Coronavirus pandemic non-socio-political discussions

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RxCowboy

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#21
March 30

Covid-19 Update:
I hope you took a break from the virus information this weekend. Here are some things to know as we start the week.

1)Let's talk about China. When there is an outbreak there are very specific steps that must be followed in order to stop/control the outbreak. Step 2 is to write a case definition. A case definition determines who is counted as "having it" and who isn't. Cases are then calculated and reported as: suspected, probable or confirmed. When you are looking at the numbers, what you are seeing is confirmed cases. That is pretty standard protocol. Each nation has the freedom to establish their own case definition - China has changed theirs a number of times. Here is why you care. Reportedly, China doesn't include anyone in their case count who is a carrier or who tests positive but isn't showing symptoms. They don't include anyone who retests positive after being released from medical care and in some instances isn't reporting anyone with mild symptoms. So China's numbers are artificially low. Remember, the bulk of people have mild symptoms - so the numbers they are reporting are most likely very low compared to what is actually happening. This effects our ability to put an accurate timeline on the virus among other things.

2) Reinfection - we discussed this one once before but there have been more cases reported so I wanted to update you. Keep in mind the reports of reinfection are coming out of China - and primarily from people who are sneaking the information out, so we have to consider it in that context, and details are slim. There have been more cases of people testing negative, being released from medical care and then testing positive again. The possibilities are: a) false negative test due to a faulty test (this is a real thing), b) improperly administered test due to human error (also a real thing and to be expected), c) virus reactivation after a period of dormancy (think chicken pox to shingles type thing) or d) having the disease doesn't protect you from getting it again. It is WAY to soon to know which of these it is but research is being done so hopefully we will have answers soon.

3) Post intensive care-syndrome - People who are in intensive care for long periods of time tend to develop this. The longer you are in ICU the more risk you have of developing it. Considering covid-19 patients require a ventilator for an average of 20 days they are at high risk for this syndrome which includes physical, emotional and mental effects. Doctors suspect this is due to being sedated so long. Also, patients in ICU with covid-19 are not allowed family and friends in with them, which is known to intensify the long term effects. Yet another reason to do your part.

4) There's a app for that. Apple and the CDC created a Covid-19 self-screening app. It's free, it's simple to use and it is available on the app store. https://apps.apple.com/us/app/apple-covid-19/id1504132184

5) There is now a "Social Distancing Scoreboard" to see how states are doing on social distancing and staying home. A company named Unacast is collecting and analyzing data from our cell phones. You can track how your state is doing here: https://www.unacast.com/covid19/social-distancing-scoreboard

6) Another company has stepped up to help. Dyson switched their production from vaccums to ventilators to help close the gap. This is good news.
 

John C

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#22
March 30

Covid-19 Update:
I hope you took a break from the virus information this weekend. Here are some things to know as we start the week.

1)Let's talk about China. When there is an outbreak there are very specific steps that must be followed in order to stop/control the outbreak. Step 2 is to write a case definition. A case definition determines who is counted as "having it" and who isn't. Cases are then calculated and reported as: suspected, probable or confirmed. When you are looking at the numbers, what you are seeing is confirmed cases. That is pretty standard protocol. Each nation has the freedom to establish their own case definition - China has changed theirs a number of times. Here is why you care. Reportedly, China doesn't include anyone in their case count who is a carrier or who tests positive but isn't showing symptoms. They don't include anyone who retests positive after being released from medical care and in some instances isn't reporting anyone with mild symptoms. So China's numbers are artificially low. Remember, the bulk of people have mild symptoms - so the numbers they are reporting are most likely very low compared to what is actually happening. This effects our ability to put an accurate timeline on the virus among other things.

2) Reinfection - we discussed this one once before but there have been more cases reported so I wanted to update you. Keep in mind the reports of reinfection are coming out of China - and primarily from people who are sneaking the information out, so we have to consider it in that context, and details are slim. There have been more cases of people testing negative, being released from medical care and then testing positive again. The possibilities are: a) false negative test due to a faulty test (this is a real thing), b) improperly administered test due to human error (also a real thing and to be expected), c) virus reactivation after a period of dormancy (think chicken pox to shingles type thing) or d) having the disease doesn't protect you from getting it again. It is WAY to soon to know which of these it is but research is being done so hopefully we will have answers soon.

3) Post intensive care-syndrome - People who are in intensive care for long periods of time tend to develop this. The longer you are in ICU the more risk you have of developing it. Considering covid-19 patients require a ventilator for an average of 20 days they are at high risk for this syndrome which includes physical, emotional and mental effects. Doctors suspect this is due to being sedated so long. Also, patients in ICU with covid-19 are not allowed family and friends in with them, which is known to intensify the long term effects. Yet another reason to do your part.

4) There's a app for that. Apple and the CDC created a Covid-19 self-screening app. It's free, it's simple to use and it is available on the app store. https://apps.apple.com/us/app/apple-covid-19/id1504132184

5) There is now a "Social Distancing Scoreboard" to see how states are doing on social distancing and staying home. A company named Unacast is collecting and analyzing data from our cell phones. You can track how your state is doing here: https://www.unacast.com/covid19/social-distancing-scoreboard

6) Another company has stepped up to help. Dyson switched their production from vaccums to ventilators to help close the gap. This is good news.
I looked at the map from #5. New York received an A, but they have the highest number of people who have contracted the disease. I appreciate their attempt, but their grade determination methodology is flawed.
If I live in NYC, I might be able to walk to the corner deli to get food (or soup from the Soup Nazi) and my cell phone never changes towers. If I live in OK, I might have to drive five miles to go to Walmart, since there isn’t a corner deli. If the cell tower changes, then Oklahomans aren’t social distancing, but New Yorkers are, by their methodology.
 

RxCowboy

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#23
March 31

Covid-19 Update: aside from the numbers, it was a quiet day in Covid-19 news yesterday for which I am thankful. Here are a few reminders and updates.

1) there is a shortage of tests so right now they are being prioritized for healthcare workers, police, and other front line workers (not exclusively of course, it is just the priority - every area is doing things slightly differently). If you have mild symptoms you don't have to go in or be tested (remember you should not just show up but should call first). The test situation has been a bit of a.....situation. And now there seems to be a swab shortage - swabs are needed to do the test. Keep in mind that in some areas test results can take up to 2 weeks. So as you are seeing the numbers shift - they can be actual cases detected that day or cases that were tested up to 2 weeks ago. I mention this because some people are playing the statistical numbers game (we only have x number of cases in my area so it doesn't matter if I go out, the chances of getting it are slim). But your official case count is severely under reported due to a whole host of reasons. Trust me on this one.

2) Why can't anyone tell us how long this will last? I have gotten that question a lot and the answer is rather simple. People are the great unknown. A virus "runs its course" in the human body ending in 1 of 2 ways: the person gets better due to treatment or immune response or the person dies. In a population, the virus will continue spreading until we break the chain of infection. We can't do that if people don't cooperate. What we do, each one of us, determines how this goes. Think of the scene in Finding Nemo when the fish were caught in the net. They all had to swim in the same direction to free themselves. More of us have to swim in the same direction than aren't. We see this with vaccinations too - if enough of us get vaccinated, it protects everyone. (and remember, not everyone can stay home. it's up to those who can to do so, we all have our part to play). But you need to set your mindset to months - not weeks or days.

3) Just a reminder that Ibuprofen and Covid-19 do not go together. For now, don't take it.

4) Doorknobs, light switches, tables, remote controls, drawer handles (really all handles) desks, toilets, sinks and chairs are the germiest areas in your home. Consider cleaning/disinfecting those regularly. A 10% bleach solution is a great option but not the only one. And regularly doesn't need to mean obsessively.

5) I want to remind everyone that what we are doing right now is trying to slow things down enough that we aren't completely overwhelming our medical system. We don't have enough ICU beds or ventilators for this. We have run out of PPE in many places and our healthcare professionals are getting creative - and infected. When we overwhelm the system we force the healthcare teams to determine who gets what - and that is no good. Thank you to those who are staying home, please continue to do so. "Do not grow weary of doing good"

FINAL THOUGHT: Health is more than physical well being. Health has three components: physical, mental and social. Right now, we are facing challenges of all three. Be mindful of your mental and social well being. Tend to it. We can't do the things we were doing but there is still plenty we can do and ways we can interact. We can create shared experiences in new ways. Self assess - what do you need today?
 

RxCowboy

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#24
April 1

Covid19 update: Yesterday was a pretty active day, here are some highlights.

1) Some new theories are emerging on social distancing. The basis of it is about the size of the virus and the droplets you expel when you sneeze or cough. Some droplets are small, and some are large. Large droplets tend to drop quicker where small ones travel further. Some studies have shown those small ones can travel further than we thought. Because the amount of exposure you need to get covid19 is so low, the idea is that we may need greater distance from those small droplets than we thought. Lots of studies are looking at this right now. Worst case scenario came out of MIT and suggests they can travel up to 27 feet. That's pretty far. Most scientist believe this would be only in extreme instances (think hospital procedures that promote aerosolization or massively strong sneezes that aren't covered). More realistic, less extreme situations may result in an 8 foot distance recommendation. Stay tuned for more on this as further research is done and be sure to cover coughs and sneezes.

2) To follow up on the other methods of transmission content I shared previously - studies are starting to emerge that support that. It is now believed that the virus can also be spread through body fluids such as semen and blood as well as through fecal/oral route.

3) Two things happened with the numbers yesterday that are worth noting. First China said they may start counting asymptomatic people in their case count. That would result in a spike in cases from them (about a 25-50% increase). So, if you see their numbers going up don't get too excited about a resurgence - it could just be the way they are counting is changing again (remember, their current numbers are artificially low compared to other nations due to their case definition protocols). Second, I have been monitoring how long it takes us to add 100K new cases globally. We moved from 4 days, to 2 days to 1 day. That is worth watching. We should hit a million cases globally by tomorrow. If the 100K a day trend continues we will have nearly 2 million by this time next week - globally.

4) Remember our discussion on masks? They are designed to keep the wearer from spreading it - not from getting it. Well now research is suggesting that up to 50% of people may have covid19 and not know it. This finding is now causing a reconsideration of if we should be asking people to wear the masks out in public (like when you go grocery shopping). The purpose would be to keep those who are carriers or who are sick but don't know it yet, from spreading it to others unknowingly. Of course there is a shortage of masks so discussions are happening regarding IF they do make that recommendation, what the public could use instead of masks. Its a matter of figuring out what might be most effective and if it would help. Please note that not wearing the masks right doesn't help, its not as simple as just putting it on or off. Please see prior post on proper technique if needed.

5)In very good news, the FDA approved a new technique of testing - essentially finding that a technique deployed in WA state of having patients self test was as effective as practitioners testing them. This is a huge win for front line practitioners and could reduce their exposure. I will link the new recommendations in the comments for anyone interested.

6) Also want to offer a reminder that you should NOT use Ibuprofen or any other NSAID if you have or think you could possibly have covid19. If you are wondering if your fever reducer/headache med is an NSAID a quick Google search will tell you. IF you are taking baby aspirin for medical reasons please keep taking it and call your doctor if you are concerned.

7) one of the overlooked public health issues of the disease is the indirect impact on some. For example, children in families without computers or internet at home (yes, they do exist) who are now faced with closed schools and online learning when they don't have the means to do that. Victims of domestic/family violence being locked-down with their abusers. Low income kids who were dependent on school lunches and meal programs to eat. Fixed income individuals and families who can't afford to "stock pile" food. Families dependent on WIC who can only buy WIC approved items in the grocery store but now can't find them due to panic shopping. The list goes on and impact is tremendous, be mindful of the many hidden hardships and the widening gap.

FINAL THOUGHT: As we head into our third real week of this, people are being forced into a new way of life - if only for a little while. It is stressful and frustrating and nothing we would have ever chosen. Those 4,059 deaths in America are real people, real lives lost with family who are grieving that loss. Lives changed forever, hearts broken, families that will never again be the same. Disruption is everywhere and many are struggling through a very rapid adjustment to this "new normal". Tempers are running high and emotions are running low. Look around and offer a hand to those who need it or raise your hand if that is you. If ever there was a time to give each other some grace and compassion this is it.
 

RxCowboy

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#25
March 27, 2020
Treatment of 5 Critically Ill Patients With COVID-19 With Convalescent Plasma
Chenguang Shen, PhD1; Zhaoqin Wang, PhD1; Fang Zhao, PhD1; et alYang Yang, MD1; Jinxiu Li, MD1; Jing Yuan, MD1; Fuxiang Wang, MD1; Delin Li, PhD1,2; Minghui Yang, PhD1; Li Xing, MM1; Jinli Wei, MM1; Haixia Xiao, PhD1,2; Yan Yang, MM1; Jiuxin Qu, MD1; Ling Qing, MM1; Li Chen, MD1; Zhixiang Xu, MM1; Ling Peng, MM1; Yanjie Li, MM1; Haixia Zheng, MM1; Feng Chen, MM1; Kun Huang, MM1; Yujing Jiang, MM1; Dongjing Liu, MD1; Zheng Zhang, MD1; Yingxia Liu, MD1; Lei Liu, MD1

JAMA. Published online March 27, 2020. doi:10.1001/jama.2020.4783

Key Points
Question Could administration of convalescent plasma transfusion be beneficial in the treatment of critically ill patients with coronavirus disease 2019 (COVID-19)?

Findings In this uncontrolled case series of 5 critically ill patients with COVID-19 and acute respiratory distress syndrome (ARDS), administration of convalescent plasma containing neutralizing antibody was followed by an improvement in clinical status.

Meaning These preliminary findings raise the possibility that convalescent plasma transfusion may be helpful in the treatment of critically ill patients with COVID-19 and ARDS, but this approach requires evaluation in randomized clinical trials.

Abstract
Importance Coronavirus disease 2019 (COVID-19) is a pandemic with no specific therapeutic agents and substantial mortality. It is critical to find new treatments.

Objective To determine whether convalescent plasma transfusion may be beneficial in the treatment of critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Design, Setting, and Participants Case series of 5 critically ill patients with laboratory-confirmed COVID-19 and acute respiratory distress syndrome (ARDS) who met the following criteria: severe pneumonia with rapid progression and continuously high viral load despite antiviral treatment; Pao2/Fio2 <300; and mechanical ventilation. All 5 were treated with convalescent plasma transfusion. The study was conducted at the infectious disease department, Shenzhen Third People's Hospital in Shenzhen, China, from January 20, 2020, to March 25, 2020; final date of follow-up was March 25, 2020. Clinical outcomes were compared before and after convalescent plasma transfusion.

Exposures Patients received transfusion with convalescent plasma with a SARS-CoV-2–specific antibody (IgG) binding titer greater than 1:1000 (end point dilution titer, by enzyme-linked immunosorbent assay [ELISA]) and a neutralization titer greater than 40 (end point dilution titer) that had been obtained from 5 patients who recovered from COVID-19. Convalescent plasma was administered between 10 and 22 days after admission.

Main Outcomes and Measures Changes of body temperature, Sequential Organ Failure Assessment (SOFA) score (range 0-24, with higher scores indicating more severe illness), Pao2/Fio2, viral load, serum antibody titer, routine blood biochemical index, ARDS, and ventilatory and extracorporeal membrane oxygenation (ECMO) supports before and after convalescent plasma transfusion.

Results All 5 patients (age range, 36-65 years; 2 women) were receiving mechanical ventilation at the time of treatment and all had received antiviral agents and methylprednisolone. Following plasma transfusion, body temperature normalized within 3 days in 4 of 5 patients, the SOFA score decreased, and Pao2/Fio2 increased within 12 days (range, 172-276 before and 284-366 after). Viral loads also decreased and became negative within 12 days after the transfusion, and SARS-CoV-2–specific ELISA and neutralizing antibody titers increased following the transfusion (range, 40-60 before and 80-320 on day 7). ARDS resolved in 4 patients at 12 days after transfusion, and 3 patients were weaned from mechanical ventilation within 2 weeks of treatment. Of the 5 patients, 3 have been discharged from the hospital (length of stay: 53, 51, and 55 days), and 2 are in stable condition at 37 days after transfusion.

Conclusions and Relevance In this preliminary uncontrolled case series of 5 critically ill patients with COVID-19 and ARDS, administration of convalescent plasma containing neutralizing antibody was followed by improvement in their clinical status. The limited sample size and study design preclude a definitive statement about the potential effectiveness of this treatment, and these observations require evaluation in clinical trials.
 

OSUCowboy787

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#26
March 27, 2020
Treatment of 5 Critically Ill Patients With COVID-19 With Convalescent Plasma
Chenguang Shen, PhD1; Zhaoqin Wang, PhD1; Fang Zhao, PhD1; et alYang Yang, MD1; Jinxiu Li, MD1; Jing Yuan, MD1; Fuxiang Wang, MD1; Delin Li, PhD1,2; Minghui Yang, PhD1; Li Xing, MM1; Jinli Wei, MM1; Haixia Xiao, PhD1,2; Yan Yang, MM1; Jiuxin Qu, MD1; Ling Qing, MM1; Li Chen, MD1; Zhixiang Xu, MM1; Ling Peng, MM1; Yanjie Li, MM1; Haixia Zheng, MM1; Feng Chen, MM1; Kun Huang, MM1; Yujing Jiang, MM1; Dongjing Liu, MD1; Zheng Zhang, MD1; Yingxia Liu, MD1; Lei Liu, MD1

JAMA. Published online March 27, 2020. doi:10.1001/jama.2020.4783

Key Points
Question Could administration of convalescent plasma transfusion be beneficial in the treatment of critically ill patients with coronavirus disease 2019 (COVID-19)?

Findings In this uncontrolled case series of 5 critically ill patients with COVID-19 and acute respiratory distress syndrome (ARDS), administration of convalescent plasma containing neutralizing antibody was followed by an improvement in clinical status.

Meaning These preliminary findings raise the possibility that convalescent plasma transfusion may be helpful in the treatment of critically ill patients with COVID-19 and ARDS, but this approach requires evaluation in randomized clinical trials.

Abstract
Importance Coronavirus disease 2019 (COVID-19) is a pandemic with no specific therapeutic agents and substantial mortality. It is critical to find new treatments.

Objective To determine whether convalescent plasma transfusion may be beneficial in the treatment of critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Design, Setting, and Participants Case series of 5 critically ill patients with laboratory-confirmed COVID-19 and acute respiratory distress syndrome (ARDS) who met the following criteria: severe pneumonia with rapid progression and continuously high viral load despite antiviral treatment; Pao2/Fio2 <300; and mechanical ventilation. All 5 were treated with convalescent plasma transfusion. The study was conducted at the infectious disease department, Shenzhen Third People's Hospital in Shenzhen, China, from January 20, 2020, to March 25, 2020; final date of follow-up was March 25, 2020. Clinical outcomes were compared before and after convalescent plasma transfusion.

Exposures Patients received transfusion with convalescent plasma with a SARS-CoV-2–specific antibody (IgG) binding titer greater than 1:1000 (end point dilution titer, by enzyme-linked immunosorbent assay [ELISA]) and a neutralization titer greater than 40 (end point dilution titer) that had been obtained from 5 patients who recovered from COVID-19. Convalescent plasma was administered between 10 and 22 days after admission.

Main Outcomes and Measures Changes of body temperature, Sequential Organ Failure Assessment (SOFA) score (range 0-24, with higher scores indicating more severe illness), Pao2/Fio2, viral load, serum antibody titer, routine blood biochemical index, ARDS, and ventilatory and extracorporeal membrane oxygenation (ECMO) supports before and after convalescent plasma transfusion.

Results All 5 patients (age range, 36-65 years; 2 women) were receiving mechanical ventilation at the time of treatment and all had received antiviral agents and methylprednisolone. Following plasma transfusion, body temperature normalized within 3 days in 4 of 5 patients, the SOFA score decreased, and Pao2/Fio2 increased within 12 days (range, 172-276 before and 284-366 after). Viral loads also decreased and became negative within 12 days after the transfusion, and SARS-CoV-2–specific ELISA and neutralizing antibody titers increased following the transfusion (range, 40-60 before and 80-320 on day 7). ARDS resolved in 4 patients at 12 days after transfusion, and 3 patients were weaned from mechanical ventilation within 2 weeks of treatment. Of the 5 patients, 3 have been discharged from the hospital (length of stay: 53, 51, and 55 days), and 2 are in stable condition at 37 days after transfusion.

Conclusions and Relevance In this preliminary uncontrolled case series of 5 critically ill patients with COVID-19 and ARDS, administration of convalescent plasma containing neutralizing antibody was followed by improvement in their clinical status. The limited sample size and study design preclude a definitive statement about the potential effectiveness of this treatment, and these observations require evaluation in clinical trials.
This is what i think will be the most promising. If those who've recovered can and will start donating plasma maybe we could limit the deaths even further.
 

RxCowboy

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#30
April 2

Covid19 Update: here is the latest and a few things to keep in the forefront of your mind as the news prepares to swirl. I ran kind of long today so you may want to get a cup of coffee.

1) Current tests are being done on BCG a vaccine that has been around for about 100 years. It is a TB drug that the NIH (among others) have been testing for a host of things (like possibly for bladder cancer). Current research is looking at it for a treatment for Covid-19 due to its immune boosting properties and people seem excited about it. Australia is leading the study, it will take 6 months before they know anything solid. Another promising treatment that is being explored is plasma from survivors. You may recall we used this same option for Ebola patients. The idea is we take the antigens from the blood plasma of those who survived and fashion a treatment. This has been done in a handful of cases of covid-19 with success. One formal study has been conducted on a very small sample (n=5) and they had success but it was not a miracle cure. More work is being done. Rest assured some of the brightest minds in the world are scrambling to find effective treatments and cures, but of course it takes time. They don't want to rush and end up making the situation worse.

2) China is in the news a lot. You may recall a day or two ago we discussed how each country determines what to count as a case, and China opted not to count people who were carriers as cases which causes their numbers to be low. We now need to discuss how deaths are counted. When someone dies of anything a cause of death is assigned. Sometimes this is straightforward - but sometimes it is complicated. Let's use AIDS as an example. No one really dies of AIDS, they die of the complications caused by AIDS. So when someone with AIDS gets pneumonia as an AIDS complication and dies, we have to decide, do we count that as an AIDS death or a pneumonia death? Those decisions are made and become protocol. Every country makes these decisions for their own countries, which can make tracking global mortality challenging. So this situation is no different. Covid-19 is the obvious cause of death in otherwise healthy people. But in those high risk individuals with other health issues (who are the ones most likely to die) it becomes a little more complex. The WHO issued a recommendation for how to deal with this but then countries can decide for themselves what they actually do. Most of us are counting anyone who tests positive for Covid-19 and then dies as a case fatality. Meaning they had it and they died. (obviously if they died in a car accident or something that would be an exception). But China is not using that same standard. Anyone with a comorbidity - meaning they have another health issue, like heart disease, lung issues etc. - is not being counted in their death rate. Instead they are counting the death as whatever the other health issue was, or some related lung problem etc. Whatever they choose to use, it isn't Covid-19. So again, their numbers are artificially low - really low. As we have discussed, comparing against China is simply a bad idea. This does impact our information and data - so just a reminder not to use China as the number model/comparison and don't listen to comparisons that do.

3) 11 States haven't issued "Shelter in Place" orders. They are: Alabama, Arkansas, Iowa, Missouri, North Dakota, Nebraska, South Carolina, South Dakota, Tennessee, Utah and Wyoming. I have not gone to look at numbers for each of these states (that may be a fun activity for this afternoon) but I do know that in Iowa total identified cases (remember, there are many more than what we know about) are still somewhat low which I am sure is the reason they have not yet done that. Tennessee is the surprise to me in the group. I mention this because there seems to be some grumbling happening around this issue, so I thought it may be helpful to know which states people are talking about.

4) You may also recall we discussed the Strategic National Stockpile (SNS) and that it is a repository of medical supplies and equipment the government keeps on hand for emergencies. In our prior discussion I mentioned that it hadn't been deployed. Days later it was. Now it is gone. Not the entirety of the supplies of course, but the PPE we needed. (there is lots of different things in there). You may recall that we used in during SARS and it was apparently never restocked. So that has now been deployed and depleted. Reportedly, Russia sent a plane full of medical supplies to help us out. This is a significant issue for us right now for many reasons but let me share just one. When working with a sick patient, coughs and sneezes happen. When you are fighting to breath or being intubated, you may not be so careful about covering your mouth. And the people working on you can't stay 6 feet away, they have to be right there, close and personal. This puts them well inside the danger zone. If they get sick - they obviously become a patient not a provider. For each person in ICU on a ventilator, it can take 20 HCPs to care for them. Twenty. That's quite a few. The more of our health professionals that get sick, the less of them that are available to help. This may be a good time to mention the MRC (medical reserve corps). If you are a retired medical professional (or just one who isn't working in your current state - or one who is but would like to be involved more) you can register with the Medical Reserve Corps of your state and be called upon to help should it come to that. Just Google: Medical Reserve Corps and your state then sign up. You can also sign up through the HHS (health and human services) website. I will share the civilian/non-medical equivalent tomorrow.

5) Globally what we are seeing: about 80% of cases are mild, 15% are severe - meaning the person requires oxygen. 5% are considered critical - meaning the person requires a ventilator. For those of you still comparing to the flu - the number of severe and critical is much higher than we would see with the flu. The crude mortality rate globally is around 3.5% - flu is typically 0.1% So this gives you a sense of why this is a big deal. Keep in mind, "crude rates" mean we haven't adjusted for anything like age or risk factors - its just a crude number. Also remember, mortality rate uses total population as the denominator (bottom number). It is easy to confuse mortality and fatality but they are different numbers. And of course, not everyone is counting deaths the same way, and we aren't capturing all cases, - so we know our numbers are going to be off a bit. In epidemiology numbers are fluid and ever changing. They are what we have captured to date - so it is important to always keep that in mind. It's not like 2 + 2 = 4, its more like counting the apples in an orchard where wild horses are eating them as you count and new ones are falling from the trees. Numbers are rough and fluid.

6) Iceland is moving into the forefront as having done a good job with containment. I am happy to report they have been following outbreak 101 rules. You may recall we discussed what still needs to be done to move us from defense to offense. Well Iceland is doing those things. Widespread testing is step one of that. We have to identify all the people who are carriers - passing the disease around without even knowing it. On that front two big things are happening. 1) the government is reconsidering their recommendation on wearing masks. Not because what you were previously told isn't true, but because wearing a mask keeps you from spreading it. Right now we can't widely test - so we can't know who is a carrier or who has it and just hasn't gotten sick yet. By wearing a mask you remove yourself from the equation making it more likely that you won't spread it to others. 2) a five minute test (called rapid test) is reportedly close. That will help tremendously. For the record, we aren't the only country that has struggled to get the whole test thing right.

6)We are going to hit a million cases today, which we knew would happen and isn't alarming. Continue to monitor the time it takes for us (globally) to add 100k. Also watching deaths per million and cases per million gives you better insight on what is really happening. But remember the wild horses too. (#5 above)

FINAL THOUGHT: some really amazing things are happening among all the darkness. Yesterday I heard about Naples Pizza in CT. This isn't new news it was just new to me. The owner was taking free pizzas to the hospital in his area once a week. People found out, regular people, and started donating to the cause. Eventually he had enough donations to take food twice a day, every day. He spread the wealth and started inviting other restaurants to help and they did. They are keeping the healthcare providers cared for while the community is keeping the restaurants afloat.

Teachers all over this country quietly and quickly rushed to figure out how to educate their students from a distance. They learned new technologies and pedagogy to do so. This was no small task but they have done it and we have heard precious little about the struggle. People all over are stepping up and doing amazing things. Let that be an encouragement.
 

RxCowboy

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#31
So, I've had some discussions in the twitter-verse about whether or not COVID-19 is bioengineered. There was one person who was insistent that because it is more virulent that it had to be bioengineered. So, I decided to look at what the R0 is for human coronavirus and SARS coronavirus, and thought I would share here.

So, you've all heard it said that human coronavirus normally only causes the "common cold". There are in fact several viruses that cause colds, rhinovirus (RV) being the most common, and human coronavirus (HCoV) being the second most common. In 2002 there was an outbreak of SARS-CoV again beginning in China. COVID-19 is actually also known as SARS-CoV-2. To save confusion and make it easier for me to type, I'm going to refer to them as CoV19, HCoV, and SARS. Here is a comparison of the virulence (R0) of our seasonal respiratory viruses.

1585859737206.png

HCoV has a mean R0 of 4.18, which means every contagious person infects 4 others. That compares to RV (1.88) and flu (1.68), which means that HCoV is more virulent than either of those. However, again, as you've heard, it generally only causes the "common cold".

So, what about CoV-19 and SARS? The clip below is from The Lancet published just the other day. Notice the highlighted portion. CoV-19 has an R0=2.2 and SARS R0=3.6. That means, if we're going in order of virulence:

HCoV > SARS > CoV-19 > RV > flu

The bottom line for the twitter-verse discussion, there's nothing about the virulence of CoV-19 to suggest it's man-made, it is similar to other known coronaviruses. But it is worse than RV or flu, we have no immunity to it, and people are contagious for 4-7 days before symptoms show up (which means everyone needs to be wearing masks).
1585859522214.png
 

RxCowboy

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#32
I had questions about latency, the period that you are contagious before symptoms appear. Below is from CDC and Medical Microbiology. CoV-19, SARS, and HCoV are all similar.

CDC
1585922807202.png


Medical Microbiology
1585922820752.png
 

RxCowboy

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#33
April 3

Covid-19 update:
I ran long yesterday so I am going to try to keep it shorter today. As normal, I won't be doing any updates over the weekend because I try to follow my own advice and take breaks from it.

1) I want to start with a headline that is scary but mostly hype. "Covid-19 is now the third biggest killer in America" or some variation thereof. The articles are going on to say only heart disease and cancer kill more people and then sharing some stats with large numbers and a quote by a doctor. This is taken WAY out of context. This is true in regards to single day fatality - meaning the number of people who died in a single day. But to take a single day death count from an outbreak and use it to make something the third biggest killer in America is inappropriate. Nearly 650k people die from heart disease every year - we are no where near that, it is a bit premature to start making statements like that. So when you see it, scroll on by.

2) A small study came out of China indicating that it may be possible to keep spreading the disease even after recovery. There were only 16 patients in the study so keep that in mind but it is somewhat consistent with other findings in other places so its worth noting. Of the 16 patients, only 1 required ventilation during illness - so we are talking about moderate and mild cases primarily. Here is what is relevant, 1/2 of them were still shedding the disease after they had recovered. You may recall that "shedding" means you are spreading it. This means, even after you recover you could still contaminate others. On average, they were still contagious for 2.5 days after all of their own symptoms had resolved. Some were found to be contagious for 8 days after they no longer had any symptoms. This is significant and reinforces the prior recommendations we discussed that people be at least 72 hours without symptoms before they be considered ok to be around other people If that number would be the same for more serious cases we don't know. more research is needed to know any of it "for sure" but it is a precaution worth taking until we do.

3) You may see multiple names showing up for this "disease". It can be confusing so I wanted to address that. Originally we were all calling it coronavirus because it falls into that family of viruses - think of that as its family name, and it didn't yet have a disease name. Just as there can be more than one member of a family, there are multiple viruses that are coronaviruses (thus the Lysol can labeling) Then we moved to Covid-19. Covid-19 is the name of the disease it causes. Short for, coronavirus disease - 19 (the number is because the first case presented in 2019). Diseases are named by the World Health Organization according to the International Classification of Diseases (ICD) (Any coders out there?) This assures everyone around the world is referring to the same thing. SARS-Cov-2 is the name that has been given to the actual virus. Viruses have a very specific naming convention protocol overseen by the International Committee on Taxonomy of Viruses (ICTV). This assures that virologists, scientists, healthcare workers, epidemiologists and all the other "gists" have a common language and are also all talking about the same thing. The disease and the virus are different and must be dealt with differently. The virus is the actual germ causing the problem and our focus is on understanding how it works, how it replicates, how it mutates, how we can create a vaccine, how long it lives on surfaces etc. When focusing on the disease we are looking for what is the best treatment, what health issues does it cause, what PPE is needed, what medications work, etc. Lots of different fields and people are all working together on different elements and having a disease name vs a virus name helps keep it all straight. Another great reason for having different names for the virus and the disease is that sometimes a disease can be caused by more than one germ. Hepatitis is a great example, it can be caused by a virus or a bacteria. It is important to know which germ is causing it because the treatments follow the germ not the disease, so if you had viral hepatitis you would get one treatment and bacterial hepatitis would render a different treatment. Currently I am seeing people use the words all intermingled, which is to be expected. But just know that technically there is a difference, much like we had to learn that HIV is the virus that causes AIDS.

FINAL THOUGHT: It's Friday and we have made it though another week of this. A week full of hard news, some disappointment, and some sorrow. A week also marked by incredible kindness and compassion. People all over the world are joining together for a common cause. While we are all experiencing this in different ways we are all in it together. Each of us has a unique roll to play. Spread kindness, look for little ways you can help because people need help and helping makes you feel better. Small acts of kindness make a world of difference. And that can make the world different.
 

RxCowboy

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#38
This is preclinical, which means we have no idea whether or not it will actually treat, cure, or prevent disease in humans. But this gives an idea of how rapidly the research is progressing.

Antiviral Research
Available online 3 April 2020, 104787

The FDA-approved Drug Ivermectin inhibits the replication of SARS-CoV-2 in vitro
Leon Caly, Julian D. Druce, Mike G. Catton, David A. Jans, Kylie M. Wagstaff

https://doi.org/10.1016/j.antiviral.2020.104787

Highlights
• Ivermectin is an inhibitor of the COVID-19 causative virus (SARS-CoV-2) in vitro.
• A single treatment able to effect ~5000-fold reduction in virus at 48h in cell culture.
• Ivermectin is FDA-approved for parasitic infections, and therefore has a potential for repurposing.
• Ivermectin is widely available, due to its inclusion on the WHO model list of essential medicines.

Abstract
Although several clinical trials are now underway to test possible therapies, the worldwide response to the COVID-19 outbreak has been largely limited to monitoring/containment. We report here that Ivermectin, an FDA-approved anti-parasitic previously shown to have broad-spectrum anti-viral activity in vitro, is an inhibitor of the causative virus (SARS-CoV-2), with a single addition to Vero-hSLAM cells 2 hours post infection with SARS-CoV-2 able to effect ~5000-fold reduction in viral RNA at 48 h. Ivermectin therefore warrants further investigation for possible benefits in humans.
 

bleedinorange

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#39
One of the positives about this virus is the presence of a steady, consistent genome irrespective of noted mutation. This indicates any successful vaccine developed will be effective should there be a future outbreak. I've not read up on the rna/dna present (if any since some viruses have little or none). Maybe @RxCowboy can speak to that and its relevance.
 

RxCowboy

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#40
April 6

Covid-19 Update: Welcome to week 4. Here are things to watch and know.

1) Some tigers in the Bronx zoo tested positive for the disease. It would seem they caught the virus from an asymptomatic (a person not showing symptoms) zoo worker who tested positive. While we have seen that humans can pass it to animals (remember the dogs in Hong Kong?) previously the animals did not get sick - the tigers have. This is worth watching. It is still unknown if animals can spread it - so far there is no evidence that they do (meaning none have). But we now know they can catch it (we already knew this was possible) and become ill. This could have significant implications for wildlife and pets - so limit those pet snuggles if you have been exposed or get ill. I imagine veterinarians all over are now very much on the alert.

2) The government changed its recommendation on masks for the general public. This was something we expected based on the fact that you can have the virus and be spreading it before you ever feel ill, and for up to a week after you have "recovered". Wearing the masks is your way of protecting those around you from catching something you may have and not even know. There are lots and lots of DIY videos out there for ways to make a mask. The CDC shared a "design" that used a piece of cloth or bandanna that is simple to make if you don't already have a favorite. Remember, it won't really protect you from other people (it's like covering your mouth to cough - it protects those around you) so you want to continue to also use the precautions designed to protect yourself (social distancing, hand-washing, disinfecting etc.). Also, you should wash your hands immediately when removing the mask. (see prior posts on safe mask use).

3) I want to talk about hand-washing for a second. I have seen lots and lots of hand-washing videos but I have noticed two important things missing from them. (admittedly I have not watched all of them and rarely watch to the end, so some may have it) There are two key things to remember when washing your hands (other than the 20 seconds rule and using warm water and soap, washing all surfaces etc. basically in addition to what has already been covered). a) angle your hands down in the sink. As you rinse your hands your arms/hands should be angled down so the water is running from your wrists, down your hands to your fingers and then down the drain. You don't want the dirty water running up your arm. b) once your hands are clean, you don't want to use them to turn off the water. Think about it, you just touched the handle with dirty hands. If you then put your hand on the handle to turn the water off, you are recontaminating them. Use something else, your forearm, your elbow, a paper towel etc. (elbows are good because you can't accidentally touch your face with it later.) Don't use your chin - just in case you were tempted. This won't always be possible of course but do your best to avoid touching the faucet/handles after washing.

4) Scientists around the world are scrambling to find a treatment and there are some options emerging. The University of Pittsburgh School of Medicine has been testing a vaccine that is currently undergoing animal testing. The results so far are promising. The vaccine they are working on has some significant advantages (it's a nano patch - meaning you put it on like a band-aid, it is easily scalable so if it proves effective and safe they can mass produce it pretty quickly, and it is built around techniques known to be effective in SARS and smallpox. There are 35 American companies/labs working on a vaccine so why mention this one? Because it is the first one that has been peer-reviewed (meaning scientists not involved in the development reviewed their work and found it to be sound). Lest we get too excited, they are still testing in mice. It takes time to make sure the vaccine is safe and actually works. And of course, we need to know long term effects. While they are fast-tracking things as much as possible - we honestly don't want to skip over quality testing so patience is required. There is a lot happening in the way of treatment and vaccines Lots of promising stuff out there, we just have to wait for it. Developing a treatment or vaccine is not an easy task and a drug that works for one person may not work for all. This is why we have more than one option for most things. We have to also figure out the dosing - how much do we need to do the job? It won't be the same for everyone. And how much is too much? And what are the side effects? Is it safe for children? Is it safe for pregnant women? What if you have other health conditions (which many COVID patients do)? What if you are on other medications, will they interact causing issues? There is a lot to know. But progress is being made. Patients that are critical are volunteering to try some of the treatments. Progress is happening, but we can't rush it.

5)There is a new website (talktomira)that is publishing estimated peak and end dates by state. They are using a variety of modeling for their projects although I have not seen the exact methodology. This is interesting, and models are generally used to forecast outbreaks but it needs to be done by people who understand how to do it. I have not evaluated this site in-depth enough to know if they are using the correct modeling - but I do know this: forecasts are just that - a forecast. It's a guess - an educated guess but still a guess. As we have discussed in the past, there are lots of variables that will impact it - one of which is human behavior. So just keep that in mind. In reviewing my own state on the site, I think the peak date is optimistic, very optimistic. But the end date is in alignment with what I would expect. Again - just remember that in an outbreak numbers are shifting and changing constantly, so don't put too much stock in it.

FINAL THOUGHTS: We are in our 4th week of this (for most of us, CA and WA have been at it longer) and while to some degree we are establishing new routines and some things may be getting easier, others are getting harder. Focus on the positive, look for the stories of kindness, generosity, and compassion. People are doing amazing things out there - focus on those things and be part of that story.