been linked to a man going to multiple nightclubs there. I hope our states are paying attention.
  • From Becker's: our hospitals are going to take a 200 billion dollar hit over the next 4 months. There were 1.4 million healthcare jobs lost in April.
  • Harvard's Global Heath Institute has stated we need 900,000 tests per day to safely reopen.  Each state has different requirements based on cases. They feel Alaska, Hawaii, Montana, Oregon, Tennessee, North Dakota, Utah, West Virginia, and Wyoming all have sufficient testing to reopen.
  • As you all probably know, one of Trumps aides, Pence's press secretary, and Ivanka's (remote) personal assistant, have all tested positive. I hope they all start wearing masks.
  • In Haiti, arguably the poorest country in the world, things are heating up. They now have 100 cases and 11 deaths. Because of the conditions there, there is a risk for a large scale outbreak. They went on lockdown in March, except for the textile mills. Close to 4 million Haitians were experiencing hunger issues prior to the pandemic. If they have an escalation of cases, there will be a humanitarian crisis of epic proportions. Maybe instead of euthanizing chickens, and plowing under crops, we could find a way to help.

 

Stay safe, isolate, wear a mask when out in public.

 

 

Update from his sister, an ICU nurse in Atlanta

May 9, 2020

 

Hello all of my friends

On the eve of my daughters first mothers day and after 2.5 months of all CoVID all the time, I  want to share  one of many  moments of my last week with you.

On Friday, I was honored to escort  a family member, enclosed in full PPE for a specially arranged end of life visit with her beloved, unconscious critically ill husband in the ICU. This was an extraordinarily deep emotional moment as the patient was in the active process of dying.  His wife of thirty years and I, fully gowned, gloved and masked, went into his room escorted by the most remarkable nurse, Maria. His wife held his hand, spoke to him of her love, cried and then called his mother and momma sang a few halting, beautiful spirituals to him over the phone. As she sang "we are climbing Jacobs ladder" a tear rolled down his cheek, his heart rate slowed, and his blood pressure dropped. As I stood behind his wife with my gloved hand on the rail of the bed, I looked across at Maria, whose eyes and spirit comforted me as well as her, in this profoundly horrific and beautiful moment.  Garbed and enclosed and separate we all are, but these moments of comfort and peace and love and sadness all tangled up, continue to serve as a reminder that we are all still connected to each other. And that no matter how old we are, our mother's voice brings us to serenity. The wife, overcome with grief and heat, uncomfortable in the cloak we wear every day all day, asked to leave the room. 

After the arduous process of my disrobing (doffing) her PPE and then doffing my own, we stood outside the room with her lovelight shining upon her husband through the window. As we proceeded to the outer area, prior to escorting her back out of the hospital, she realized she had left her phone.  I returned to the unit to pick it up and looking into the room, I saw that her husband had given up his suffering. With Maria by his side, gently, softly passing his spirit into the universe, heaven, the great unknown. His wife and his mother had released the tether that held him to his physical body, wrought with the virus...a week ago a strong man, who loved his children, his wife and his mother, performing good works and guiding his own family and all around him  I rejoined his wife, and we talked of his passing. She spoke of all he had taught her and their children and how the 30 years they had been together would continue to be her guiding light. After some time, she was ready to leave the hospital, but we made a few short stops along the way so she could sob and smile.

Over the last week, I have had 8 of these visits, each defined differently, but all sharing one thing... this slippery, deadly virus, that approaches discreetly, destroys without discrimination and continues to permeate our every cell, our lives and death, our every day.  And that no matter how old we are, our mother's voice brings us to serenity. And as we celebrate the mothers among us, let us honor them with intelligence and practice safely so we can celebrate the next Mother’s Day with them as well. No matter how humbled I am by each experience and  how grateful for a system that allows me to assist families in crisis, I do not want  others, our staff or you  to live through this  experience for a moment, a week  a month or a year...or  for the rest of your life.  Love each other every moment and stay home until impossible to do so due to financial need, not boredom. And then when you must venture out into this deadly world, wear a mask, don't touch, stay 6-8 feet way when your mask is ON, and above all wash your hands for 20 seconds on all your hand surfaces, especially your fingertips, after touching anything! Here is to mothers and fathers and children and humans everywhere. May we all survive this together.

 

 

Covid-19  Update #54  

May 10, 2020

 

  • One of the most frequently asked questions is, "If I have antibodies, am I immune?" The answer is, we don't know yet. Testing projects like this one will give us answers over time. We probably won't really know until we have a second wave. 
  • My opinion is that having high antibody titers will confer immunity. The second question is, how long will it last? Serial antibody testing over time, will answer this question as well. Retesting every three months will give us that answer. I hope it will be measured in years. That's what we need.
  • If you have options, have your test done by someone who is gathering data. The Response Group is working with Stanford on the analytics. Sadly, only 22 states are partially gathering data. Thus far, only California, Louisiana, and New York are requiring it.
  • There is a lot of angst out there over accuracy of testing. The FDA should be soon pulling those that can't prove they are accurate. The Response Group has carefully vetted their test for over a month. It looks good.
  • Locally, you may now have a PCR test if you have been exposed to someone who has tested positive. This will go a long way toward keeping the lid on our local cases. If you test positive, you should self-quarantine for 14 days. You should let everyone you have had contact with know, so they can be tested as well. If you are ill, and test PCR negative, you should go and have an antibody test. Remember, PCR misses 1/3 on its best day.
  • Speaking of quarantine, the head of the CDC, the FDA rep, and Dr. Fauci (despite limited exposure), are self-quarantining for 14 days. The rest of the task force should be doing this as well, but they are not. They should wear masks to protect others, but they won't. When you don't wear a mask, especially when you have been exposed, it says you don't care about the health of the people around you.
  • Trump has just stated that testing doesn't have much value. I thought Sanjay Gupta was going to have a stroke. Testing and contact tracing are our greatest hope to contain this pandemic.
  • Over the past few years, hospitals have been buying physician practices. They are now laying off doctors to control expenses. In a survey of independent doctors, 97% have had a drop in income. More than half will be laying off staff in May.
  • Use of imaging is projected to drop 50-70% over the coming months. This loss, plus the loss of elective surgeries will be crushing to healthcare systems.
  • The CDC is becoming more and more useful. They are pushing for a ramp up of testing in homeless shelters. They have issued guidelines for meatpackers. Their 16-page document on reopening is in the edit process. I listened to an interview with Dr. Brix, another experienced scientist on the task force. She indicated she is the one who is working with the CDC on the edit. This is a good thing. I was afraid it would be Jared.
  • There is only enough Remdesivir to treat 200,000 patients. The Department of Health and Human Services is responsible for distributing the donated doses. Doctors are saying they are getting no answers from HHS when they ask how to get it. It should all be deployed right now. Gilead is ramping up production. They hope to have enough to treat 1 million patients by the end of the year. It currently takes 6 months to manufacture the drug, down from a year. We can hope they will find a way to speed this up. We are still waiting for publication of their trial results.
  • From my perspective, the next big thing will be monoclonal antibodies. Many are working on this right now. The more different companies that work on it, the more likely we are to hit a homerun. This basically takes plasma from patients who have recovered, and tries to isolate the most powerful antibodies. Once detected, the antibodies are cloned and mass produced. Think of this as plasma infusion on steroids.
  • My favorite of the group looking at this remains Regeneron. They and others feel they will have a product ready to market by the end of summer. Others looking will have to find a partner to scale production. Regeneron is already in production in anticipation of positive results, and they have enormous capability.
  • An ex-CDC chief is predicting greater than 100,000 deaths by the end of May. I believe he will be proven correct, with a further escalation in June.
  • The death toll is now at 78,718. Seventeen states have a bad trajectory of new cases. Arizona, Minnesota, Wisconsin, Nebraska, and Kansas have curves that look straight up.
  • New York, and New Jersey continue to decline.
  • Montana and Hawaii are still the best.
  • Meatpacking plants in the Midwest are driving the numbers. CDC reports 4,900 meat and poultry workers are positive over 19 states. Twenty have died. In South Dakota, Smithfield has more than 1,000 workers positive. Tyson has hundreds in three plants in Iowa.
  • Other hotspots include migrant camps worldwide. They have been stripped of their livelihood, live in dangerous conditions, and have no easy way home. Long term care facilities in the U.S. account for 30% of the deaths. Our prisons are horrible. All these situations need to be approached aggressively, if we are to stem the tide.
  • Black Americans and Hispanics are bearing the brunt of the virus. In counties where Blacks are higher than the 13.4% national average, they account for 1/2 of the cases, and 60% of the deaths. This is multifactorial, but it's a moral imperative that we figure this out.

 

People tend to rebel when they are told what to do. I don't like being told what to do. This is not the time to dig in your heels. Practice physical distancing, wear a mask in public, wash your hands, isolate as much as possible. Be part of the solution, not part of the problem.

 

If you need it to be real, read my sister’s post which I have shared. She is a frontline ICU nurse in Atlanta.

 

 

Update from The Professor

May 10, 2020

 

“The Buck Stops Here”. President Harry Truman The United States is at war. It is not a conventional war against a military opponent. It is a war against an invisible virus - Covid-19. The virus struck quietly and without warning. We have clearly lost the early battles and are settling in for a prolonged contest. This war has killed 75,000 citizens at this reckoning, and we will clearly lose many more. That number is more than the casualties in the Vietnam war and all the Middle East wars since then. By the time this pandemic subsides, it will have claimed more American lives than all armed combat since World War II! Yet we fight without an organized response or a consistent strategy to defeat the virus.

 

To defend us from foreign threats, the United States maintains military forces which are legitimately the best equipped and trained in the world. Leadership is taught from day one in the service academies and fostered in all service personnel. A rigid honor code is instilled in academy graduates emphasizing the need for personal honesty and to be responsible for your actions. They cadets are taught every commander will make a mistake and it is imperative that they recognize the mistake in real time, accept responsibility, and make necessary adjustments.

 

Combat troops have a clear-cut chain of command. A specified commander directs the action and is responsible for the outcome. The various services communicate in real time. They drill together to ensure optimal function in case of an emergency. They constantly hold maneuvers to hone and perfect their craft. They have active intelligence services to seek out and analyze information concerning possible threats. Senior officers war-game to anticipate possible threat scenarios and develop detailed plans to meet these threats. They consistently update these plans to keep them current. They anticipate perceived needs. When the nation’s interest is threatened, the services implement established war plans. They then consistently analyze the results to learn from ongoing circumstance. This may involve a change in enemy battle tactics, a change of perceived adversarial strength, or the inevitable problems which develop from the fog of war. When these systems break down, outcomes are poor.

 

The armed services do not necessarily stockpile all the equipment or supplies necessary to meet every possible action. No country can afford the expense and the equipment cannot be expected to function without continued ongoing maintenance. A standing effective supply corps is in place to make sure the troops, sailors, and airmen/women have what they need to do their job. The staff ensures the chain of supply is monitored and functional. The country does not hesitate to employ the Defense Production Act if necessary. There are reserve forces ready to provide necessary personnel beyond active duty troops.

 

I will caution: This will be the political part.

 

The U.S. has not fought this current war against Covid-19 using this defense model. The current administration embraced a lack of respect for science as a core value from day one. The intelligence staff was dismantled two years ago. There was no clear-cut chain of command to bring developing intelligence to those who needed to act on it. Cabinet level access was eliminated. There was no strategy for victory clearly enunciated and implemented. No rapid response team was deployed to contain the infection before it exploded in our country. There was NO leadership review of the ongoing events leading to proper responses. There was NO acceptance of responsibility for miscues and defeats such that necessary change could be implemented. There was no honest commentary informing the U.S. public of the extent of the problem and its potential human and economic cost.

 

There WERE adequate warnings that a potential pandemic could wreak havoc on our lives. Recent real time experience by prior administrations with HIV, Ebola, Zika and H1N1 (Swine) influenza have taught us the need to respond quickly and effectively to microbial disease. There had been constant university and CDC monitoring of novel influenza strains in order to avoid a “Spanish Flu” repeat. Numerous scientists have been sounding alarms about potential threats for years. As a result, there was presidential direction by Presidents Bush and Obama to increase our capability to anticipate and intervene in future infectious disease threats. The effort was funded and its chairman had cabinet level access. This is the capability sorely missed today.

 

The Melinda & Bill Gates Foundation has made disease control a core function. Bill Gates made numerous speeches warning that a pandemic is a greater threat to our civilization than nuclear war! Dr. Fauci warned incoming members of the Trump administration in January 2017 of the “inevitability of a surprise outbreak” of a “new disease”. He said at the time the U.S. needed to do more to prepare. “There is no question that there will be a challenge to the coming administration in the area of infectious disease” Dr. Fauci stated at a speech at Georgetown University in 2018. He called on the Trump administration to prepare the U.S. for such challenges before they arise by improving global health-surveillance systems, by investing in research, and setting aside emergency funds. “We do need a public-health emergency fund. It’s tough to get it … but we need it.” Dr. Fauci said. Rather than heed these warnings the administration chose to actively reduce funding for surveillance, eliminate personnel from key positions, and reduce appropriations for necessary preparedness.

 

When the warnings about the emergence of a new infectious threat in China were sounded at the end of December they were not heard. The extent of a potential problem was continuously ignored, then downplayed, and advocates for action were publicly ridiculed. Communications with China were subsumed to consideration of trade agreements. The U.S. delayed THREE months before appropriate actions were begun in fits and starts. Three months is an eternity in combating an infectious disease. The results are staring us in the face every day.

 

The response was not coordinated from a federal level and the individual states were left to develop and implement their individual strategies. There was no coordination of effort and the states were left to compete against one another for resources. The equipment (testing and PPE) necessary for public health containment was not available in sufficient quantity and no supply corps was available to manage the problem. States scrambled for medical equipment and bed/ICU capacity as existing facilities were overwhelmed. There was some federal help with emergency overflow hospitals generally supplied by the military. Conscientious individuals rose to the occasion to do their best, often heroically and often with great sacrifice. The military term would be fighting a rear-guard action. Melinda Gates gave the effort a D-.

 

As a result, we have unreal and precedented morbidity and mortality statistics to contemplate. Our economy is in shambles. Our educational structure is damaged. Colleges are financially threatened. Public schools are closed with guarded re-opening considered for the Fall. Our medical institutions are strained, financially threatened, with rural hospitals facing closure. Our first responders are at the end of their rope having faithfully performed beyond any reasonable limit. Athletic competition is a distant memory. Arts and entertainment are shuttered. State and municipal governments face insolvency having been left to provide increased services with decreased tax revenues. Public trust in government and elected officials has been seriously eroded. The list goes on.

 

It did NOT need to happen this way. The virus was sure to come. The outcome did not need to be this severe. Other countries managed the same challenge with better results, learning from miscues, and altering their response as necessary. May was projected to be the great re-opening. The re-opening is proceeding under great public and presidential pressure while the virus continues to infect more and more people. In most states the incidence and death curves have not flattened. The curves continue to rise while the potential for increased exposures loom with reopening the economy. A second wave of infection seems inevitable.

 

We are left to looking for the miraculously rapid appearance of effective vaccines to control the U. S. expression of the pandemic. We anticipate for improved treatment of identified cases. We look for adequate testing and contact tracing.

 

Alternatively, appropriate and well executed actions have proven effective in other countries. Australia, a large nation of 25 million diverse souls is now reopening its economy. There have been less than 100 deaths from Covid-19. At the first sign of infection, they closed their borders to international traffic. Returning citizens were quarantined in hotels at government expense for 14 days. Comprehensive testing was initiated and contact tracing instituted. The populace accepted tracking by cellphone as a necessary personally invasive measure for the common good. They also stayed at home. Australia has a federal system with independent states, but the effort was coordinated centrally. As a result, the “curve” was not flattened - it was crushed. Scheduled re-opening with ongoing testing, tracking and common-sense group measures is scheduled for May 11. New Zealand is on track for similar results. Granted these countries are relatively isolated but some European countries were able to achieve similar results.

 

The Scandinavian countries provided a control group trial of potential responses to the pandemic threat. They are relatively small countries with homogenous populations. They have well established public health systems. Their borders (EU mandated) are open. Denmark, Norway, and Finland elected to utilized extensive testing, contact training, and social lockdown. Anders Tegnell, chief epidemiologist for Sweden’s public health agency proposed a goal of achieving “herd Immunity” to control the epidemic. It was a well thought-out proposal. He encouraged elderly, ill and otherwise vulnerable citizens to self-quarantine while others behave in a relatively normal pattern. Restaurants and bars remained open. Shopping was permitted. Educational institutions continued to function. Large congregations of people were discouraged. Dr Tegnell wanted this population to become infected with benign courses, develop immunity and therefore prevent further spread. Current estimates are at a 15-20% immune level. 70-80% is projected for effective “herd immunity”. He is now not convinced of the wisdom of his approach. Sweden has twice the population of its neighbors. It has 26,000 confirmed cases and 3220 deaths including significant numbers of young adults and children.  Denmark has recorded 10,000 cases and 526 deaths. Finland 5880 cases and 265 deaths. Norway 8070 cases and 218 deaths. The Swedish death rate is twice that of the U.S., triple of Finland and Denmark and six times Norway. Sweden is now planning for a second wave and is considering lockdown. Using Sweden as the control group it does appears social distancing and shelter-in-place with extensive testing and contact tracing is the best community approach to reduction of morbidity and mortality in the Covid-19 pandemic. The key to economic revival is control of the underlying pandemic. The Chinese government has announced mistakes in its management of the pandemic. They are examining their response and will be restructuring their public health systems.

 

The great re-opening of America is now advancing inexorably. It is not being managed in as coordinated, unified process. The CDC has laid out guidelines. Governors are directing the process. Mayors are interpreting and local implementation proceeds.

 

There are two sets of recommendations coming. The first set is for managing Covid-19 with May 11 as day 1. What should we do at the current time with the problem at hand? The second set concerns the structural changes to government and health institutions anticipating the next pandemic. It will surely arrive. Our response needs to be managed better.

 

Once again, my thanks to my faithful wife and partner, for her research input and editing.

 

Covid-19  Update #55  
May 11, 2020

 

I continue to marvel at the explosion of data on the pandemic. I will try to bring you the most impactful material on your daily lives.

Researchers from Mt. Sinai posted an article on MedRxiv this past week. As you may know from prior posts, Mt. Sinai is leading the pack on testing. MedRx is a server for posting as yet unpublished articles, they therefore are not yet peer reviewed. In the most comprehensive study yet, they looked at PCR testing, and serologic conversion using there own two-step ELISA assay. Their assay is 93% sensitive, with only 1% false positives. They enrolled 1,343 patients, who had either documented or suspected infections with SARS-CoV-2. They were all patients with mild disease. It is a very long paper, full of statistics. A brief synopsis follows.

  • Of those patients who were presumed infected but not tested, only 36% were positive. What this means is, if you or your doctor thinks you were infected, and you are 3 to 4 weeks out from the onset of symptoms, or more than 2 weeks post resolution of symptoms, you should have an antibody test. Most of the time it will have been something else.
  • Out of those with documented infections, 99% seroconverted. This means almost everyone who catches the virus develops antibody. This is huge news. Does this mean you are immune? (see below) It took from 7 to 50 days to mount an IgG response from the onset of symptoms, median 24 days.
  • There was no evidence of decreasing antibody over time. They plan to track their cohort over 6 months to see if there is any lowering of levels. Remember, ELISA assays are semi-quantitative. This means, the stronger the test result, the higher your antibody titer.
  • They found that positive PCR testing lasted as long as 43 days from symptom onset, and up to 28 days from symptom resolution, mean of 20 days. They don't know if this long positivity means anything with regard to contagion, in fact they suggest PCR testing, as a sign of contagion, may fall away.

Other news:

  • Dr. Krammer, a virologist  from Washington University in St. Louis, has done extensive work with neutralizing antibody. This means antibodies that stop the virus. His work thus far is leading him to conclude that almost everybody with antibody will have some degree of immunity to the virus. There is more work to be done here.
  • The FDA has issued another EUA, this time it's for something new, a rapid antigen test for a company named Quidel. This is done in the doctors office with a rapid answer. Dr. Gottlieb, former head of the FDA, says it's a game changer, I'm not so sure.
  • Two members of the joint chiefs have also been exposed to the virus.
  • The Disney park in Shanghai has reopened, this will be one of the largest tests of whether mass gatherings are safe. Seems like a bad idea to me.
  • IHME is now projecting 137,000 U.S. deaths by early August based on the changes in behavior. They have a track record for under predicting.
  • Google and Facebook are telling their employees they will be working from home until the end of 2020.
  • New York has its fewest deaths in in 6 weeks. The U.K., Italy, and Germany the fewest since March. Russia has had 8 straight days of over 10,000 new cases. I expect it is many times this number.
  • The U.S., with 5% of the world's population, has 28% of the world's deaths. That should tell you something. We had 25,621 new cases on Sunday. Former president Obama called the Trump administration's response to the pandemic," an absolute chaotic disaster."
  • Shulan, a city in Northeastern China, bordering on North Korea, is under lockdown for a new outbreak.
  • [Local Idaho County] had 4 new cases on May 9 after only 2 new cases in the 6 days prior.

 

The question is still being asked, do precautions work?  We have an answer in the Scandinavian countries with Sweden as the control group. The following is a quote from the Professors recent post.

  • "Sweden has twice the population of its neighbors. It has 26,000 confirmed cases and 3,220 deaths, including significant numbers of young adults and children. Denmark has recorded 10,000 cases and 526 deaths. Finland 5,880 cases and 265 deaths. Norway 8070 cases and and 218 deaths. The Swedish death rate is twice that of the U.S., triple of Finland and Denmark, and six times Norway."  I assume he means deaths per infected person.
  • The U.K., who also experimented with herd immunity early has the most deaths in Europe, more than Italy and Spain.

 

Preventative measures work.

Stay safe, isolate, wear a mask in public, wash your hands. Be part of the solution.

 

Covid-19  Update #56  
May 12, 2020

 

Once again, feel free to share this post if you find it useful. My primary goal is to provide useful, reliable information.

  • The only hard science today is regarding Abbott labs instrumented antibody test. The FDA has given it an EUA, the fourth for antibody testing. It tests for IgG, so 2 weeks out from infection minimal, 3-4 weeks optimal. They are sending out 30 million this month, and 60 million in June.
  • The University of Washington has vetted this test, they find it to be 99.9% specific, and 100% sensitive. This is unprecedented accuracy. The hospitals and research labs that employ this will have a powerful tool for research and reliability going forward.
  • The House is bringing forward a bipartisan bill to create a National Public Health Corps. Its mandate will be to fill the most dire medical and economic needs, to develop a national testing policy, develop contact tracing, and eventually, vaccinations. It will employ hundreds of thousands, if passed. I am praying this is expedited, and isn't vetoed.
  • Russia has risen to number four on the Johns Hopkins website list of countries, with 22,344 cases and 2,009 deaths. I expect these numbers are low. In the face of this, Putin has ended the national stay at home order, leaving it up to regions. It sounds familiar, and is not a good plan.
  • There are 607,000 vials of Remdesivir available for use in the U.S. That's enough for 78,000 hospitalized patients, not nearly enough.
  • Wuhan, China has 6 new cases, already under quarantine. They plan to test the entire city over the next weeks.
  • Germany has more than 900 new cases. Their R naught has risen to 1.1. Any county with more than 50 new cases per 100,000 population, will snap back into lockdown. The problem will be the lag time, and asymptomatic carriers. Remember, Germany has been very cautious about reopening.
  • Singapore had less than 2,000 cases at the beginning of April, now they have more than 23,000.
  • Hong Kong is doing well. They have gone 21 days with no new local infections. We should be looking at them
  • As of Monday, the U.S. had 19,710 new cases, a better number.
  • Washington D.C. had 6,389 cases and 328 deaths as of Monday. Most people in the White House will have to wear a mask, but not President Trump.
  • JAMA pediatrics published a report on pediatric illness due to standard Covid-19 - 48 cases, from 14 hospitals, infants to age 21. Two have died, 18 on ventilators. These numbers are tiny by comparison, but very sad to hear.
  • Dr. Thomas R. Freiden, a former head of the CDC, had a few comments to make regarding the reopening. He stated, "We're not reopening based on science." Further, "We're reopening based on politics, ideology and public pressure. And I think it's going to end badly."
    • I totally agree. Many are predicting wavelets from the reopening. I think it will be a wave, hopefully not a tidal wave.
  • Dr. Fauci will be telling a Senate committee today, that premature opening will cause needless suffering and death.
  • We are up to 300,000 tests a day, improving, but nowhere near victory. We are not yet even close to "everyone who wants a test can get one"....yet.
  • All but two states will partially reopen by this weekend. This, as the death toll goes over 80,000.
  • Republican led counties in Pennsylvania are planning on defying the orders from the governor on reopening. I have no idea where this one will go.
  • Let's look at our most successful state, Hawaii. There is a 14 day quarantine on those arriving. Those who violate this are warned once. If they do it again, they are arrested and subject to a $5,000.00 fine and up to a year in jail. Hawaii has crushed the curve.
  • Today's most interesting fact, Cocoa Beach, Florida was open over the weekend. Its visitors left behind 12,000 pounds of trash, that's 6 tons. Yuch!

 

Stay safe, isolate, wear a mask in public. Don't believe everything you hear.

 

 

 

Covid-19 Update # 57
May 13, 2020

 

  • The big news for the day is that my favorite big pharma company, Gilead, has made a decision much like they made with the cure for Hep-C. They have licensed Remdesivir to 5 generic manufacturers in India and Pakistan. They will be allowed to market the drug to low and middle income countries. This will be royalty free until another drug is approved, or a vaccine developed. It will also end when the pandemic is declared over, whichever happens first. It will be a while before this has any impact, the drug takes time to manufacture, but it's a start.
  • Takeda pharmaceuticals will begin human testing on a plasma based therapy in June.
  • Dr. Fauci stated in testimony yesterday, "there is real risk that you will trigger an outbreak that you may not be able to control, which in fact paradoxically, will set you back, not only leading to some suffering and death that could be avoided but could even set you back on the road to try to get economic recovery."
    • He further stated that children are not immune as previously thought. We need to be careful on reopening schools.
    • My worry is that much like the flu, school children will bring the virus home to their parents and older family members while being minimally ill or asymptomatic.
  • I have trouble understanding why Dr. Fauci won't be allowed to speak to the House, as they have requested. They need as much information as possible to make informed decisions, as do we all.
  • Republican Senator Paul from Kentucky, made some good points. Maybe we should allow all those under 45 back to work, and accept the consequences. I didn't agree that Sweden is a model we should aspire to. (See previous posts)
  • Sweden's death rate is at 32/100,000, we are at 24, Denmark at 9. they are changing some policy as deaths in care facilities spike up.
  • The spiking death rates in South America are roughly equal to those in Europe. It is hard to get a precise handle on this. Mexico may be suppressing numbers. Other countries like Peru, are not testing much, and many poor dying at home. The Times is postulating that a better way may be to look at the total number of deaths over a countries average per day or month, as a better estimate. It will still be just an estimate.
  • Brazil had 881 reported deaths yesterday, the total now 12,400, trailing only the U.S. in daily deaths. Mexico reported 353 deaths.
  • China has now closed three cities in its Northeast. They reported 22 cases, they feel they may be spilling over from No. Korea. People traveling from Russia, will have to quarantine for 35 days!  That is a long time, they are being very careful.
  • Chinese backed bots may be spreading false information on social media. One researcher claims he has found 1,000 false accounts on Twitter.
  • The EU, is seeing a spike in cases around its own slaughter houses.
  • Russia is now up to number two in total Covid-19 infections, this includes Putin's spokesman.
  • Ten thousand volunteers have been signed up to be exposed to the virus after vaccination to test efficacy, this to expedite trials.
  • On the bright side, there have been less than 200 deaths in New York for 2 consecutive days, and the daily new case numbers are declining.
  • In a survey by the Times, the percent of Americans staying at home has dropped from 44 to 36 over the past week.
  • There were 21,495 new cases in the U.S. yesterday, up from the past two days, but below the 7 day moving average. Florida had a 2.3% increase in cases up to 41,923 yesterday, let's hope this is not a trend.
  • Hong Kong, has broken its more than three week streak, they reported 2 new local infections.

 

Stay safe, isolate, wear a mask in public.

 

This post was not proofread by his wife

 

XYZ

 

Update from The Professor

May 13, 2020
 

“Responsibility is the Price of Greatness”: Prime Minister Winston Churchill

 

We have reviewed the state of the Covid-19 pandemic in America. What do we do now? How do we restructure our health care establishment to identify, contain, and manage future novel infectious disease processes?

 

There is no doubt that the overwhelming need and desire to return to a more normal way of life is inexorably pushing the “re-opening” of America.  Workers do need to return to wage earning positions. College students do need to return to functioning, physical institutions. Children do need to return to formal classroom education. All require a return to the social contact that makes us human. The re-opening will proceed with a mandate and push from the President with an abdication of power and responsibility to the states and their governors. Unfortunately, the re-opening is proceeding without published CDC guidelines and without meeting prior published requirements for the process. 

 

The CDC has produced a working document for guidance on how to proceed on a prudent, prescribed basis. It is quite detailed. This document has not been vetted by the administration for political reasons. It is available, online thanks to customary Washington leaks, with clear conditions for proceeding. There are certainly areas of the country with less of a threat than others and the guidelines account for this. The guidelines provide for local implementation and control. The guidelines do need to be followed.

 

The conditions of declining incidence, available structured testing protocols and contact tracing are not in place in most areas. Nonetheless the process proceeds with a momentum of its own. It involves a tradeoff between economic activity and increased infections and loss of life. Dr. Fauci testified to the Senate yesterday and raised the possibility of a second wave of infection and the possible loss of ability to impose any control on the rebounding pandemic. Dr. Rick Bright, recently removed from his post at NIH will be testifying tomorrow before the House of Representatives. There is pre-released text. He predicts “without a large coordinated national response, we are in for the darkest, deadliest winter we have ever seen. He is afraid the window of opportunity to control the pandemic will soon close”. We are now on track for a doubling of deaths by August with an increased death rate of 3000/day by June. The governors and local governments will need to implement the guidelines with respect to local conditions. If new infections get out of control, lockdowns may need to be re-imposed. A recurring cycle of opening and lockdown will be likely seen as intolerable to the body politic.

 

The critical absence of the reliable, locally available, rapidly reported incidence (PCR or antigen) testing and antibody testing remains the major roadblock to a considered policy of re-opening the economy. Despite administration celebrations of the triumph of American testing capability reminiscent of a prior “Mission Accomplished” banner; the tests available in excess for the West Wing are just not available on a local basis. The acquisition and institution of the testing is still being left to local government entities without active management and acceptance of responsibility at the federal level. The responsibility for and provision of this function with the necessary subsequent contact tracing needs to be implemented on a national level. Contact tracing is not new. Every state has lists of reportable diseases (sexually transmitted disease, HIV, TB, etc.) where providers are required by law to advise local health departments if they diagnose and treat. The function has long tradition and not the invasion of privacy or personal freedom being hysterically proclaimed by some politically motivated news outlets. This is a prudent public health measure critical to contain the pandemic and permit safe opening of commerce and education.

 

We are fortunate that our incredibly talented scientific capabilities will provide appropriate therapy and vaccines at some point. The public and private effort needs to be nurtured and directed, not controlled. The specific need is for public funding to provide for vaccine production prior to completion of safety and efficacy trials. This will assure a supply of vaccine will be available if and when trials are successful. The physical supply of vials, stoppers, syringes, etc. needs to be accumulated. A well thought out plan for implementation of a vaccine campaign needs to be in place even before the advent of a vaccine. Priorities need to be established and vetted by the scientific epidemiologic community.  The virus does not respect political boundaries. Neither can the response.

 

Similarly, the FDA process for pharmaceutical approval needs to “fast tracked” for prompt availability of potential therapeutic agents. Classic clinical trials assuring safety and efficacy will need to be done but the regulatory process may be streamlined.

 

Federal assumption of medical service supply responsibility needs to be implemented immediately. States and hospitals simply cannot be bidding against each other for the necessary material to operate under current conditions. Domestic supply chains need to ramp up for all critical supplies emphasizing local production if possible.

 

The most critical change is a clear demonstration of national leadership. Cheerleading is appropriate for high school sporting events not pandemic management. We need clear statements of fact with respect for evidence-based medicine. We need clear economic and financial projections. We need structured federal aid in massive quantities efficiently distributed to those in need. There is no place for magical thinking and Pollyanna projections. The message needs to be concise and to the point. It needs to be delivered in an appropriate fashion at a suitable venue and with minimal political overtones. The virus dictates the necessity for common sense not the red or blue color of the geographic venue, its leaders or election politics. Americans respect the truth and function far better with it than without. There is no place for antagonizing the foreign governments and international organizations we need to work with to solve a world-wide problem. There is no need for petulant responses to reasoned inquiry.

 

Long term planning will be reviewed in my next posting.

 

 

 

 

Covid -19  Update #58   
May 14, 2020

 

First let's look at the hard science.

 

  • Researchers from Mt. Sinai published a paper in the JACC, one of our premier cardiology journals. They looked at anticoagulation in patients with severe Covid-19. The survival rate for those on ventilators, fully anticoagulated, was 62.7% versus 29.1% for those not anticoagulated. More clear evidence that blood clots are playing a major role in death from Covid-19. At this point, it seems a no-brainer to anti-coagulate everyone sick enough to be in the hospital, especially those who are severely ill.
  • The NIH is starting a trial combining Remdesivir with Eli Lilly's arthritis drug, Baricitinib. This is an attempt to ameliorate the "cytokine storm", while inhibiting the virus. This kind of combo has great promise.
  • The NIH is also starting a study to look at the effect of the virus on children.
  • Trinity, in Dublin, published a meta analysis (pooling data from studies not designed to look at a specific problem) in the Irish Medical Journal. It demonstrated an association between low vitamin-D levels and mortality from Covid-19. This and other published analysis should inform forward-looking controlled studies to see if this is real. Association does not equal causality.
    • That being said, if I didn't already take Vitamin D, which I do, I would start. Perhaps 800 units a day would be a reasonable number for everyone. There is no downside at this dosage.
  • Sanofi has announced that the U.S. will be first in line if indeed they can produce a workable vaccine. This has engendered a lot of pushback, especially from France, where the company is located.
  • JAMA cardiology has suggested that exercise be limited for two weeks after a positive test for SARs-Cov-2 or from symptom resolution in those who become ill. This could be difficult, as many have symptoms of fatigue, shortness of breath and chest discomfort lasting long after the virus has cleared.

 

Now, on to statistics.

 

  • As of yesterday, the U.S. had 2,130 new cases, and 84,136 deaths. President Trump has said we will have 100,000 deaths from the pandemic. We will reach that number by next weekend.
  • Washington D.C. appears to be the latest hotspot. New cases and deaths are stubbornly high in L.A. and Chicago. Overall, the country appears to be in a slowly declining plateau. This, in the face of big declines in New York and New Jersey.
  • My state of Idaho is indeed declining in new cases, with the exception of Twin Falls.
  • New cases in Russia have dropped to 9,974. Their data is open to question.
  • Rick Bright is set to give testimony before congress today. The ousted vaccine researcher is expected to say, "without clear planning and implementation of the steps that I and other experts have outlined, 2020 will be (the) darkest winter in modern history."
  • L.A. county is reopening beaches today for surfing and running. Good luck holding it to that.
  • Trump has appointed GSK's former vaccine chief, Moncef Slaoui, and a four star army general to run the logistics of project "warp speed". They are charged with ramping up production and distribution of any workable vaccine. This is a very important thing to do. It sounds to me like he has made good choices.
  • Trump says 300 million doses of vaccine will be available by January. The Novartis CEO, by contrast, says we won't have a vaccine until the end of 2021. I am still hoping Oxford's candidate vaccine will pan out and meet its September release expectation.

 

 

Stay safe, isolate, wear a mask in public.

 

If you run a reopening business, find a link to the CDC document on reopening. It should be very helpful. It is still being stalled by the White House.

 

ZYX 

 

 

MadScientistMatt
MadScientistMatt PowerDork
5/5/20 2:41 p.m.

Any thoughts on what's going on in India or Russia? A while ago people were talking about India like they'd beaten this thing, which I didn't believe, and the curve in both countries looks like unrestrained, exponential growth right now.

aircooled
aircooled MegaDork
5/5/20 2:45 p.m.

I have read that at least three healthcare workers who complained about the conditions in Russia have "suicided" out of windows...    numbers from either country are going to a bit tough to come by for different reasons.  I suspect some secondary measure may be the best way to guess.

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/5/20 2:59 p.m.
aircooled said:

I have read that at least three healthcare workers who complained about the conditions in Russia have "suicided" out of windows...    numbers from either country are going to a bit tough to come by for different reasons.  I suspect some secondary measure may be the best way to guess.

I have nothing on the current situation, but when my mom was in nursing school (graduated 1982) she took a trip with her class to the Soviet Union. She said that back then, the conditions were appalling. Operating rooms with open windows, nobody wearing masks, surgeon smoking a cigarette. This has no bearing on the current situation, just something interesting to think about. 

iceracer
iceracer MegaDork
5/5/20 6:19 p.m.

Saw a mother out playing with her 3+-son today. She wore a face mask, son zero.

 Drove through the village of Wells, NY this afternoon, not a face mask in sight and  personal distancing did not exist.

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/6/20 12:16 p.m.

Updated 5/6, looks like another coming later in the day.

Stefan (Forum Supporter)
Stefan (Forum Supporter) MegaDork
5/6/20 1:53 p.m.
iceracer said:

Saw a mother out playing with her 3+-son today. She wore a face mask, son zero.

 Drove through the village of Wells, NY this afternoon, not a face mask in sight and  personal distancing did not exist.

Children under 10 typically aren't required to wear masks.

That said, we have masks for our 3 and 1 year old as they go out on walks and to play in the street with Mom and Auntie.

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/7/20 8:36 a.m.
Stefan (Forum Supporter) said:
iceracer said:

Saw a mother out playing with her 3+-son today. She wore a face mask, son zero.

 Drove through the village of Wells, NY this afternoon, not a face mask in sight and  personal distancing did not exist.

Children under 10 typically aren't required to wear masks.

That said, we have masks for our 3 and 1 year old as they go out on walks and to play in the street with Mom and Auntie.

I think that "The" pediatric association, not sure what it is called, said that babies should not be wearing them. At least that is what my wife said, but our kiddo is only 2 months old.

iceracer
iceracer MegaDork
5/7/20 10:56 a.m.

NYS made a survey of newly admitted patients

96% had other serious health problems.

57% lived in NYC.

29% in the suburbs

14% on the rest of the state

75% are older than 50 yrs.

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/7/20 4:25 p.m.

Updated for Part 2 of May 6, an update from the Professor on May 6, and two posts for May 7. So 4 updates in total. These are arguably the most political posts yet, so skip them if you may be upset by them. 

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/8/20 10:19 a.m.

Updated on 5/8 with an update from the Professor, dated 5/7

EDIT: Updated again on 5/8. I did not move the "XYZ" since it had only been up for an hour or so. 

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/10/20 6:47 p.m.

Numerous updates - one for Saturday and Sunday each, as well as 1 from the Professor and 1 from the Clinicians sister, an ICU Nurse in Atlanta. 

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/12/20 10:14 a.m.

Updated with 5/11's post. 

tuna55 (Forum Supporter)
tuna55 (Forum Supporter) MegaDork
5/12/20 10:26 a.m.

One comment on one bullet point which I am extremely familiar with.

 

GE is permanently cutting 25% of its workforce.

 

Yeah, that's fake news. I was cut from GE's workforce last year. GE has been shedding town sized chunks of employees for years, (realistically a few hundred each month or two) this was likely either news twisted to COVID 19 relevancy or a convenient excuse for them.

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/12/20 11:09 a.m.
tuna55 (Forum Supporter) said:

One comment on one bullet point which I am extremely familiar with.

 

GE is permanently cutting 25% of its workforce.

 

Yeah, that's fake news. I was cut from GE's workforce last year. GE has been shedding town sized chunks of employees for years, (realistically a few hundred each month or two) this was likely either news twisted to COVID 19 relevancy or a convenient excuse for them.

Based on the reporting I read, I'd lean toward the convenient excuse explanation. But I think it was more mis-reported. They're cutting 25% of their aviation jobs. Aviation industry has been destroyed by this, so I'm not sure that it is fake news or a convenient excuse. 

tuna55 (Forum Supporter)
tuna55 (Forum Supporter) MegaDork
5/12/20 11:27 a.m.

In reply to mtn (Forum Supporter) :

I hear you, and I think you're a reasonable and intelligent person. I see headlines like this, and bullets like it even above that I don't have intimate knowledge of, and because I see so many that contradict what I know to be true, they all get discounted immediately in my mind. I either need source material or a wealth of differing reporting to believe what I am reading. In God we trust, all others bring data. 

wae (Forum Supporter)
wae (Forum Supporter) UltraDork
5/12/20 11:33 a.m.

Aviation is here in my hometown and the company I work for does a lot of business with them and other parts of GE, so I am close to the rumor mill on this.  GE's been having trouble for a while now and we always talk about them as an organization that just breathes people:  They'll inhale a whole bunch, hold on to them for a while, and then exhale.  Sometimes the exhalation is more than then breathed in last, sometimes it's fewer, but it's always going on.  When planes aren't flying, engines don't rack up hours, which means they don't need any service.  Planes aren't getting built, so they don't need new engines hung on the wings.  GE never does anything "permanently", it's always what's expedient right now.  So they're shedding contractors left and right at the current time, and letting people go, but when and if the airline industry picks back up, they'll start hiring back.  Although, that hiring back might be via contract work instead of full-timers.

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/13/20 11:36 a.m.

Updated for 5/12 and 5/13

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/14/20 12:55 p.m.

Updated with a post from the professor and May 14 update. 


One takeaway: Start taking Vitamin D if you're not already. Might help, won't hurt, and you're probably deficient in it anyway - it is about the only supplement that my wife, the Dietitian, has an almost blanket recommendation to take. 

  • Trinity, in Dublin, published a meta analysis (pooling data from studies not designed to look at a specific problem) in the Irish Medical Journal. It demonstrated an association between low vitamin-D levels and mortality from Covid-19. This and other published analysis should inform forward-looking controlled studies to see if this is real. Association does not equal causality.
    • That being said, if I didn't already take Vitamin D, which I do, I would start. Perhaps 800 units a day would be a reasonable number for everyone. There is no downside at this dosage.
aircooled
aircooled MegaDork
5/14/20 1:05 p.m.

OK, that is very interesting.  Guess what the natural way is to get vitamin D?..... Sunlight!   That may be one of the reasons hot weather seems to get rid of these things.

Regular sun exposure is the most natural way to get enough vitamin D. To maintain healthy blood levels, aim to get 10–30 minutes of midday sunlight, several times per week. People with darker skin may need a little more than this

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/14/20 1:18 p.m.
aircooled said:

OK, that is very interesting.  Guess what the natural way is to get vitamin D?..... Sunlight!   That may be one of the reasons hot weather seems to get rid of these things.

Regular sun exposure is the most natural way to get enough vitamin D. To maintain healthy blood levels, aim to get 10–30 minutes of midday sunlight, several times per week. People with darker skin may need a little more than this

Yeah, even with the supplement my wife is always telling me 15 minutes of sunlight to your hands and face a day. Kinda impossible living where we live and working how we work, except for a few months of the year... hence we're back to the supplement. But I doubt this has much of an impact on anything (and as he notes, association!=causation), because I'd be curious about the possible smaple size in Ireland - probably the entire island is vitamin d deficient. Again, Might Help... Won't hurt. 

slowride
slowride Dork
5/15/20 7:55 a.m.

In reply to mtn (Forum Supporter) :

I guess I'm going to need to supplement my supplement (currently Costco multi that provides 500 Units per day). I was told earlier this year that I need to protect myself from the sun more. I'll have to ask my dermatologist for advice next time I'm there.

wvumtnbkr
wvumtnbkr UberDork
5/18/20 11:57 a.m.

Any updates?

 

This is really where I have gotten most of the reliable info on this pandemic.  

 

It's really good to have a start and then go verify and expand on the bullet points.

 

In other words, thank you!

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/18/20 12:09 p.m.

Yes - I need to get them uploaded. Had a busy few days, I think I'm about 5 behind. 

mtn (Forum Supporter)
mtn (Forum Supporter) MegaDork
5/19/20 12:54 p.m.

About to start Page 4 with a bunch of catch-up updates. Wally, you got called out!

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