COVID-19 Updates

 

Update from The Professor

Pediatric Covid-19 Update III

 

The American Academy of Pediatrics has released an urgent advisory message to its membership highlighting a secondary consequence of the current Covid-19 pandemic.

 

In light of the pandemic, parents are logically reluctant to take their children to the pediatrician’s office for routine problems, well child-care, and immunizations.  They are delaying sick-child visits until “absolutely necessary”. They are avoiding urgent care facilities and pediatric emergency rooms as possible centers for Covid-19 transmission.

 

The medical consequences are becoming a serious threat to the health of our children. Vaccinations are being delayed. It is critical to maintain vaccine protection against common childhood illness. Particularly important is a commitment to immunize against influenza this Fall. Children are the “canary in the coal mine” with influenza. School absence heralds the onset of flu each year with 2/3 of all cases in school age children. While vulnerable seniors bear the brunt of the mortality, healthy children do die from influenza and they are often the vector transmitting the disease. Only 60% of children received effective immunization (40% in adults) to prevent Influenza. Measles is incredibly contagious, and it takes a 90% vaccination rate to prevent outbreaks. It is a severe illness with observable mortality and long term neurologic and pulmonary consequences. Whooping cough, polio, meningitis, mumps, rubella, and rotavirus are just waiting for decreased immunization rates to unleash their own burden to childhood illness. It would be insult to injury to experience an epidemic of vaccine preventable illness while trying to contain and control Covid-19!

 

Well child-care is the opportunity for pediatricians, family physicians and nurse practitioners to identify significant growth problems, developmental delays and chronic illnesses early in their course to reduce long term problems. It is critically important when young families are isolated and need an authoritative voice to advise young, inexperienced parents There has been a noticeable uptick in illness brought late to medical attention leading to significant consequences. Appendicitis with rupture is increasing due to delay in diagnosis and treatment. Type I diabetes control is suffering leading to increased admission for keto-acidosis. Respiratory illnesses - asthma, RSV bronchiolitis, pneumonia – are being admitted with increased severity. Exacerbation of school issues due to lack of active management are not as visible with school closure, but the increased burden is being focused on the home-schooling parent. The list goes on.

 

Parents are urged to remember that although Covid-19 gets the most “ink and TV attention” the usual panoply of pediatric problems demand the attention devoted to them prior to the pandemic‘s appearance.

 

It is time to maintain the intimate medical relationship between child, parent and provider necessary to raise a healthy child. Immunize. Immunize. Immunize!

 

The CDC has posted an alert recognizing Multisystem Inflammatory Syndrome in Children (MISC). The case definition has been revised and published. There are now 17 states reporting cases. The CDC decided to put a hyphen in the acronym -now MIS-C.

 

Covid-19   Update #59  
May 15, 2020

 

• The CDC has finally released its guidance for reopening document after a one month delay. The original document has been decimated. I thought the original 16 page document was really well done. Each section had three to four pages with endless links. This one is a series of one pagers, the section on reopening places of worship has been completely removed. This is a pure political play, and a disgrace.
• Mt. Sinai has opened 'The Center for Post Covid Care'. It will help individuals recover and will do research on the long term effects of having had the virus, as many continue to suffer in recovery.
• There was an article published in "Nature" yesterday which I would classify as a major milestone. This article is from a group of medical virologists out of Frankfurt University Hospital. This is one of those articles written in science. In the simplest of terms, they grew the virus in a human cell culture model. They were then able to see how this virus behaves and what it does to human cells.
  • Its mechanism is very different from that of SARS-1 and most other viruses. It hijacks the cells protein manufacturing process and increases it. The virus then feeds off the excess proteins that are generated.
  • They have then, in turn, identified a number of compounds that inhibits this excess protein manufacturing process in human cells. These included drugs already available like ribavirin and a cancer drug WP1122. They function as translation inhibitors and prevent the virus from reproducing in a host, basically starving it. The effect of these drugs in humans is already well characterized.
  • This opens a whole new pathway for preventing the virus from making us sick. Human trials on the compounds already identified should be forthcoming soon. This is really good news.
• A study has been published in "The Proceedings of The National Academy of Science". It showed, using laser technology, that human speech releases 2,600 small droplets per second. This helps inform how people with no symptoms (no sneezing or coughing) can spread the virus. Maybe a mask would be a good idea.
• Wisconsin's recovery plan has become more than a little chaotic, following the ruling by the state supreme court. Many are continuing to shelter in place, but many are heading for the bars. Good luck with that.
• In households making under $40,000 a year, a full 40% of primary breadwinners have lost their jobs. This is horrible to even think about.
• With regard to the opening of schools, the president of the National Education Association, a large teachers union, Lily Eskelsen Garcia has stated., "I'm waiting for Dr. Fauci."
• Trump has announced plans to stockpile 90 days worth of critical supplies against a second wave. This is a great idea. Hopefully this doesn't happen until current needs are met.
• In Florida, Miami-Dade and Broward counties will begin to reopen Monday. Their beaches will remain closed.

 

Now for the statistics:

• We had 27,368 new cases yesterday, this is an unwelcome increase, the death toll is now 85,906.
• New Jersey's deaths increased to 244, the first time in a week they have been more than 200.
• As I looked at the statistical maps two things struck me. Massachusetts has more cases than California, and California's death rate per infected person seems much lower than most other states. I wonder why that is.
• Texas had its biggest one day rise yet in both cases and deaths. This is two weeks into the reopening. They had 1,448 new cases, more than the previous high on April 10th. They had 58 deaths taking the total to 1,200. Remember, there is at least a two week lag between increased cases and increased deaths.
• California had a 2.8% increase in new cases and a 3.3% increase in deaths, both above the national average. Florida by comparison had increases of only 1.9% and 2.6% respectively.
• Italy had a jump in new cases to 992 from 888, with 262 fatalities.
• Belgium surged to 356 new cases, a 16% increase.
• Moscow, the epicenter in Russia, is up to 130,716 cases. Its mayor says the number is really about 300,000. Sounds about right.

 

Stay safe, isolate when possible, be safe at work, WEAR A MASK.

 

 

Covid-19  Update #60
May 16, 2020

 

Let's start today with the good news on the science front.

• A small biotech from California made a big splash yesterday. I was sent a link which I then followed.
• The company claims to have found a cure for SARS-CoV-2. Using their technology, they have been looking at a myriad of antibodies for the virus. They have isolated one, STI-1499 that reportedly achieves 100% neutralization at a very low dose, in the lab. They plan to develop a cocktail of antibodies so the virus can't mutate away from it. (This is a big problem for vaccines that target a single surface protein.)
• The company is requesting priority evaluation, and accelerated review. We'll have to see how the FDA responds. They are producing 200,000 doses a month with a goal of 1 million doses, while awaiting approval. They are seeking partners to scale up, and government support.
• Their website has not been updated to reflect this. That being said, they do have 7 drugs in their pipeline, some being tested for multiple indications. Four of the drugs are immunotherapy.
• I will be looking at this daily. If this is for real, and I have no reason to think it is not. It will be a game changer. It wouldn't surprise me to see this company bought out by a big player.

 

My old friend Tom, who lives in Hawaii, sent me a link to some work being done on Nitric oxide and BCG.

• There was a pilot study on nitric oxide by inhalation done for SARS-1. It looked promising. It is now in a phase II trial for SARS-CoV-2. The hope is it will improve pulmonary function, while also directly affecting the viral receptor in the lungs. Little to lose as it is well tolerated, much to potentially gain.
• BCG is used as a vaccination against TB. It has been noted that it also seems to stimulate resistance to multiple other respiratory pathogens. There is an association with a decrease in incidence and severity of SARS-CoV-2 in populations that are immunized. It is being evaluated in a phase IV trial. A total of 1800 patients are being enrolled. The trial is double blinded, placebo controlled and randomized.  This is the best kind of study. It will be a year before the primary is finished, and it won't be over until Nov 2021. My hope is that, if effective, the control committee will call it early. BCG is also used for bladder cancer, it also has local release of nitric oxide as a pathway.

 

On testing and Warp Speed:

• PCR (swab) testing is taking a lot of negative press for false negatives, especially Abbott's rapid PCR. I don't understand this. As you may recall from multiple prior posts, this test on its best day misses 1/3 of those infected, and gets lower over time. The people doing the testing should know this. When done in conjunction with antibody testing the numbers shoot up to well over 90%.
• The "warp speed" project is also getting a lot of press. Hundreds of millions of doses of a fully approved vaccine ready by the end of the year?  This seems like total fantasy. Maybe by the end of 2021. Cutting all the red tape will certainly help. Remember, the record for a new vaccine in the U.S. currently stands at 4 years. Safety and efficacy just take time.

 

Now a word about disinformation and preprint articles:

• Sonjay Gupta said this morning, "a torrent of propaganda and deliberate misinformation, in some cases pushed by global power players, muddles the picture even more." We are participating in this as well. Information coming from Russia doesn't seem to add up.
• One study has shown that more than 1/4 of YouTube videos contain disinformation. Just because you find it on the internet doesn't mean it's true.
• Please be careful of pre-print articles. There are two major pre-print sites I use all the time. They are bioRxiv and medRxiv. These are servers, where articles not yet accepted for publication may be posted. They are screened to make sure they are real science articles, not plagiarizer, not hoaxes or disinformation. There are over 3,300 posted articles, with a hundred posted daily. The number has been doubling monthly. Only 129 have made it to peer reviewed journals. The peer review process used to take 117 days, it has been trimmed to 60.

 

And now for the rest:

• There were 25,050 new cases in the U.S. yesterday, and more than 100,000 worldwide. U.S. total deaths are at 87,568.
• Brazil's president is still in denial as the death count mounts in that country. They just lost their second minister of health in a month, The first was fired, the second quit. They had 15,305 new cases yesterday, their total confirmed now 218,000 with 14,000 deaths... this with a lack of testing. This will be really bad.
• Russia just had its most deaths in a single day. They report less than10,000 new cases. This number seems low.
• India is now the Asian hotspot, despite the country's recently extended lockdown.
• Fatalities in tiny Belgium are now more than 9,000.
• South Korea has 162 new cases related to its previous nightclub reopening's. They are all closed now.
• On the bright side, Germany had only 13 deaths yesterday, new cases are up, but only to 755. Taiwan has had only 440 cases and 7 deaths.
• Viet Nam has had only 300 cases and no deaths. The information has been validated by multiple sources. How did they do it?
• First, the have a lot of experience managing outbreaks. They had SARS in 2003, bird flu in 2010, measles and dengue. They used this to their advantage.
• In early January they imposed travel restrictions. They then closed the China border. They closed their schools by the end of January. They just reopened them. All visitors are quarantined for 14 days and all are tested. Forty percent of the positives were asymptomatic.
• They have full bore contact tracing. We, by contrast, are basically doing none...yet. There are notable exceptions like Blaine county, Idaho. New York is gearing up. We need a national policy.  My thanks to Dr. Luber (The Professor) for sending this link to me.
• Homelessness in our country may increase by up to 40% by the end of the year. Without government intervention, I fear it could be much more.

 

 

Covid-19  Update #61-Part 1 
May 17, 2020

 

Thought this would be a short post today, instead, after taking the day off from reading yesterday, I'm going to put the post in two parts. Part one will deal mostly with Blaine County and Idaho, although comments on safety in reopening will apply to all.

Part two will be the U.S. and worldwide.

 

• Our state has done incredibly well with regard to the virus. Today, CNN listed it as one of the three states where cases are dropping the fastest. We have had 2,419 cases, which is 135 per 100,000. We have had 73 deaths, which is 4 per 100,000. Twin Falls has been spiking recently, if you live there, be very careful. Tiny Blaine County has had 497 total cases, Twin Falls has had 256.
• Blaine County has done exceptionally well. Despite being the worst place in the country to be per capita early on, new cases are now a rarity here. I think this is largely due to a diligent effort to track and isolate by our public health department.
• This may all be about to change. There are few states that meet criteria to reopen. I believe we are one of them, our county included.
• Governor Little has taken us to phase II... restaurants, hair salons and gyms will reopen this weekend. Bars will reopen on May 30th. The order for out of state visitors to quarantine is over. Little says only those coming from areas with common spread will need to do so. Good luck enforcing that.
• Given what is happening, the dates to look at for new cases will be June1st, June 15th, and June 30th. I, with Patti's help, will be looking every day.
• If you have kept up with Dr. Erin Bromage from U Mass Dartmouth, you will be ahead of the game.  His posts have been exceptional. There should be one right below this on my timeline.
• Our greatest risks are at home, and public spaces where we spend a fair amount of time with poor ventilation. Being outdoors with distancing is very safe.
• Gyms are bad for spread of infections during normal times. If you go, wear a mask, wear gloves, leave, if it becomes too crowded. Ask them to keep doors and windows open if possible. Wash your hands on return home, drop your gym clothes in the laundry. Keep your hands away from your face. To that end, bring a towel. Surface contacts at gyms are dreadful.
• Dining rooms are a high risk area as well. If you go, try to sit outside, with social distancing. Rico's set up looks perfect.
• With regard to bars and night clubs, we have but to look at So. Korea. They opened them and then closed them all back down. They have 168 cases related to this, stemming back to one infected person who went to multiple clubs.
• In Blaine County, we have our own set of problems. Tourists from all over will be arriving soon. They will bring the bug with them. The asymptomatic carriers will be a big problem. Protect yourself. We will have the usual visitors and second home owners from Seattle, L.A., Chicago, and NYC.
• Blaine County facilities will open Monday, May 18th. Call ahead. Many services, like the DMV, will be by appointment only. Bring your masks.
• BCRD will be running its summer camps for kids. Daycare for kids whose parents are returning to work will be an issue as well.
• As for me, I'll be hiding under the bed for the next month.

 

It is economically important to reopen. Protect yourself.

 

Covid-19  Update #61-Part 2  
May 17, 2020

 

First of all, a short recap:  It is fine and encouraged, to share these posts, if you find them worthwhile. There is no need to ask permission. I am a retired specialist in Internal Medicine (adult diagnostics). I live in Sun Valley, Idaho with my wife, Patti. I don't take friend requests from people I don't know. If we have mutual friends, I make an exception. Back when I let everyone in, I had a malware attack. No good deed goes unpunished.

 

• I made two changes to my post from yesterday. One was prompted, the other was not. If you are reposting, you might want to go back and repost that entry as revised. If you find an error, not just a difference of opinion, please let me know so I may repair it.:
  • I recall thinking, while writing the bit about nitric oxide, that people might confuse it with nitrous oxide that we use at the dentist's office. I then proceeded to write 'nitrous oxide'. I have corrected that, thanks to an astute reader.
  • When I commented on our lack of contact tracing, I was talking about nationally. Blaine County has done a really good job of this. I am sure there are many other locations that have done so as well. NYC has big plans for this, as they get set to reopen.
• A brief revisit on masks as we get set to reopen: They help to block the droplets and aerosols we all send out, when we breathe and talk, much less cough or sneeze. They protect others from us in the event that we are infected, and don't know it. When, for example, we go to the grocery store our risks are minimal. The people who work there, are exposed all day long in an enclosed space. We wear masks to protect them from us. It saddens me to think that they are not only at risk from the virus and frequently for low wages, but also now from physical abuse, even to being shot, when they ask others to wear a mask. We live in the freest country in the world. You are not free to put others at risk or harm them.
• There is much concern about people becoming positive for a second time. It is hard to sort out what that means. We would need to know the interval between tests, and if they became ill, especially severely ill. Given the nature of PCR testing, these are likely not second infections. PCR positivity can last a long time. This doesn't mean you stay contagious. On the best day (around day 5) they miss 1/3 of those infected. Two or three weeks out, they can miss 90% of those still shedding viral particles. You could, theoretically, test 3 weeks in, for 7 days in a row, and have only one be positive.
  • There was a nice piece posted on the NEJM journal watch. It looked at an article published in "The Annals of Internal Medicine"  It reviewed PCR testing. PCR testing likely has 100% false negative results on day 1. By the time people have symptoms (day 4), the false negative rate is 38%. If you have a single negative PCR, it does not mean you don't have the virus. It's not even close.
• China's top medical adviser, Dr. Zhong Nanshan, has admitted that local officials in Wuhan province suppressed details about how bad the outbreak was early on. He sounds like their version of Dr. Fauci. I hope they don't throw him out a window.
• Russia has the second most cases in the world at this point. The 281,000 reported is probably low by a factor of more than double. The mayor of Moscow stated a few days back, he thought the city had 300,000 cases. Russia spans 11 time zones, half its reported cases are in Moscow.
• The reported death rate in Russia is incredibly low. The politicians state it's due to their superior medical care. The scientific world does not believe them. It seems they are only reporting a death as Covid-19, when it is proven by autopsy. Many of the deaths are being called pneumonia. I think whatever gain they may have on the propaganda side, is out- weighed by the lack of preparedness their medical folks must have, to deal with the caseload based on inaccurate statistics.
• Spain, Italy and Iran have had their lowest daily deaths in two months.
• The total cases in the U.S is almost 1.5 million. We have 89,000 deaths. That's 28% of the deaths in the world with 5% of the population.
• The new cases in Texas jumped by 1,801 yesterday, a new record. Their total is now 46,999. Hospital admissions are moving up as well.
• Looking at Rikers Island prison in N.Y., there is some really bad news. They have released 2,600 inmates, many of whom were awaiting trial. A total of 363 inmates have tested positive, and 1,300 correctional workers. There have been 3 inmates and 10 correction officers die. I have been unable to figure out why so many workers. I hope it was a typo, but probably not, this from CNN.
• The number of people leaving their homes each day last week was 25 million more than the six weeks prior. Put another way, the number staying at home dropped from 43.8% to 36.1%, this from the NY Times.
• The WHO published a modeling study in the British Medical Journal. It predicts that of the 223 million they follow in Africa, 22% will have been infected by year end.

 

While I have another two pages of notes, I am gong to call it a day. I'll post about an editorial in the Lancet, and a posting on VOX tomorrow.

 

Stay safe, isolate, wear a mask in public.

 

Update from the Professor

LONG TERM PLANNING

 

The test of our progress is not whether we add more to the abundance of those who have much; it Is whether we provide enough for those who have little: President Franklin Delano Roosevelt This message is posted as the great re-opening of American social society and economic activity officially begins. Schedules proposed will be very difficult to recall or modify even with increased activity of Covid-19. We all are hoping for a successful implementation of the CDC and state guidelines managed by prudent governors, mayors, state legislatures and city councils. We will surely see the results of these actions in the next few weeks. It is genuinely a time for personally responsible behavior and perhaps some prayer.

 

Central government management of long-term planning for and response to anticipated pandemic threats is an essential societal function. We must recognize and respect the certain future emergence of novel infectious disease threats. Absolutely required is a citizen-based government return to respect for science and the scientific method. We cannot condone magical and wishful thinking as a basis for policy making. The long-term institutional response will also ultimately require reorganization of American medical care into a comprehensive national system based on models successfully in place elsewhere in the world. These tasks are not easily managed.

 

The Covid-19 pandemic has caused more casualties and wreaked more financial havoc than any event since World War II. There WILL be further such events in the foreseeable future. In order to anticipate, contain and manage these threats; there needs to be a cabinet level office on a fiscal and organizational par with the Department of Defense. Established agencies concerned with public health – Center for Disease Control (CDC), National Institutes of Health (NIH), Food and Drug Administration (FDA), Surgeon General’s office, Center for Medicare/Medicaid services (CMS), Biomedical Advanced Research Development Authority (BARDA) – would be incorporated into the new federal Department of Public Health. Other relevant agencies throughout the federal government charged with public health concerns would also be placed. Functional and durable links with state and local health departments must be established. A clear chain of command for all services would be established. The management of an identified  potential threat will require a functioning health care delivery system. That system is not in place in the United States at this writing.

 

The occurrence of a major catastrophic event (weather, fire, pandemic) will not necessarily break existing public systems but they will most surely expose significant weaknesses. We have been hearing indictments of American medical care for many years. We spend twice as much per capita for health care as any other nation, yet our health measures (life span, maternal and infant mortality, cardiac survival, mental health) are not even in the top ten. We have developed the most creative and innovative research centers in our universities. We develop and implement state-of-the art procedures and pharmaceuticals. We hospitalize more people and perform more tests and procedures than any other nation. We have not distributed these attributes broadly across our population. We have not translated this expertise into meaningful change in the physical and mental health of our communities.

 

Our medical institutions work best when treating a specific patient in need. Watch the news on daily television. We see the heroic, selfless and frankly dangerous performance of our first responders, physicians, nurses and all support personnel in overwhelmed Emergency Departments and ICU’s. Their skill and dedication are palpable. The physical and mental toll has been horrendous. Yet they have returned to work daily to faithfully fulfill their calling. We need to translate this level of competence and commitment to the provision of comprehensive, intelligent care to all our citizens. Health care is truly a right.

 

Throughout the course of the current Covid-19 epidemic/pandemic frequent mention of, referral to, and discussion of the “health care system” has been heard. It is important to recognize there is NO health care system in the United States remotely resembling those in place in virtually all other western nations. Governor Mario Cuomo of New York stated it most definitively. We have a patchwork collection of hospitals – public, nonprofit, proprietary, university affiliated. Some have satellite facilities and clinics with comprehensive associated medical staffs. Some are single entities. Physician practices range from solo to large multi-specialty clinics. We have comprehensive health maintenance organizations (HMOs). We have specialty hospitals dedicated to single diseases. We have publicly sponsored financial management systems -Medicare/Medicaid – utilizing all these facilities. These entities do not often talk to each other. Rather than plan together for the common good, they are more often competing for the medical care dollar.

 

All these entities whether for profit, non-profit, university based, or HMO operate on the business model of profit or loss. They need to generate more income than incur expense. They will necessarily operate “lean”. They cannot afford to maintain excess capacity; such as beds/ICU/laboratory, and supplies in anticipation of a catastrophic event. They cannot maintain excess staff-physicians, RNs, respiratory and lab techs, maintenance and service personnel anticipating a sudden increase in need. They will procure equipment and supplies from the least expensive source – often overseas. Their inventory will not support catastrophic event utilization out of financial limitations. These organizations and their patients obtain pharmaceuticals (55% of health care costs) at several times the cost of other western nations as Congress has specifically prevented negotiation of drug prices in America.

 

To effectively counteract the next pandemic, we will literally have to implement the long overdue restructuring of health care in America to ensure a responsive system able to meet the next challenge. As previously stated, providers in the United States perform more operations, order more laboratory tests and diagnostic procedures, prescribe more medications, and utilize more specialty therapists than any other nation. These components are often costly and utilized without the support of evidenced based medicine for either need or efficacy. Providers and institutions practice expensive defensive medicine responding to the litigious nature of our society.

 

American patients have come to value and demand these services. Their physicians and hospitals respond to these demands. Providers and hospitals are largely compensated on a piece-work basis with pricing set by insurance companies. There are elaborate systems of discounts awarded to contracting third-party payors. Even more elaborate coding systems attempt to quantify provider value. They have historically been set to reward performance of procedures over the thought processes to determine the need for the procedure. Virtually no one working in the system can actually tell a patient what their health care will cost! The result of all these arcane machinations is the more hospitalizations, procedures and tests performed; the more the provider or hospital makes. These individuals and institutions are human. They are motivated to provide the demanded health care and are rewarded for it. There is little incentive to economize. To deny a patient request is to risk alienating the patient and risk malpractice action. There is minimal incentive save for a professional’s “sense of calling” to maintain the health of the patient or population. Costs inevitably escalate.

 

Access to this “system” is through money provided either by employer sponsored commercial health insurance or secondarily by government entities. Commercial insurance administrative costs (15%) and corporate profits (10%) consume over 25% of health care dollars. There is over $500 billion dollars not purchasing actual health care. This contrasts with Medicare where administrative costs are estimated between two and five percent. Working with these programs as a patient is daunting. Who has not experienced the increased deductibles and copays of the past decade? Who has not had to justify the need or wait for a pre-authorization? Who has not tried to understand a medical bill or a balance due, much less access someone who can explain it? Who isn’t aware of the sudden loss of coverage through job change or layoff? Who isn’t aware of denial of coverage for pre-existing conditions? Who hasn’t been billed for “uncovered” or out of network procedures? Understand that there are 40 million Americans with NO health care coverage. This number is now growing rapidly with the mass layoffs occurring when people need the coverage most. The uninsured are left with the Emergency Department for all health care needs. They know they cannot be turned away by law. It is also the single most inefficient and costly way to obtain routine health care. For many it is the only option.

 

It is popular to condemn universal health insurance and a single-payor system as socialized medicine, to be avoided at all costs. It is easy to forget that Medicare is one of the largest socialized medicine programs in the world. It has its flaws. It has some inefficacies. However, its enrollees will viciously attack any threat to “their” Medicare because they recognize its worth and convenience.

 

The proposed Department of Public Health would be responsible for development and implementation of a comprehensive medical delivery system for all citizens in the United States. An in-house supply corps would ensure adequate supply chains for medical equipment and supplies to ensure availability of necessary materials at the best possible price. It would provide for domestic provision of critical manufacturing such the U.S. would not be dependent on the good will of other countries for critical supplies, equipment and pharmaceuticals. With federal funding it would be possible to maintain adequate reserve supplies and distribute them nationally when appropriate. The Department would also monitor trained manpower requirements such that adequate personnel would be available when and where necessary.

 

The Department of Public Health will be responsible for the defense of the nation from all health threats just as the Department of Defense protects us from military intimidation. It will need to maintain adequate surveillance of possible jeopardy to American health on a global basis. It will maintain a fixed liaison with other governmental intelligence services with mandatory sharing of data. It will actively work with the World Health Organization (WHO) and other national health surveillance teams to provide real-time data from around the world. The department and its agencies will be ready to intervene across the globe to eliminate threats as early as possible.

 

Nothing can be more certain than the emergence of another infectious agent with pandemic. Pray we are better prepared for the next occurrence.

 

Covid-19  Update #62  
May 18, 2020

 

First, a brief update on vaccines:

• Oxford's vaccine is still on track. They have announced that if successful, the U.K. will have first access. A vaccine plant is being built, but won't be ready until next summer. They have partnered with Astra Zeneca. Their goal is still 30 million doses by September, 100 million doses by the end of the year.
• The population of the U.K. is 67 million, this means, even if successful, the U.S won't be seeing any significant amount of this vaccine from them for more than a year, maybe longer.
• oderna's vaccine is getting a lot of hype today, and perhaps driving the stock market. They are early in safety testing, but have commented that two low doses of their vaccine invokes an antibody response at least as much as a person who has been ill with the virus. While this is good news, it is as expected. Is it safe? and does it provide immunity? are the real questions.
• The early stage biotech, Sorrento, has scanned billions of antibodies to find hundreds with promise. Their lead candidate, which they claim is 100% effective at neutralizing the virus in the lab, now will need to be tested in animals before human trials can begin.
• Many biotechs are looking hard at antibody therapy,  with Regeneron and Lilly leading the pack.
• Azar, the HHS secretary, stated over the weekend that the "Warp Speed" project has a goal of hundreds of millions of doses of vaccine by year end. It is not a pledge. Sounded like a promise to me, when it was first announced.
• China has stated that if their vaccine candidates pan out, they will be used for the global public good. After they vaccinate their whole country, I don't expect we'd be very high on their list.

 

If you pull up VOX, there is a piece "Scolding Is Not Working" written by a 29 year old doc at Elmhurst hospital, one of the worst hit hospitals in NYC. It is worth a read.

 

Next, a look at statistics. Remember the new case numbers don't accurately reflect those that are mild or asymptomatic. The most accurate way to follow progress is in admissions to the hospital and ICU.

• The U.S. continues on a slightly declining plateau. Total cases are at 1,486,742, deaths at 89,564. The only country in the world with more cases per million people than the U.S. is Spain. Their curve is way down. We will be number one soon. The only country with a chance to be worse in the short term is Brazil.
• We should be trying to emulate Germany's contact tracing, if we are to have any hope of keeping new cases under control, as we reopen the economy.
• Daily new cases in California and Georgia look flat.
• Brazil, despite a lack of testing, has moved up to number four in total cases by country, overtaking Spain. It is averaging 15,000 new cases a day for Friday and Saturday, and 24,996 on Sunday. They are functioning without a minister of health, and with a president who rejects science. Their country will be a disaster of epic proportions.
• The U.N. projects that the pandemic could send another 130 million into severe poverty.
• New York is doing 40,000 PCRs per day. They reported 139 new deaths yesterday, the lowest since March 26th.
• China has put 100 million people back in lockdown.

 

Next, a bit about the economy and reopening.

• The Fed chair, Jerome Powell, appeared on 60 minutes last night. Worth a listen for sure. He feels the government needs to do all it can to help small businesses avoid bankruptcy. He also believes we should be helping individuals avoid insolvency. He states the GDP will shrink by 30% on an annualized basis in the second quarter. He thinks the economy will recover by the end of 2021, if there is no second wave.
• There has been a 300% increase in the number of tents in the Tenderloin in S.F. Homeless shelters have been thinned out. There have been 1,000 hotel rooms made available to the homeless. One businessman called the Tenderloin, "a horror show." The homeless crisis is just beginning.
• All but two states, Connecticut and Massachusetts are at least partially reopening today. The president says he wants to see big stadiums full of people.
• Disney will begin to reopen shops and restaurants in Florida. They will also reopen a mall near Orlando.
• Apple is reopening 25 stores in the U.S.
• I think we are watching the demise of "big box" stores and malls. Walmart, Target, Amazon, and their online presence are here to stay. Amazon is still fastest, but the others are closing the gap. Walmart's on line business increased 30% in February and March. Targets increased 275% last month.

 

 

 

Covid-19  Update #65  
May 21, 2020

 

• I learn something new every day. Beximco Pharma, a manufacturer in Bangladesh, will be producing for sale generic Remdesivir. Apparently, this is legal without a license for patented drugs for countries at low levels of GDP, under agreement with the World Trade Organization.
  • They will supply vials for free to state run hospitals.
  • They will sell it to private clinics at $71 per vial. It takes 6 vials to treat one person. They are willing to export it.
  • Gilead has licensed 5 generic manufacturers in India and Pakistan. This is not one of them.
  • As Bangladesh has reported only 26,000 cases and 386 deaths, we may be buying it from them, with Gilead not making a dime. It doesn't seem quite right to me.
• The U.S. has contributed 1 billion dollars to Astra Zeneca to help develop the Oxford vaccine. I think the hope is that this will move us up in line for distribution, if it works.
• Modelers from Columbia in NY have stated, that according to their work, if we had started social distancing one week earlier, it would have saved 36 thousand lives. If the lockdown had begun two weeks earlier, there would have been an 86% reduction. This is really hard to hear. It is just a model.
• BARDA (Biomedical Advanced Research and Development Authority) a division of HHS, has agreed to fund Phlow (a pharmaceutical manufacturer). The grant is 354 million dollars, and may go as high as 812 million.
  • This grant is intended to enable the manufacture of essential drugs and their precursors on U.S. soil, and to decrease our dependence on foreign based supply chains. They manufacture drugs for ventilator sedation, pain management, and critical antibiotics. The also work with SAPIR (Strategic Active Pharmaceutical Ingredients Reserve).
  • They use "flow chemistry" to create generic drugs that insure higher quality, safety, volume, at a decreased price.
  • Good for BARDA, this is a very important thing going forward. Thanks to Richard O'Hara for sharing the link.
• Deliberate disinformation is making decisions much more difficult in our troubled world. I am having great difficulty trying to figure out why, given this crisis, this is happening.
• Brazil has now 291,579 cases with at least 18,859 deaths. They had 19,951 new cases yesterday. They may displace us as the number one country in the world for new cases. They are under tested, have a president in denial, and many die at home, untested and uncounted. If we believe their data, they have one of the lowest death rates per case in the world. That seems a bit unlikely.
• Russia is the world champ at undercounting cases and deaths. Their posted deaths are more than ten times lower per infected people than ours. We will never know what really happened there.
• India's new case curve looks terrible, it is just one of many worldwide.
• Even with these gross exaggerations, the world has reached 5 million documented cases with 106,000 new cases yesterday. The average weekly death count is decreasing but is still greater than 91,000 a day. There are several better ways to estimate Covid deaths, perhaps we will switch over.
• Virginia, Georgia and Texas are adding antibody testing to their test totals to try to meet reopening criteria. It is an illusion.
• New cases in Chicago and L.A. are remaining stubbornly high.
• I listened to Florida's governor today. He talks about being safe and smart. He also blames the Chinese.
• The Florida governor's office and the State Medical Examiner are at odds over the death count. The governor's office wishing to use criteria that minimize that number. They are not as bad as Russia...yet.

 

There is more on reopening, but I will save that for tomorrow.

 

Stay safe, isolate, wear your mask in public. Wearing your mask is the true badge of honor.
 

 

Covid-19  Update #66  
May 22, 2020

 

It is snowing this morning in Sun Valley.

 

I am going to work on two new things today. One reader has suggested I form a group and share the posts to it. I have created a group entitled "Dr. McLean's Covid-19 Updates". Patti and I will work on that, when I'm done with today's post.

 

I frequently answer worthwhile and interesting questions in the comments after posts. It has become obvious to me that these comments do not travel, when others repost my material. One example is a lengthy explanation I gave when asked how vaccine development and deployment could be sped up. Part of that explanation included deliberately exposing volunteers to the virus after vaccination to speed up efficacy evaluation. A statement on Patti's timeline made it obvious, that explanation had not been widely read. From this point forward, I will answer such questions in the body of the next day's post.

 

I have been wondering what happened to Dr. Fauci. I thought perhaps he was absent secondary to his self-imposed 14-day quarantine. It appears now, that he has been removed from the briefings as part of Trump's campaign strategy for the last 2-1/2 weeks. Trump is now surrounding himself with doctors, who are in lockstep with his views. This is a great loss to all of us. I really looked forward to Dr. Fauci's comments and updates. Patti told me last night, that he has appeared on Julia Roberts' Instagram account, and will be taking it over to disseminate information regarding the pandemic. I guess Instagram reading will be added to my things to do list.

 

• The Oxford vaccine candidate is passing another milestone. It is now recruiting 10,000 volunteers for its safety and efficacy trial. They will add children 5 to 10 years old, and adults over the age of 55. They will use meningococcal vaccine as a control.
• The U.S. has pledged 1.2 billion to this effort, which moves us up on the distribution list. It is possible, if the vaccine is successful, that we could have doses as early as October. There are a lot of 'ifs' here.
• I have reviewed an article, that has been accepted for publication in "Cell". This article looks at cell mediated immunity in Covid-19. This is a separate from the antibody mediated immunity that has been in the spotlight. 
  • They compared 10 previously infected patients with 11 who had not been infected. They mainly looked at two kinds of T- cells. The first is CD4 or helper T-cells, the second is CD8, or killer T-cells (sounds good doesn't it). They found that the cell mediated immunity was preserved in 70 to 100% of the infected. The CD4 response to spike protein was referred to as robust. This is terrific news.
  • They also found that in the uninfected, there was a cell immunity response in 40-60% of the CD4 cells, likely secondary to one of the corona viruses that cause the common cold (up to 30% of them). They don't feel this affords any protection from SARS-CoV-2.
• The CDC is now estimating that 35% of infected patients never have symptoms. They also estimate that 40% of infections are spread before people have symptoms... more great reasons we should all be wearing masks.  I looked at their website today; the guidance is up, under Resources and Guidance. One of the sections listed separately was "what construction workers need to know", along with many others.
• Sweden's herd immunity experiment has failed. In Stockholm, only 7.3% of people have antibody. Remember it takes roughly 70% to end a pandemic.
• China pledges to reform its reporting, making it direct and early. Premier Li said that they will, "ensure prompt, open and transparent release of epidemic information." I hope this is real. I wonder why he used the word epidemic and not pandemic.
• Hong Kong has now joined the WHO in the middle of the conflict between Trump and China. All the rhetoric and posturing is making me nervous. Trump is trying to bully them. Their response is not helpful.
• The U.S. added 26,182 new cases as of this morning. That number is up. The descending plateau has now flattened. Let's hope this is not a trend. New deaths are dropping. Only 1,281 were added yesterday, the total now 94,729.
• This is a pleasant surprise. I thought we'd be up to 100,000 this weekend. A lot of this is the improvement in NY and NJ, and I'd like to think we are doing much better against the disease in the severely ill. There is a 2 to 3 week lag from new cases and admissions to deaths, so we will see. I hope this trend continues.
• Susan G posted a reference to an NPR report. If we look at these deaths in terms of full flights of 737s over the past 10 weeks, it makes the numbers easier to conceptualize. How would we feel if 10 fully loaded planes crashed with no survivors every day for 10 weeks. We'd be horrified, we should be now.
• There is one ICU bed left in Montgomery, Alabama.  Severely ill will have to be transferred to Birmingham. Hospitals across the state are near capacity. Montgomery's mayor stated if you become severely ill in the central part of the state, there may not be an intensive care bed available. It may be time for the Army to work their magic. I hope the governor is asking.

 

I have pages more of notes, but that's enough for now.

 

Stay safe, isolate, wear a mask in public.

 

 

 

Covid-19  Update #67-Part 1  
May 23, 2020

 

Just a reminder, these posts are meant to be read in sequence. I prefer, in the interest of brevity and time, not to define terms, or explain concepts over and over again.

 

There is so much information out there on a daily basis, that I can't possibly write about all of it. I have 12 pages of yellow pad notes to draw from today. There is an equal amount of disinformation out there.

• Dr. Mike Ryan of the WHO has stated that, "fighting misinformation is just as important as fighting the virus itself." I'm not sure I agree with that, but his point is important.
• Researchers at Carnegie Mellon University have concluded that nearly half the accounts on Twitter propagating Covid-19 conversations could be bots.
• Don't believe everything you read. Just because it's on the internet doesn't mean it's true.

 

In the days before all my medical journals were on line, I would read about medical news first in the Wall Street Journal, and then read the article it was based on 3 days later when my print copy of the New England Journal of Medicine would arrive. I was always amazed at how different the actual articles were from what had been reported. Nothing has changed. I'll give you one example below.

• You may recall when Remdesivir was first found to be effective in an NIH study, which Dr. Fauci commented on publicly. Gilead then donated a large portion of its supply. We have all been waiting for the actual study to be published to more carefully review the data.
• It was indeed finally published in the NEJM on May 22nd. Before I actually read the article itself, I read several mainstream press reports that portrayed the results as disappointing. That is, in my mind, incorrect.
• The article expanded on the initial comments on its results, The data was well presented and there were many graphs and charts. Nothing had changed.
• I have previously reported on those results, so this is largely a review. The trial was a double blind, placebo controlled randomized trial (the best kind), which had enrolled 1063 patients, all of whom had evidence of respiratory tract involvement and required oxygen support or more to maintain oxygenation.
• The data and safety monitoring board called a halt to the placebo control side of the study when the drugs effectiveness became very clear.
• The median recovery period, when given the drug, was 11 days versus 15 days in the placebo arm, p<0.001.
• Five day treatment was the same as 10 days with fewer side effects. Kaplan-Meier estimate of of mortality by 14 days was 7.1% in the treated group vs.11.9% in the placebo arm.
• This study was begun before we understood how long people were going to remain ill. Some reports have shown the average length of stay was 33 days. The study was revised midstream to look at 28 day results, this is unusual, but warranted. The authors revisited the results of the trial on May 18th and felt the results were similar.
• This prelim report will be updated over time and the data published. The authors suggested that Remdesivir be studied in combination with other therapies, to see if mortality could be improved. As you may recall, there are multiple trials in place and ongoing with this drug. 

 

There was another great article published in the NEJM on May 15th, entitled "Severe Covid-19". This article provided a roadmap for clinicians on how to approach the severely ill in a step by step manner, and basically defines the standard of care.

• It made a strong point on anticoagulation, which I believe will save many many lives.
• The only thing I would have added would have been the interferon + ribavirin + aids combo protocol, I have previously reported on. If Remdesivir were not available, I would want to be on this combination as early as possible.

 

The Lancet( the British equivalent of our NEJM) published two articles of interest.

• The first was a study looking at chloroquine and hydroxychloroquine in the severely ill. I've posted about many of these studies before. This is the largest yet. It reported on 96,000 patients over 6 continents. The drugs not only weren't helpful, the use of these drugs caused measurable harm.
• The second article reviewed one of China's vaccine candidate's prelim data. They had enrolled 108 people in Wuhan, who had not been infected. They were given low, medium, or high dose vaccine. Nearly half had fever, 44% had fatigue, 39% had headache, and 9% were severe enough to curtail activity. Overall, there was not a strong immune response. The high dose group did achieve antibodies in 3/4 of recipients, however, the side effects were so severe in this group that high dose was abandoned.
  • In my opinion, this one belongs on the scrap heap. I wouldn't be taking it.

 

Idaho had its largest number of cases on Friday since April 4th.

• The new cases were 98 in number, with 91 of them in the South Central Health District.
• 32 of these were in Twin Falls, and 23 in tiny Jerome.
• Rite Stuff foods in Jerome, a potato processing plant, has had more than 50 positive employees. In my opinion, they should close and clean the plant and put in safety measures.
• This is where contact tracing, testing and isolation come into play. If not put into play rapidly, this will be bad.

 

Look for part two later today. If you want something else to read in the interim pull up Atul Gawande's article from the May 13th issue of the New Yorker.

 

Stay safe, isolate, wear a mask in public.

Covid-19  Update #67-Part 2  

May 23, 2020

 

• I read a piece from "The Atlantic", which went after the CDC for lumping PCR tests and antibody test together when reporting.  From my perspective this is a difficult subject.
  • Some states are doing this to show they have enough testing, in doing so, overstating capabilities.
  • Statisticians hate this, as it leaves them comparing apples to oranges and makes their work more difficult.
  • If what we are trying to do is get an accurate count of how many have been infected, it is likely our best tool, as long as people aren't counted twice. If you have both positive, it only counts as one.
  • As I have previously explained, PCR on its best day misses 1/3 of cases and gets worse over time. When you add in antibody testing, we miss very few, especially if the antibody tests are done 6 weeks out.
• Read Dr. Luber's (the Professor, see below) post on pediatrics. I've shared it on my timeline and in the group.
• The U.S. now has 96,002 total deaths, of which 1,852 are new. Our new cases continue to be on a plateau. New York has under 100 deaths for the first time since March.
  • Trump disputes the death toll, though most experts feel we are undercounting.
• Speaking of undercounting, I looked at deaths per 100,000 population today for many countries. Spain is at 61, we are at 29, Brazil is at 10, and Russia reports 2. I'm not sure why I bother listing the Russia numbers. Brazil is under reporting, but not like Russia.
• As I look at new cases per country, there are 66 countries that are increasing, some rapidly. Peru (and South America in general) look bad. Africa is heating up, and India is at 125,000 and rising.
• Mexico had its highest single-day surge in deaths.
• Their are 39 countries that are improving. We are not one of them.
• Brazil has overtaken Russia in the number of confirmed cases. Their curve looks straight up. They had 21,048 new cases yesterday, we had 23,790.
• China reports no new symptomatic cases and no new deaths for the first time since the pandemic started.

 

Next up, the reopening:

• Ford has had to close 2 recently opened plants over infections. mtn note: These plants both had been shut down, then reopened, then shut down again due to positive infections. The 2^nd shutdown, which is referred to here, turned out to be less than 48 hours if I read the reports correctly
• Elon Musk pushed his California plant to open. The production line is unchanged, and distancing is not possible. Some employees feel he is putting profit ahead of people. He had famously predicted there would be no new cases in the U.S. in April. We have yet another test case going forward.
• Kids in South Korea are back in high school. I am sure with many restrictions.
• The tourist industry worldwide is set to have its worst year since 1950. Are you traveling this weekend?
• Hertz has filed for bankruptcy. They have been in business since 1918.
• Places of worship are in the spotlight. Twelve hundred pastors in California have said they will resume in-person services in defiance of the governor. The California Federal Appeals Court has ruled they must comply. Trump has stated they are essential and that he will override the governors.
• I wish the CDC's guidance had not been withdrawn. I think places of worship should reopen, but with safety in mind.
• The MMWR (morbidity mortality weekly report) published this past week that 38% of 92 people attending a church service in Arkansas had tested positive. The first two were the pastor and his wife. Patti told me a few minutes ago that three had died.
• My favorite medical author in the modern era is Dr. Atul Gawande. I have read and loved all of his books. He had a piece published in the May 13th issue of The New Yorker entitled "Amid the Coronavirus Crisis, a Regime for Reentry". You should read the whole article, its free.

 

I will elaborate on the 5 major points he makes in tomorrow's post, if I have time.

 

Stay safe, isolate, wear you masks in public.

 

Update from The Professor:

Pediatric Covid-19 in Children IV

 

Multisystem Inflammatory Syndrome in Children (MIS-C) is increasingly being identified around the United States and the World. Twenty-seven states and the District of Columbia have reported cases to the CDC with over 150 in New York alone. Three additional deaths, age 5,7,17, have occurred in NYC. Thirteen countries are also identifying children with the syndrome. It continues to resemble Kawasaki’s Disease with subtle laboratory and symptom differences. It has also proven more lethal and difficult to treat. Supportive care with use of IV Gamma Globulin and anti-inflammatories (Aspirin) remain the core of treatment. Early identification and treatment is critical. Parents and physicians need to be alert to the child with fever, gastrointestinal symptoms, rash, cherry red tongue and desquamation of skin around the fingertips. Classic symptoms of Covid-19, cough and respiratory distress, are not common at presentation.

 

More distressing is recent identification of the syndrome in older patients. Older adolescents and young adults are now being diagnosed. A twenty-year old in San Diego and a twenty-five-year old in New York are now hospitalized with the syndrome. NYU has several other patients hospitalized who have symptoms suggestive of but not yet meeting full diagnostic criteria. The older adolescents and the young adults appear to have a more severe course than the younger children. How this syndrome will relate to Covid-19 adults with rapid progression of symptoms and cytokine storm will be the subject of intense investigation.

 

The appearance in young adults is a matter of special concern as internists have not commonly seen or treated Kawasaki’s in the past. It has been a disease of young children. The treating physician may not instinctively recognize the pattern of illness. Early identification is important for treatment success and advisories to providers seeing older adolescents and young adults are being circulated.

 

The apparent resistance to Covid-19 in young children has long been a source of discussion and research. A recent study published in the Journal of the American Medical Association (JAMA) for children by researchers at Mt. Sinai Hospital in New York has shed some light on the subject. Covid-19 “spikes” attach preferentially to Angiotensin Converting Enzyme 2 (ACE2) in the airway. This attachment permits viral entrance into host cell and hence infection. The researchers measured gene expression for this enzyme in the upper and lower airway obtained by bronchial lavage. They found a statistically significant logarithmic increase in expression with age. The groups measured were young children under 10, older children 10 – 17, young adults 18-24, and adults over 25. 305 subjects 4-60 were studied and balanced for sex. The study has been published and certainly will be subject to further peer review. This is how science is done.

 

There is also significant media and press fascination with the idea of someone being infectious for several days before recognizing symptoms of Covid-19 infection or of asymptomatic people being infectious. This is not a surprise to Pediatricians. Medicine has long recognized that most of our symptoms of common respiratory illnesses, including other corona viruses, are caused by our immune system fighting the infectious agent. By the time the illness is recognized the patient is well on the way to recovery. The patient has also infected susceptible candidates in their home, school, and community long before the disease process was recognized. This occurrence with Covid-19 is not new and certainly not surprising.

 

It is easy to be confused by the myriad of ways this virus causes illness. It is easy to question medical experts when historically they did not predict the extent of pathology or released information that later proved to be wrong. It is easy to be confused about statements of potential immunity and the ability of blood tests to confirm or reject whether a person is safe from infection or reinfection. This is a “novel” virus. Prior to 2020 it was unknown, unstudied, and there was no way to predict exactly who it would infect, how it would spread, and how the infection would present. We have learned a phenomenal amount of knowledge in a very short time utilizing bioscience techniques which were not available ten years ago. This will continue with questions answered, new questions raised, and old truths rejected in the coming months. That is the nature of science.

 

Stay tuned, stay safe, wear a mask and maintain social distance.

 

To re-inform: I was trained in medicine and pediatrics at the University of California San Francisco. I had a solo practice at the Mollie Scott Clinic in Sun Valley for 18 years. I then worked at Rockwood Clinic in Spokane affiliated with the University of Washington Medical School. I was fortunate to have participated as a Principal Investigator in over 140 clinical trials. Vaccine trials were a significant emphasis at our site as were antivirals including the development of Synagis (RSV) and Tamiflu (Influenza). My wife and editor is a Pediatric Nurse Practitioner who also trained at UCSF. She had a varied career including private practice general pediatrics, Lead School Nurse for Spokane Public Schools, and public health outreach for high risk young mothers.

 

We are both recently retired.

 

 

Covid-19  Update #68  
May 24, 2020

 

• First up, a pre-publication paper from Dr. Bouvier at Mt. Sinai. As you know they are at the forefront of convalescent plasma research. I was unable to find the actual paper to read, but will keep looking.
  • They reported on a small number of patients given convalescent plasma, They looked at results on 39 patients with matched controls.
  • The death rate was 13% of the treated, and 24% in the control group.
  • By the time patients were on a ventilator, it was ineffective.
  • Once again, as expected, early is better.
  • Once again, I want this as I hit the door of the hospital. Larger studies are needed, they are in progress.
• A study was published in Singapore regarding contagion. It came from the National Center for Infectious Disease. As I looked at it, it was actually a position paper. It did demonstrate that roughly 11 days into infection, 73 studied patients were no longer contagious, despite some remaining PCR positive. Virus could not be isolated, nor cultured. Active replication drops off quickly after week one. I think the 14-day rule gives us adequate leeway.
• The Oxford vaccine project has hit a major hurdle. It was not unexpected. They are testing 10,000 volunteers. As the infection rate is dropping in the U.K., they will likely have less than 50 contract the virus. If the number is less than 20 the data will be statistically worthless.
  • My suggestion, set up shop in Brazil.
  • Another alternative, intentionally expose paid and informed volunteers, at low risk for severe disease.
• Dr. Deborah Brix has taken over for Dr. Fauci. She appealed to all to wear masks and practice social distancing over the holiday weekend. Her advice is being ignored. She gave a talk about percent positive tests in different cities. D.C., Minneapolis, Baltimore and Chicago are the worst.
• In Germany, 40 churchgoers in Frankfurt were infected. The church has gone back to online.
• I saw a picture of the boardwalk in Venice beach. the crowd gave me chills. The streets of Austin were packed last night.
• The Museum of Fine Art in Houston is reopening. It is the first major art museum to do so.
• Trump has stopped taking hydroxychloroquine.
• On Thursday, 300,000 went through airport security in the U.S. That is the most since March, but just over 10% of the pre-pandemic numbers. TSA agents are wearing masks. Apparently, travelers are not required. Boy is that dumb.

 

Now on to statistics:

 

• The U.S. has 1,660,006 cases. We have 97,477 deaths. while new cases still look flat, the death rate is definitely improving. We have better information and improved treatment virtually daily.
• Arkansas is having a second spike. The first 30 days ago was 160 cases, yesterday they had 163. North Carolina had 1,107 new cases yesterday, its highest single day. Alabama, which had a spike on the 20th, seems to have dropped back to its normal trajectory.
• In New York, the number of daily deaths has dropped to 84. It was more than 800 at the peak. In the NYPD, 43 officers have died. More than 5,700 have tested positive.
• The problems in our nursing homes, prisons, and meat and poultry plants continue to rage on.
• The number of new cases worldwide continues to increase despite underreporting and inadequate testing.
• South America is really heating up. Brazil has 347,398 total cases with 22,013 new. Their president is encouraging businesses to reopen. Their medical people are more than unhappy with this. Peru had 4,056 new cases and Chile added 3,536.
• The favelas, or urban slums in Brazil are being especially hard hit. I expect many are dying in place, having never been tested or seen at a hospital.
• India is spiking. they had 6,600 new cases, their largest single day.
• Looking at the curves of the countries which are decreasing, Italy stands out. Its curve looks straight down. They added only 669 new cases yesterday.

 

Stay safe, isolate, wear a mask in public. If you go out over the holiday, try hard to maintain social distancing.

 

This isn't over, not even close.

Covid-19   Update #68-Part 2  
May 24, 2020

 

• This one goes out to my friend John Koth. John is a masters level physical therapist, who has helped me rehab a shoulder and knee. He asked for a synopsis of Atul Gawande's article. Here it is. The 5 things we should all do during the reopening.

1. Regular hand washing. He cited a paper which showed soldiers in boot camp had a 45% reduction in visits for respiratory illnesses when they washed their hands 5 times a day.
2. Practice physical distancing, even if you have a meeting down the hall, do the meeting virtually. (I don't see how John can do this.)
3. Dr. Gawande talks about best practices in the hospital and about daily screening. He relates that in the early days of infection, less than 50% of people run temperatures. So, while temp screening has value, it should be augmented by a symptom check list. At his hospital he can check in and complete the check list with an app on his phone. Our local hospital, and yours should adopt this
4. Continuous wearing of masks: He states that surgical masks are three times better than the homemade variety. At Mass General Brigham, they are treating used masks with hydrogen peroxide vapor. By doing it this way, a masks filtration is maintained for 20 cycles.
5. Dr. Gawande talks about sterile techniques like are used in the OR. Meaning, for us to be careful what we touch, and not touching our faces after contact with others and surfaces. What he is really saying, is that we have to change the way we do things in our culture. This is the most difficult one of all.

• This requires people to care about the safety of others, not just themselves. This is why we wear masks at the grocery store, to protect the personnel, who work there all day long.
• While I am at it, there was a short term behavior modeling study in "Science", which looked at what had worked in Germany. They came up with three things that had effect.

1. Canceling large events
2. School closures
3. Banning contact and closure of non-essential businesses

 

• Of these, only number three stopped exponential growth of the epidemic.  Lifting these restrictions too soon could well negate the positive effects. This is just a modeling study, but gives one pause to think.
• I did take a deeper look at Sorrento Therapeutics, the early stage biotech company, that touted they had found the "cure". As you may recall, they had identified an antibody that 100% neutralized the virus in low concentrations in the lab.
  • They have built a vast library of human antibodies through their immuno-oncology platform. Sorrento's G-MAB library contains 10 quadrillion distinct antibody sequences. This is one example of how AI is changing the research world, along with 5-G speed. It is one of the largest human antibody libraries in the world.
  • Earlier this month Sorrento teamed up with Mt. Sinai, one of my favorites in the war against the virus. They screened 15,000 recovered patients for antibodies that fight the virus. Using a combo of this data plus their library, they isolated 12 that were highly effective. The ultimate goal is to develop a shield cocktail of multiple antibodies.
  • All they need now is FDA approval to proceed. It will likely take a working animal model to be approved for human testing. As previously mentioned, they are producing the "cure" STI-1499 as I write, and hope for a million doses while they work through the approval process.
  • My best guess, we will be hearing more from this company.

 

Take your cues from Dr. Gawande. Wash your hands frequently, practice social distancing, wear your mask in public and think about the safety of others. If you have a temp or symptoms of the virus, isolate yourself and get tested.

 

Sound familiar?

 

 

Covid-19  Update #69  
May 25th, 2020

 

First off, a few comments on the group. It's fine to send your interested friends. The only requirement is one mutual friend. They will all be approved. Please don't have them ask to friend me. I will, when I have time, send all the old posts to the group page. I may ask Patti if she is willing to do this. It's fine to send a note, when you first sign on, I will delete them after a few days. We want people to be able to find the posts without a lot in the way. I'd prefer you click on the like (or love) button. If you have a link you would like to post, feel free, let's limit them to hard science. I will vet them and delete the misinformation..

• Feel free to ask questions, that many in the group might like to hear the answer to.
• Please don't send the science haters. 
• If you want to email posts, see Pam Jonas' question and Patti's answer for how to do that.
• Anita Susan Brener posted two links to the group that are worthwhile. Take a look.
• I have asked Professor Luber to post his articles directly to the group.

 

Monday is usually a slow science day. I think the holiday makes it even slower.

 

Patti shared a survey published in the New York Post. It stated that hydroxychloroquine with or without a Z-pack is the most recommended treatment by physicians for Covid-19. While this may be accurate, it is without any scientific basis. The hardest thing to do in medicine is nothing. It takes much more time and discussion. While I was in practice, we had this problem with docs prescribing antibiotics for viral illnesses. Every medical society warned the docs not to do this, but it was very hard to change that behavior. Hate to say this, but many docs don't read much. I'll ask my friend, Professor Luber, to weigh in on this, when he has time. I don't think his comments will be so gentle.

 

Alison Rosen asked why a doc would tell a recovered patient it would be okay not to wear a mask. If we agree that people can't be infected a second time, at least in the short term, it would be reasonable to give that permission. That behavior does make others feel less secure, so I would encourage patients to wear one when social distancing is not possible, for the benefit of others. There we go again thinking about other peoples feeling and risks.

 

Next up, a look at the stats:

• The U.S. has 26,229 new cases. Deaths are at 97,684. Looking at the curves, the new cases are relatively flat, the deaths are dramatically down. The latter is great news.
• Looking at the 12 individual states that are increasing in number of cases, and the slopes of their curves, Wisconsin and North Carolina look the worst to me. While its number of cases are small, No. Dakota's curve looks bad.
• Among the states that look mostly the same for new cases, Illinois has 110,541, Texas 56,050, Florida 50,850 and Georgia 40,989. Several states that are staying the same are because they have so few cases.
• Of those states that are declining, New York's curve looks the best... great job with a nearly impossible task.
• The New York Times has stated that in the U.S. and a dozen other nations, deaths are under-reported due to limited testing ability. That bias should be declining in the U.S.
• I think there is a bias toward lower case reporting on Sundays and holidays. Brazil reported only 15,813 new cases yesterday, and only 653 deaths. India had its largest day yet, with 6,977... its curve looks bad. Mexico added only 2,764. Italy added only 531 new cases, and their curve continues down.
• The U.S. has banned travel from Brazil... what a good idea.
• India is resuming domestic flights... a two-edged sword.
• Mayor Neto of the city of  Manaus, Brazil says, President Bolsonaro should both resign and "shut up and stay at home."
• Trump is threatening to pull the Republican National Convention from North Carolina because Governor Cooper is "unable to guarantee" that the arena can be filled to capacity.
• I saw a video clip from the weekend from the Lake of the Ozarks in Missouri... talk about lack of social distancing.

 

As the rest of the country opens up, seniors and those at high risk are experiencing an increased sense of isolation. Many states, including Georgia, continue to have shelter in place orders for these folks. As this continues, withdrawal and isolation will ramp up leading to widespread pronounced situational depression and functional decline. Those that are ready for extended care have horrible options.

 

If you have seniors in your life, reach out and engage them whenever possible. It could make a huge difference.

 

NAMI (National Association on Mental Illness) has, on their website, Covid-19 information and resource guide. It includes toll free numbers.

 

Stay safe, isolate, wear your mask in public.

 

Covid-19  Update #70  
May 26, 2020

 

It's a bit of a slow news day, I assume due to the three-day weekend.

 

Spent some time today cleaning up the group site (Dr. McLean's Covid-19 updates.) While I love hearing that the information is useful, let's limit it to likes and other reactions as opposed to words. It will make it easier to find posts (questions and comments.)  I will leave useful links up. If your friends would like in, just send them to or invite them to the group site. If they have one mutual friend (you), they will be allowed to join automatically.

 

• The WHO has suspended all of its trials on hydroxychloroquine over safety concerns after the huge review of cases published in Lancet.
• As many talk about the second wave and when or if it will come, Dr. Mike Ryan of the WHO reminds us that on a global basis, we are right in the middle of the first wave, and worldwide cases have not peaked, yet.
• Looking at the drugs and vaccines in progress... little new to report on vaccines, they will just take time.
• I looked at the production of Remdesivir by Gilead. As previously mentioned, the drug takes six months to manufacture, down from a year. There are 25 chemical steps to make the powder, it must then be added to sterile water and placed in vials. The biggest issues, in my opinion, will be in the supply chain for precursor compounds and elements, many of which come from China. Hopefully the supply chain issues will be repaired before our next pandemic.
• There are many companies looking at monoclonal antibodies against SARS-CoV-2. The leader of the pack in terms of time frame is Regeneron. I have written about them several times. They are already in production of their lead candidate and hope to start clinical trials in June. They also are looking at having an antibody cocktail.
• There are also many companies looking at ways to attenuate the "cytokine storm". Regeneron has been evaluating its drug Kevzara. This drug is an IL-6 receptor blocker. A large portion of the clinical trial in the U.S. has been terminated due to lack of effect. It doesn't help the severe patients at all. The critical patient arm will continue, but only at the higher dose.  This is really bad news, as the whole class may have no value.
• I did find one small trial involving JAK inhibitors, and was hoping someone would be looking at this. There is a 400 patient trial on this pathway. I'll do a deeper dive on this later today... have always had an interest in JAK-2.

 

Next, a few statistics:

• The daily death toll in the U.S. continues to decline. The total is now 98,191. The downslope is 7 days in, so it's not just chance. Let's hope it persists. We added only 19,056 new cases yesterday. Am thinking there may be a holiday weekend bias here in the U.S., tomorrow will tell. Looking at the chart, new cases have resumed a slowly declining plateau, instead of being just flat.
• In the states with increasing new case numbers, Florida and Georgia are the most interesting. I will follow them daily and let you know if things change substantially.
• Brazil's new cases dropped to only 11,687. The death toll is beginning to mount.
• India's new case numbers also dropped to 6,535. We will see.
• The federal policy on testing announced Sunday, is to leave the ramp up... up to the individual states. This is a really bad plan.
• The city of Wuhan ran 6.5 million tests in 9 days during its last outbreak. That is part of how they controlled it. That number of tests did not come from the province.
• Five beaches in France were closed due to unacceptable behavior this weekend.
• The mayor of Montgomery, Alabama stated that he feels the lifting of restrictions has lead to a false sense of security. People are willing to take some risk to have a more normal life. They are ignoring the fact that they also put others at risk with their behavior.
• Patti shared a link on a man who intentionally coughed near a supermarket employee, and then told her he had the virus. He was arrested and charged with making a terrorist threat in the 3rd degree, and 4th degree of obstructing administration of the law. These are both felonies in New Jersey. He faces up to 7 years in prison, and up to a $26,000 fine.
  • As we all know, prison can be a death sentence now. I'll bet this guy tests negative after all. Hopefully this will discourage others.

 

Stay safe, isolate, wear your mask in public, despite what others are doing. Be part of the solution, not part of the problem.

 

 

Covid-19  Update #71  
May 27, 2020

 

As predicted, the information flow has returned after the long holiday weekend. Now for the task of turning 6 pages of notes into something coherent and useful.

 

• The CDC has issued its guidance for religious groups. I hope they will be used. It was included in their initial guidance, but absent from the second and third iterations. If you plan to attend in-person services, it might be useful to read beforehand.
• The CDC has a piece on facemasks. They advise we all use cloth masks. The surgical masks and N-95 respirators belong on the frontline, as the supply is inadequate to meet their needs.
• The CDC has also posted a piece on antibody testing. I found it tremendously disappointing. It reads like it was written by a lawyer and not people of science. The news pieces that accompanied it were terribly misleading. They talked about how inaccurate the tests were. I am trying to give them the benefit of the doubt, but that is a struggle. Given the massive reopening in the U.S. and Europe, the time for ultra conservative guidance is over, in my opinion. I could write a term paper on this, but I'll try to keep it short.
  • They state that more data is needed before they can make any statements regarding immunity. I have yet to see a single report on someone testing positive for a second time and having viable virus present. There will be some, I am sure, but with 1.5 million cases worldwide, it won't be statistically significant. I believe we can say without any question, that having antibodies, following confirmed infection, provides considerable protection. We don't know how long that will last.
  • They used a term in further discussion, positive predictive value (PPV), meaning the chances that a positive test will be correct and not a false positive. They then posted a complex graph. The take home from this information is, only tests with high specificity, like 99.5% or better are going to be useful, and the number of people who have had the virus in your area is important, as PPV goes up with prevalence. In places like New York City, and Blaine County, Idaho, the positive predictive value will be much higher than in say Hamilton, Montana. You need the data if you have an antibody test. A tough concept, but that's the best I can do to put it in English.
• France has suspended the use of hydroxychloroquine in clinical trials. As you may recall, they were the ones pushing it along with Trump, early on. One day later, they revoked its approval of the drug for use for Covid-19 in clinical practice.
• The most interesting science of the day comes from Rockefeller Hospital in New York. It was posted on bioRxiv, which as you know, is a pre-publication server for articles. This means no peer review or publication... yet.
  • That being said, they looked at neutralizing antibodies (antibodies that stop the virus from replicating) in plasma of recovered individuals. They had collected plasma for clinical use in 149 patients. They found 1/3 were not measurable. Most of the rest had poor to moderate levels. Only 1% were remarkably high... I'm assuming two of them, as the reference is plural. They recovered 40 unique antibodies from these elite responders. This should inform those researching vaccines.
  • So, now I want a plasma transfusion from an elite responder as I hit the door of the hospital. I sense a viable business opportunity here. My thanks to Dr. Tom Archie for sending this to me. Tom, Patti and I miss dancing to your band.

 

Now on to statistics:

• On Tuesday the U.S. reported 18,611 new cases, and 693 new deaths. Our new case curve is in a slowly descending plateau, much like the U.K., but nothing like the huge drop in Italy and Spain. Our death rate, however is plunging. This leads me to two conclusions. First we are doing better with the really sick people, and second, those at risk are doing a good job of sheltering in place. Total deaths are at 98,913.
• It is worth noting that Italy has stated that 95% of it fatalities were in people over the age of 60. It is also a part of why mortality in Africa looks so low. A full 60% of Africa's population is under 25 years old.
• Hopkins listed our new cases at a 1.8 % increase with the new 7 day moving average at 1.55%. Florida was at 1.6%, California at 2.6% with its 7 day moving average at 2.37.
• I saw for the first time, total cases reflected as cases per 100,000 population, on a state by state basis. I found this highly informative. Hope I can find this day to day.
• Texas came in at 5/100,000, Idaho at 4, D.C. at 62, NY at 151, NJ at 126. This explains a lot to me.
• The CDC shows at least 62,344 healthcare workers have been infected, with at least 291 deaths. Their data base does not always include professions for the death count. Perhaps it should, going forward.
• In Africa, it took 52 days for the first 10,000 cases. It took just 11 days to move from 30,000 to 50,000.
• South Korea has 40 new cases, 37 of which are locally transmitted. This is the highest since early April. The case count from the ill-fated night club reopening is now up to 250.
• Brazil, despite its undercount, has taken over as the leader in daily death count from the U.S. They added 16,324 new cases yesterday.
• India added 6,387, Mexico added 3,455 a new one day high.
• Looking at the graphs for countries increasing with more than 100,000 total reported cases, Brazil, India, Iran, Peru, Chile, and Mexico all look bad. This confirms the assertion that South America is the new global hotspot.

 

I am about halfway through my notes, but that's enough for this A.M. Perhaps a number two report later, we'll see.

 

Will leave you with one thought. It has become apparent, that whether or not you wear a mask in public, has become some kind of political statement. Please do not buy into this. Our president is setting a bad example.

 

Stay safe, isolate, wear your mask in public.

Update from The Professor

The Reckoning

 

There are now 1.7 million confirmed cases of Covid-19 in America. 100,441 deaths are directly related to the infection. That equals all American combat deaths in the Korean, Vietnam, and Middle East wars. The actual numbers are undoubtedly higher due to state variation in case identification. We have had over 40 million applications for unemployment and that number will continue to rise. The unemployment rate is now approaching 20%. We participate in economic re-opening and renewal in fits and starts with minimal compliance with the original CDC guidelines. There are causally related flares of disease as experienced in Wisconsin two weeks after the State Supreme Courts struck down public health measures.

 

We compare this toll to that of Taiwan which has both close commercial and travel contact with the Peoples Republic of China. It lies 80 miles of the coast of Mainline China. It has a population of 28 million with less than 1000 cases and just 67 deaths. Its economy is intact. Hong Kong with a population of 12 million has had just 7 deaths.

 

Taiwan was significantly impacted with the SARS epidemic of 2011. They instituted public health measures to identify and control any future infectious disease outbreak. They established government agencies charged with directing epidemic/pandemic response and fully staffed them. They rehearsed their response, stockpiled medical supplies, invested in testing capability, and integrated their health care system into the proposed response. When word of cases of unknown pneumonia emerged from Wuhan in January, 2020 they immediately implemented the planned, rehearsed measures under unified national direction with strong political support. Their citizens responded to medical and political direction for social distancing. They wore masks.

 

The United States established pandemic response teams with direct cabinet access after the Ebola and H1N1 episodes during the Bush and Obama administrations. The office was systematically emasculated and defunded during the current administration. Scientists and physicians now report to lawyers, financial officers, and political operatives. Supply stockpiles, which the current Trump administration documents confirm were present in 2016, were allowed to deteriorate.  When presented with the undeniable evidence of a potential threat our leadership denied, prevaricated and delayed response until it was too late to contain the epidemic.

 

• Dec. 31: CDC receives information of a cluster of unknown viral cases in Wuhan
• Jan. 1: CDC begins developing reports for Department of Health and Human Services (HHS)
• Jan. 3: CDC Director Robert Redfield officially notified by his Chinese counterpart of a respiratory illness outbreak in Wuhan. He notified HHS Secretary Alex Azar who notified National Security Council (NSC). Warnings are placed in President’s Brief by intelligence community.
• Jan. 18: Secretary Azar has been trying to see the President and is granted access. The president calls him an alarmist and changes meeting focus to control of “vaping”
• Jan. 22: President Trump makes his first comments. “And we have it totally under control. … It’s going to be just fine.”
• Jan. 30: President Trump states: “We think it’s going to have a very good ending for it. So that I can assure you”.
• Feb. 10: President Trump states “I think the virus is going to be — it’s going to be fine.”
• Feb. 24: President Trump states: “I think the virus is going to be “CDC and WHO have been working hard and very smart”
• Feb. 27: President Trump states: “When you have 15 people — and the 15 within a couple of days is going to be down to close to zero — that’s a pretty good job we’ve done.”
• Feb. 28: President Trump states: “It’s going to disappear. One day, it’s like a miracle, it will disappear.”
• March 3-13: Multiple governors and mayors declare local emergencies and institute stay at home orders, social distancing
• March 10: President Trump states: “Just stay calm. It will go away”.
• March 12: Former HHS Secretary states: “We basically wasted two months”.
• March 13: National Emergency is declared
• March 15: CDC issued guidance against gatherings of 50 for 8 weeks. Increasing closure of schools, public places are now widespread.

 

Epidemiologists from Columbia University in NYC modeled early progression of the epidemic and the effect of public health measures. According to their work, published on May 18, starting social distancing one week earlier would have saved 36 thousand lives. Starting the lockdown two weeks earlier would have saved 54 thousand lives. There would have been an 86% reduction over the timespan of their model.

 

We have over 100,000 deaths as of today. The total will be 150,000 -200,000 by years end.  These are not abstract numbers. They are human beings with family members often not able to say goodbye and who now mourn their deaths. They are not just the old and infirm. Forty percent are under 60. They include doctors, nurses and first responders. They include “essential workers” who kept our cities clean, public transportation moving and our grocery stores stocked.

 

Global respect for the United States has been radically diminished as we remove ourselves from the world community. Our economy is in tatters. We are either entering a severe recession or out-right depression. Careers are shattered. Families are frightened for their future. Small businesses hang on by a thread if they survive at all. Our social connections have been severed and customary norms have been altered. Grandparents cannot see their grandchildren with peace of mind. Mature adults are frightened for their adult children’s futures. The education of our school aged children is jeopardized. Colleges will attempt to open but college life will not be recognizable to the students and their parents. The arts have suffered. Athletics are on hold.

 

The only effective tools available to control this pandemic before safe and effective vaccines and pharmacotherapy are available are the established, validated public health measures other nations have employed. These are applicable to infection control and the necessary reopening of the economy. It needs to proceed with the simple tools outlined by the CDC. 1. Common sense social distancing and use of quarantine 2. Adequate and available testing 3. Contact tracing 4. Wearing of masks. These steps have been proven effective in other countries. They have to be employed evenly and with compliance by the population. The absence of any component condemns the effort to failure. There has not been a federally directed, unified policy on any of these measures. Re-opening of the economy can and must proceed.

 

Medical experts have been sidelined in the attempt to control this pandemic. It is now in the hands of the economists and financial cadres.

 

The virus was coming. It would have been dangerous in any case. The deleterious effect of the pandemic could have been dramatically reduced with coordinated public health migration measures. The economy would certainly have taken a hit but not to the current extent. A nationally coordinated re-opening could have been implemented under CDC guidelines with significantly less infectious risk. Unfortunately, the response was late, poorly orchestrated and ineffectual. There was an abject failure of leadership. This outcome did not have to happen!

 

Leadership must demonstrate to the public the right things to do. It must seek to unify the country to fight a common, invisible threat. The virus does not care if you are Republican, Libertarian, or Democrat. It does not care whether you live in a red state or a blue state. It does not care if you are white, yellow, brown or black. It does not care if you are wealthy or poor. It does care if you vote by mail because crowded polling places are ideal for its spread. It does care if you wear a mask as they have been proven to limit its spread. It does care if you work in a crowded venue as it spreads more easily. It likes crowded bars and restaurants. It thrives at large crowded events. It prefers young victims to old as they can propagate the virus silently with minimal symptoms.

 

The President is elected by the people to serve and protect the people. He needs to unite our populace. He should not seek to divide it for political gain. President Trump will not wear a mask and ridicules those who do.

 

I have come to often hear the question “Why the fuss over the corona virus? After all, influenza comes every year and there are similar death rates.” Let me clear this up. The average excess deaths from influenza is 57,000/year over the last three years. 100,000 fatalities represents a major epidemic. With influenza, the deaths occur over a 9-month span not the three months we have had with Covid-19. The death rate from influenza is .1% versus .5% -.8% from Covid-19. The corona virus is 5 to 8 times more lethal and this lethality may end up higher as we refine our statistics. Influenza has never overwhelmed our hospitals and killed our health workers and first responders. They are required to immunize against influenza. We have effective though underutilized vaccines for influenza. We have effective though underutilized pharmaceuticals (Tamiflu, Xofluza, Relenza) for influenza. The cupboard is bare for Covid-19 at this time. There is no comparison.

 

Covid-19  Update #72  
May 28, 2020

 

For those of you in the group, mtn has archived all the prior posts. See his post to gain access if you are interested. I will start taking down old posts, and work on keeping the site uncluttered.

 

• GlaxoSmithKline has announced they are moving to produce 1 billion doses of a vaccine booster that enhances the power of any vaccine to create an immune response. It might even lower the amount of vaccine needed, thus increasing the number that can be vaccinated. They have no expectation of making a profit, they are gearing up their capability at many sites.
• The Lancet Respiratory Medicine published on May 27th, an autopsy study on 10 African-Americans with the virus. These were done by a team at LSU Health. They found small vessels and capillaries filled with clot. They also found microangiopathy. This causes areas of the lung that are pulling in oxygen to fail to transmit it to the bloodstream.
• A second autopsy study was published in the NEJM (New England Journal of Medicine) also on May 27th. This study compared the lungs of seven patients, who had died from influenza, with seven lungs of patients who died from SARS-CoV-2. All had Acute Respiratory Distress Syndrome. Both groups showed extensive clots. The differences in the SARS patients were:
  • Severe endothelial damage (cells lining the respiratory tubes) and cell destruction, with visible virus (electron microscopy).
  • Nine times more alveolar (the little sacs where oxygen exchange takes place) micro thrombi (little blood clots).
  • Angiogenesis, meaning new micro vasculature  growth. Sounds like a good thing but it is not. The last finding was completely unexpected.
• A second study published in the same issue of the NEJM compared 5 and 10 day treatments with Remdesivir in 397 hospitalized patients, not yet sick enough to be on a ventilator. It was an opened label, randomized, but not placebo controlled, trial. Overall 65% improved on the drugs. On their stricter scale of improvement, 64% of the 5 day, and 54% of the 10 day improved. Sounds better, but was not statistically significant. The 5 day group had fewer serious adverse effects, again not statistically significant.
  • This confirms that 5 days is as good as ten in this group. It means to us, that twice as many can be treated.
• Roche and Gilead are enrolling up to 450 patients in a trial to look at a combination of Remdesivir and Actemra, a drug for rheumatoid arthritis. Hopefully we will see many more combination trials with Remdesivir.
• A study published in "Thorax" revealed that on a cruise ship 81% of the 128 infected didn't have symptoms. This is really bad news if true on a more generalized basis. At least these folks aren't continually coughing.
• Dr. Chris Murray of the IHME, the U of W modeling group used by the White House, stated there is now clear evidence that wearing a mask cuts the spread by 50% in the real world.
• Dr. Fauci is back on the air, touting wearing masks during the reopening, and leading by example. He feels wearing masks is a sign of respect for each other, as we protect each other.
• The British government is putting a large scale track and trace system into play. The French parliament has approved a contact tracing app, StopCovid. What are we doing?
• China reported 2 new symptomatic cases yesterday in two different regions. They also reported 23 asymptomatic patients. We need to be testing all the contacts of the infected.
• The U.S had a one day spike in deaths... 1,485, which put us over 100,400. Let's hope the spike is not a new trend. We were doing so much better.
• The graph of our new cases is continuing as a downhill plateau. All these graphs use 7 day moving averages. We had 18,857 new cases yesterday.
• California is averaging more than 2,000 new cases a day over the past two days. Florida has had three days of declining numbers, as the 3 big theme parks gear up to reopen in July. Texas added 1,506 new cases yesterday. Idaho joined the states where cases are increasing, but not by much in my estimation.
• Looking at the R naught per state, the worst is Arkansas at 1.05, Hawaii is by far the best. This means that Idaho is doing pretty darn well despite the total cases.
• Brazil added 20,599 new cases, bringing the total up to 411,821 with severe lack of testing. The death toll is now 25,598. India added 6,566 cases and Mexico added 3,463.
• South Korea added 79 cases yesterday, the most since April 5th. that is nearly double the prior day.

 

Be safe, isolate, wear your mask in public.

 

 

Covid-19 Update #73
May 29, 2020

 

There is so much going on in our country and the world right now that is deeply disturbing, and has little directly to do with the pandemic. I will try to keep this post as clean as I can, but it is becoming more difficult.

 

• The Lancet published an article yesterday regarding cancer and risks with Covid-19. It looked at 928 adults with SARS-CoV-2 and with a current or past history of invasive cancer or a hematological malignancy. The summary posted in the NEJM "physicians first watch" was simple. When I pulled the article up in the Lancet it was very difficult to read and make sense of. It read like it was written for cancer statisticians.
  • By the end of 30 days 13% had died. The only ones spared were those in complete remission. As you may recall from prior posts, the risk for dying from the virus in the U.S. is likely between 0.7 and 1%. Therefore, 16% is a huge number.
  • They also looked at the use of hydroxychloroquine alone and with a z-pac (azithromycin). When patients were on both, it tripled their risk for death. For those who like the stats, the bivariable odds ratio was 3.42, the multivariable partially adjusted odds ratio was 2.93.  Both were reported as ranges.
  • The take home message, if you have active cancer, self isolate, and make sure your household contacts are as much as possible. Do not take hydroxychloroquine.
• The VA has been giving our vets hydroxychloroquine despite the current evidence. A retrospective analysis of the 1,300 given the drug showed no benefit and increased mortality. They have cut back but are still prescribing it in small numbers.
• There were 22,471 new cases in the U.S. yesterday with 1,204 new deaths. That's  two days in a row above the 7 day moving average for deaths. Idaho remains on the list of states that are increasing, despite the fact that we only had 39 new cases yesterday.
• Governor Little announced yesterday the move up to stage 3. This was modified to include bars and movie theatres, but not night clubs. This goes into effect on Saturday. Living in a resort community this makes me more than a little nervous. He plans to open all K-12 this fall.
• California is still increasing, and is partially reopening. The beaches are one thing, the theme parks will be quite another.
• Florida is reporting decreasing new cases, many do not believe their numbers, including me.
• Texas reported 1,618 new cases, their past two days look bad, relatively speaking. The next week or so should tell the tale there. Georgia's numbers remain flat.
• Worldwide we had the highest single day increase at 116,598. Remember, most of the developing world is undertested, and many die at home having never been seen or tested. worldwide, the first wave hasn't even crested yet.
• Brazil added 26,417 a new single day high. They have reported a mere 26,754 deaths, looks low. Despite this Sao Paulo is opening up its businesses. In terms of numbers of new cases, it's the worst city in the world right now. This will not go well.
• India added 7,466 cases, also a single day high. Mexico added 3,377. The curves in Peru and Chile are still straight up.
• So. Korea, in the face of a small number of new cases, is reversing its reopening. It is closing parks, schools, museums, and theaters.
• Governor Cuomo has signed an executive order allowing businesses to refuse entry to anyone not wearing a face mask.
• The president continues to mock Biden for wearing one in public.
• A reader asked me to listen to a 28 minute podcast on Medscape yesterday. This is usually a very reliable site. The opinion piece was full of fake facts. I hope nobody listens to it and believes.
• One statement that I said I would fact check later was that half of the U.S. deaths were from nursing homes. That was also false, but the real numbers took me by surprise. It was very hard to find the data. The CDC almost says nothing about this. I sent them an inquiry as to why. I don't expect a response, but I'll let you know.
• I spent about two hours last evening looking hard. The best source was the NYT. It seems they bundle nursing home patients with their caregivers, skilled nursing facilities, residential care, and assisted living. This is a bit confusing. The numbers among all of these are staggering. The best estimates are for 147,000 cases and 37,000 deaths. Likely between 35 and 40% of our total deaths. I read that the president has told the nursing homes that they don't have to report any deaths prior to May. I only saw this in one place.
• Nursing homes are the "perfect storm" for the pandemic. We have a high risk population, living closely together, with their caregivers and visitors coming from the outside. Influenza is always a problem every year, this despite the residents taking high dose flu vaccine.
  • All that being said, I would view this as a national tragedy/emergency. It seems to me it is being suppressed or ignored. It shouldn't be.

 

Be safe, wear your mask in public, practice social distancing.

 

Patti is off rafting and camping this weekend, so no editor. Please forgive any typos, or errors. By the time I am finished I'm cross-eyed.

 

 

 

Covid-19 Update #74
May 30, 2020

 

Very little on the science front today.  The weekend seems to be like that.

 

• The Idaho Statesman, our major newspaper, has demanded that the nursing homes in our state disclose that they have cases publicly.
• We have 9,000 nursing homes and long term care facilities in the U.S., they have reported more than 37,000 deaths. Those with black and Latino patients are by far the worst.
• Following critical media reports, the Trump administration has informed nursing homes that they must disclose new cases in their facilities to the patients, and their families. They must also report them to the CDC within around 12 hours. This is a good start.
• Families with loved ones in long term care will have some very difficult choices to make going forward, care versus risk. Many are in nursing homes over safety concerns.
• When we look at the problems in prisons, with 47,000 infections and 485 deaths, they seem small by comparison.
• The U.S. has 1.7 million cases, we have added 22,471 cases, and 1,200 new deaths. We are still in a slowly declining plateau, it's about to be a flat plateau. Looking at the world curves with total numbers and curve shapes, we are the worst in the world. The only curve that looks like ours now is Sweden, among those countries past the peak. The U.K. used to look like us, but they are now in rapid decline.
• Idaho remains on the list of states that are increasing. We only reported 39 new cases. Phase III begins today. The balance is so difficult.
• Looking at the curves of the seven day moving averages, Texas, Florida, and Georgia look mostly the same. Of the states that are improving, the curve in NY looks the best, nice work NY.
• Texas has had three bad days, they added 1,721 yesterday, Their biggest day was May 15th with 1,818.
• Tennessee has the worst R naught, at 1.06, Hawaii the best at 0.6, Idaho is at 0.99 . Again, the R naught is how many new cases come from one infected person.
• The world is closing in on 6 million cases. The death toll is 364,400. The past two days we have averaged more than 115,000 per day. As the pandemic hits the developing world, the cases and deaths will be underreported. Only the WHO can help this situation effectively.
• France has rejoined the countries that are increasing, the increasing countries now number 75, again based on 7 day moving averages. The curves on Iran, South America, Mexico, and India all look straight up.
• Brazil added 27,878 cases, a new one day record. India added 7,964, also a new record. India's deaths are spiking. Mexico added 3,227 new cases, they are broadly felt to be deliberately undercounting. their deaths are decreasing. I don't believe that. I have friends in Mexico or I would stop commenting, as I have on Russia. Bad information is worse than no information.
• India's strict lockdown may end as soon as tomorrow. I hope not for their sakes. The hospitals in Mumbai are overwhelmed.  Given the size of it's urban slum I expect this will get much worse, with more and more dying in place never having medical care or testing.
• Honduras had a dengue epidemic last year with 100,000 victims which left 180 dead. It overwhelmed their medical system. How are they going to deal with the pandemic.
• In Geneva, the line for free food was one mile long. This is with distancing being observed however.
• As I look at the CDC data on the pandemic, 4% of patients are under 17. Just wait until states like Idaho reopen their schools. Those 18 to 44 weigh in at 39%. Just wait until their kids come home from school with the virus. We all know how easily they bring home viral illnesses from school and daycare. Once again, there is no right answer.
• The Supreme Court has, in a 5 to 4 vote, rejected a California church's case regarding restrictions. This is the first time they have ruled on what is basically freedom to worship versus public health. Once again. there is no right answer. I am certain there are strong feelings on both sides.

 

Once again this post has not been seen by my wife and chief editor. If you find problems let me know so I can repair them.

 

Everything else I have has strong political overtones. I will, if I'm up to it, publish a part two, only for friends. If you don't like the politics of the pandemic, just skip over it.

 

Stay safe, isolate, wear a mask when out in public and distancing isn't possible. I went to the grocery yesterday, only the checkers and myself were masked. The store was crowded. Be part of the solution, not part of the problem.

 

 

Covid-19  Update #75  
May 31, 2020

 

China has 5 vaccines in human trials. Their candidate that is furthest along, just completed phase II.

• This is an inactivated virus model vaccine, like the ones we use for polio and hepatitis.
• They tested 2,000 people and found it both safe and effective at producing antibody response.
• The trick now is in proving efficacy in a country with very few cases. The only options, in my mind, would be to test in a country with high active new cases, like Brazil, or to intentionally expose volunteers, with low risk for severe disease, to the virus to see if it affords protection. Only time will tell.
• They hope to have it generally available by the end of this year, or early next. They state they will be able to produce between 100 and 150 million doses a year.

 

A reader put up a post from elemental.medium.com. This is an article by Dana G. Smith. The article is also a good read, with many valuable points. It's clear if I go through this piecemeal, it will be way too long, so I will shorten it up.

• The article tries to drive home the theory that this disease is really a disease of blood vessels and not the lungs. It sites many references to prove the theory.
• The author uses the work of Dr. Mandeep Mehra, a physician from Brigham and Women's Hospital in Boston.  This is the facility that produces the NEJM, that I quote so often. Dr. Mehra is the director of Heart and Vascular Center at Brigham, and is a professor of medicine at Harvard.
• In one case study published in the Lancet from May 2, they demonstrated  the vasculotropic nature of the virus. They demonstrated virus in the walls of blood vessels in many areas of the body, the kidneys hearts and lungs in particular, using electron microscopy.. They also demonstrated inflammation of the lining of the vessels, endotheliitis. It also demonstrated cell death. This study was in the form of correspondence. The spellings were all very British, and in fact, Dr. Mehra was the seventh listed author.
• Ms. Smith states one article showed 9x the clots... I posted on this article, it showed nine times the clots in the alveoli, the capillary clots and lager vessel clots were the same, and to my surprise evident in those with the flu as well.
• In the 9,000 patient study she quotes, this was a study looking at a huge number of patients designed to help clinicians understand, whether the use of drugs we use for blood pressure and heart failure... the ace inhibitors and the angiotensin receptor blockers... were going to be harmful. These drugs affect the ACE-2 receptors in the lungs. The virus uses these receptors to gain entry into our bodies. The ARBs had no effect on survival, the ACE inhibitors were more common in survivors. The study informed us that these drugs in fact were doing no harm, and could be continued without fear of causing damage. It did not tout them as a therapy.
• These errors and distortions damage the point she is trying to make.
• We know the virus causes systemic problems. We know the virus affects endothelial cells in the lining of the lungs and blood vessels. We know it creates diffuse inflammation and cell death. We know it creates diffuse clotting problems. That this vascular damage should be the target is what is unclear. It may open some new lines of inquiry that could be helpful.
• The current lines of therapy, stopping the virus itself, stopping the "cytokine storm of inflammation, and preventing the virus from entering through the receptor, will remain as the primary targets of therapies.

 

A reader posted A Comprehensive Review for Clinicians on "Up to Date". This is a service that many E.R. docs use to assure what they are planning is the current standard of care. If you have a medical background, it's a great read.

 

 

The statistics of the day:

 

• The U.S. now has 1,778,000 cases. We added 24,566. That is two days above the 7 day moving average, a bit worrisome. We added 1,190 deaths, on May 25 we only had 510. The death numbers have three days above the moving average, also worrisome.
• California remains the worst of the states increasing by both numbers and shape of the curve. It has 110,100 cases.
• Idaho added only 34 new cases. It will take 4 weeks to know how phase three will affect Idaho.
• Texas added 1,275, the fourth day above the moving average.
• Illinois is finally decreasing, joining NY, NJ, as states with more than 100,000 cases, which are declining.
• Florida had a spike day, adding 1,212 new cases.
• The world added 126,179 cases, a new one day record. The number of countries increasing is now 78. The death count is now 369.203.
• Brazil added a whopping 33,274 new cases, for a total of 498,440. Deaths there are now 28,834.
• India added 7,964 and is up to 182,143. Their officials state testing is still far too restrictive. They have only tested roughly one person in a thousand, thus far.
• Mexico added 2,885.
• The curves for Peru and Chile are still straight up.
• Universal Studios in Orlando is set to reopen on Friday. There will be temp checks on admission, and masks will be required.
• The Liberty Tree Tavern in Elgin Texas is "no masks allowed". Near L.A., a flooring store also prohibits masks and encourages handshake and hugs.
• As beach towns reopen, there are few masks to be seen.
• If you are at risk, be very careful out there.

 

Stay safe, isolate, wear a mask in public.

 

 

Covid-19  Update #76  
June 1, 2020

 

Several patterns are emerging... low case counts on Sundays, and a spike in medical news on Mondays. There is a lot to digest today. Just a reminder to my friends... any of your friends are able to join the group automatically. Please do not send science haters.

 

• A research letter in JAMA Open from May 29th reported on blood clots in legs on ICU admissions of patients with SARs-CoV-2. They found by ultrasound, 65% had clots on admission. All had elevated d-dimer (blood test that goes up when clots are present). When retested 48 hours later, despite preventative blood thinning, that number rose to 79%. Clots in both legs were reported in 18%.
  • The authors suggest that full-on anticoagulation be considered in all patients sick enough to be in the ICU... I think all patients sick enough to be in the hospital, just my opinion.
• There was a very disturbing article published in The Lancet on May 29th. They reported on 1,100 patients from 235 hospitals across 24 countries with SARS-CoV-2, who underwent surgery. The patients were confirmed positive from 7 days prior to surgery to 30 days afterward. These cases were from January 1 through March 31st.
  • They reported an overall mortality rate of 24% in these cases, within 30 days of the surgery. Things which increased risk included: being male, older, major surgery, or emergency surgery. 
  • A full 50% of the cohort had pulmonary complications. Of this group, 38% died. This group had 83% of the deaths in the entire cohort.
  • The authors suggested that if you are a male over 70, you should postpone non-urgent surgery. I would suggest postponing all elective surgery.
• A study accepted for publication on May 7th in the journal, Diabetology, demonstrated that roughly 10% of diabetics admitted for SARS-CoV-2 died within the first 7 days. A full 29% had either died or had been placed on a ventilator by 7 days. If you have diabetes, you should be very careful.
• A study published in The British Medical Journal on May 29th, reviewed the first 1,000 patients with SARS-CoV-2 admitted to New York Presbyterian -CUIMC.
  • A full 34% had kidney injury, 14% had dialysis. Approximately 20% died. Over 90% had major co-morbidities (underlying risks).
  • They observed a bimodal curve as to when patients would suddenly deteriorate and require ventilators, which will be useful to all those caring for these patients.
  • Those caring for in hospital SARS-CoV-2 cases should read the whole article.
• In The New England Journal of Medicine on April 17th, published under Perspectives, there was an article about Africa in the path of COVID-19. Taken as a whole, the continent is unprepared for what is coming. It already deals with HIV, TB, and malaria.
  • Kenya for example has 200 ICU beds for 5 million people. The U.S. has, by comparison, 34 per 100,000. By my calculation, that would be 1,700 for the same 5 million. Our ICUs were overtaxed.
  • Liberia has only a few ventilators. Many millions don't even have access to clean water, much less soap. This represents a humanitarian crisis of epic proportions, ready to explode.
  • They will need multinational support; they will need the WHO.

 

Statistics for the day:

• In the U.S., we approach 1.8 million cases. We added 20,747 new cases yesterday. This is right at the 7 day moving average. We only added 606 deaths.
• California leads the pack of states with increasing numbers of cases. They added 3,014 new cases. The past three days, they have averaged just over 3,000 per day. By shape of the curve and total numbers, both Virginia and North Carolina are looking bad.
• Of the states improving, New York leads the pack. They added only 56 deaths yesterday. NYC is poised to reopen on June 8th. They expect 400,000 will return to work.
• Texas added 1,578 new cases. Their curve looks bad. Their new cases have been above the 7 day moving average for 6 days in a row. I expect they will join the states that are increasing tomorrow. Florida added 739, Georgia added 715.
• Worldwide, we have 6,167,500 cases. We added 108,324 yesterday. The death total is now 372,000. The countries that are increasing is now at 80, it seems to be increasing daily.
• Brazil had a low reporting day, adding only 16,409.
• India added 8,392, a new record. The slope of their new case curve  is steep. They are reopening in the non-hot spots as of Saturday. Places of worship, restaurants, hotels and malls will be allowed to reopen. This is a purely economic decision.
• Peru, Chile and Mexico also have steep curves for new cases. Mexico added 3,152 yesterday.
• Iran and possibly France are showing bimodal curves suggesting a second wave, particularly in Iran.
• China tested 60,000 in Wuhan yesterday and found no asymptomatic carriers.
• The CDC is set to resume regular press briefings after a three month hiatus. This, as the White House task force winds down.

 

As usual for Monday, I have pages of notes I  haven't covered.  I'll try to cover them tomorrow, including a deeper look at [a readers] post.

 

Stay safe, isolate, wear a mask in public.

 

 

ZYX

FYI, Look closely at the closing line of post 60!

In reply to mtn (Forum Supporter) :

I feel the same as that New Yorker.

mtn (Forum Supporter) said:

FYI, Look closely at the closing line of post 60!

Thanks for posting this. I am printing it out and giving it to other people I know. 

As you know, things are opening up here in Texas. 

 

 

In reply to mtn (Forum Supporter) :

Sunlight? One of the reasons I love driving a convertible. Some solace for doing essential work. 

 

Updated for 5.19 and 5.20

Bunch of updates from the weekend.

 

He's started a facebook group that he's posting this on. PM me and I'll add you to it if you're on the book of faces.

Likes and Loves.

Updated for 5/27

I was afraid that statistic that the US has 5% of the population and 20-something percent of cases wasn't going to hold - that a lot of the world would get hammered even worse, but later. Looks like that's underway now.

In the states with increasing new case numbers, Florida and Georgia are the most interesting. I will follow them daily and let you know if things change substantially.

I had been following that weird spike-and-dip in the Georgia numbers since the reopening too, and wasn't sure if it was due to a rise in testing (which was only recently opened up to anyone who wanted one) or a rise in transmission. One claim I'd heard was that the spike was due to an effort to test some groups of Hispanic migrant workers that had been reluctant to come forward and be tested - the DPH recently brought in a group of Spanish-speaking workers to reach out and reassure this group.

Given that the death charts don't appear to be reflecting the same spike, I'm hoping this is a case of increased testing over the same transmission rate, but it looks like it may take a while to be certain.

Updated for 5/28 and 5/29, along with an update from The Professor. Warning, the Professors post gets political. 

Updated for 5/30

I hope you keep posting these. I read them. 

I could care less that some people here don't. 

 

Same.

Yes, please do.

I’ve got I think three of them I’ll update tomorrow morning. 

 

Again, pm me to connect on Facebook if you want to get the updates from the source. 

I appreciate the work you put into all this.

In reply to mtn (Forum Supporter) :

Hey I sent a PM, let me know if you get it.

mtn (Forum Supporter) said:

I’ve got I think three of them I’ll update tomorrow morning. 

 

I was wrong, only 2 that I had missed.

 

tuna55 said:

In reply to mtn (Forum Supporter) :

Hey I sent a PM, let me know if you get it.

Received and replied

I see Georgia has responded to complaints that the RNA and antibody testing had been mixed together by revamping their page to separate out the two and list the % positive for both.

More infections and deaths than ever in Dallas County today. 257 infections. 15 deaths. New records. And all the local media here keeps saying is "open up, open up, open up". All those rioters downtown with no masks. Restaurants open. Barber and beauty shops open. Stores open. Everybody pretending that it's all over. 

I will be staying home and wearing a mask when I have to till this thing trends one way or another. 

 

The instant man stops fearing is the instant the species reaches a dead end, only to sink to pitiable lows, only to sit and  wait apathetically for extinction.

                                       - Schwartzwald

Any updates?

https://www.msn.com/en-us/news/us/arizona-s-covid-19-spread-is-alarming-and-action-is-needed-experts-warn/ar-BB15ilr2?ocid=spartandhp

Looks like Arizona is spiking now. Dallas just hit a new record for infections. 

Any updates from the professor? 

It seems like everywhere that is mostly open is spiking.

 

Why can't people just wear masks and wash their freaking hands?