COVID-19 updates

[LesPalenik]

So far, in Canada, the only places without any infections are the sparsely populated Northwest Territories and Nunavut.

[BJL]

I was rather reassured by today's press conference where President Trump, Dr Deborah Birx and Dr Anthony Fauci of the CDC spoke on the same stage, and from the same page. We need this sort of competent, coherent messagings to earn public trust and cooperation with some uncomfortable but hopefully short-term measures. Here is a summary of what they are urging for the next fifteen days:
https://www.whitehouse.gov/wp-content/uploads/2020/03/03.16.20_coronavirus-guidance_8.5x11_315PM.pdf

P. S. Bad gaffe in my original headline: it is "slow the spread", not "stop the spread".

[LesPalenik]

Curve Flattening explained

https://www.youtube.com/watch?v=Hks6Nq7g6P4

[pschefz]

I was rather reassured by today's press conference where President Trump, Dr Deborah Birx and Dr Anthony Fauci of the CDC spoke on the same stage, and from the same page. We need this sort of competent, coherent messagings to earn public trust and cooperation with some uncomfortable but hopefully short-term measures. Here is a summary of what they are urging for the next fifteen days:
https://www.whitehouse.gov/wp-content/uploads/2020/03/03.16.20_coronavirus-guidance_8.5x11_315PM.pdf

P. S. Bad gaffe in my original headline: it is "slow the spread", not "stop the spread".

isn't that the same guy who a few days ago said from the podium that tis will just blow over, go to work and warm weather will make it go away?
well I am glad we have coherent messaging now...that will earn public trust!

[chez]

isn't that the same guy who a few days ago said from the podium that tis will just blow over, go to work and warm weather will make it go away?
well I am glad we have coherent messaging now...that will earn public trust!

Yep...right until the tweets that contradict everything that was said...business as usual.

In a time of crisis, clear consistent messages goes a long way of reassuring the ones in charge know what they are doing.

[pschefz]

Yep...right until the tweets that contradict everything that was said...business as usual.

In a time of crisis, clear consistent messages goes a long way of reassuring the ones in charge know what they are doing.

a clear 10 out of 10....maybe even a tremendous 10

the clear and consistent messages were clear and consistent 2 weeks ago from all over the world

[armand]

My post about 'behind the counter' availability came from drug safety experts during our yearly Drug Induced Liver Injury workshops that we were coordinating with the US FDA and academic researchers.  There are some countries where it is behind the counter and your experience points that this is not universal.  Products containing pseudoephedrine were moved behind the counter here in the US because the compound is easily converted into crystal meth a la 'Breaking Bad'  One can only purchase a limited supply an in order to acquire the necessary amount to do what Walter White did, one would have to visit lots of pharmacies.

Some drugs that are OTC here in the US are not available unless by Rx in other countries.  When we were in Ireland several years ago, my wife was running low on naproxen.  I went across the street to a pharmacy in Galway and didn't see any on the shelf.  The pharmacist said it was Rx only.

The point about acetaminophen is that there are tragedies occuring all the time here in the US.  You may cavalierly believe that its safe and let's not worry.  During our DILI workshops we covered a lot of problem areas, including a mother who bought the wrong strength drops to administer to her infant.  There are case records also of patients going into liver failure from taking both pills and elixirs containing acetaminophen and in inadvertently over dosing.

This is it for me regarding this topic.

Like most other drugs things can go bad if you don’t take them as you should. There will always be people who don’t bother reading the label or talking to the pharmacist/ physician.
All said and done, when you take into account the huge number of people using it, acetaminophen has a pretty good safety profile.

[armand]

Chloroquine has a pretty bad side effect profile which is why it is not used as a Malaria prophylactic any longer.  We'll see if there is any positive clinical data.  Redesivir is a difficult molecule to synthesize at scale and as I noted is an infusion drug.  Still it could prove useful for acute cases.  There are multiple clinical trials going on in China with combinations of products.  One hopes that the data will be expeditiously published.  I presume that the same thing will be done at US teaching hospitals as case loads increase.  It would be good to test out biologicals that affect the cytokine pathways as these seem to be affected in the worst cases.

The first vaccine will go into trials at Kaiser Permanente in Seattle today according to reports.  It's one of the new gene based vaccines produced by Moderna.  We really will need good safety and potency data as quickly as possible.  There's still going to be the issue of how many people ultimately to vaccinate since the majority of patients only get mild symptoms.

I wouldn’t use it for milder cases and it’s not recommended anyway, the option was for intensive care patients. When you reach that point the side effects are not that bad in comparison, not worse than many drugs that we use.

[armand]

The hospitals are also starting to be in lock down, none to minimal visitors.
The testing in Michigan still takes appallingly long, had a test send Fri afternoon and yet to come back Mon noon.

[John Camp]

I went to our city's largest supermarket Monday night -- normal hours are from 6 a.m. to midnight -- and found that it had closed at 9 p.m. because, according to an employee who was standing outside smoking a cigarette, of the corona virus. That strikes me as exactly backwards. People have to eat, they have to go to the supermarket, so instead of restricting hours, they should extend them, to spread the crowd, rather than compress it. If you're going to have 2,000 customers a day, do you really want to squeeze them into a shorter time period, with more people in the store all at once, or spread them? Apparently, the supermarket wizards disagree with my assessment.

[armand]

Have you read none of the medical research and mathematical modeling on the benefits of flattening the curve, or are you just choosing to ignore it, perhaps deferring to some other (non-medical) authority that you trust more? Maybe you are right and the medical/epidemiology research community as a whole is wrong, but I severely doubt it.

The US has about 100,000 IC beds and 60,000 to 160,000 ventilators (depending on which ones are counted as usable [1]). Several patients can be served in rotation with one ventilator.  Data I linked to above [2] shows that it is highly likely that there will be in total far more cases needing such facilities over the next year or so: 50-fold in the case of IC cases vs IC beds.  Evidence from Italy already indicates that if handled badly leading to a short intense curve, peak demand will greatly exceed supply; and the death toll got far worse there today, so the peak is yet to come (the daily death toll is now far higher than for seasonal flu).

If for example the case load outstrips medical capacity by 10:1, potentially 90% of severe case die "avoidably" for lack of adequate treatment. spread the peak five-fold and the overload is down to 2:1, and the "avoidable" death toll during the longe, wider peak down to about 50%; spread it ten-fold, and maybe everyone who needs such care has a good chance of getting it.  And China is achieving peak reduction by large factors, as seen in sources I cite above.

Some more discussion and facts:

[1] http://www.centerforhealthsecurity.org/resources/COVID-19/200214-VentilatorAvailability-factsheet.pdf

[2] https://medium.com/@tomaspueyo/coronavirus-act-today-or-people-will-die-f4d3d9cd99ca

[3] http://www.aast.org/GeneralInformation/mechanicalventilation.aspx (which says that about half of IC cases need ventilation, and so for COVID-19 whose main threat is respiratory it is probably over 50%)

[4] https://www.businessinsider.com/coronavirus-intensive-care-unit-shortages-of-ventilators-staff-space-2020-3

[5] https://www.washingtonpost.com/health/2020/03/13/coronavirus-numbers-we-really-should-be-worried-about/

Those 100k beds are a stretched capacity, usually the numbers are much less.

I keep hearing this idea that if we get enough ventilators all is good and there are several points that I want to make.
- some people will still die regardless if you have a vent available
- 2 people per vent is more of a short term emergency, the logistics are not that simple
- and most importantly, who’s going to take care of those patients? Intubating them is not that hard and it doesn’t really fix much, they still require ICU care and as someone said “critical care nurses don’t grow on trees”. Neither do the respiratory therapists and critical care physicians. Quality ICU care is dependent on low staffing ratios and some medical personal will get sick making those numbers even smaller.

If you watch some chinese videos and the level of protection they had, because unfortunately it does seem to aerosolize quite easily with various procedures, you realize that we will have a very hard time to keep up with the required protective equipment needs.

[degrub]

As from last night, Serbia is in a state of emergency, after only 48 confirmed cases. Borders closed, schools, kindergartens, gyms, etc. closed through the rest of the year. Restaurants and bars open till 8pm. No one over 65 shall be on the streets or risk a 3-year jail sentence. Police and military would patrol the streets. I am in a self-quarantine, day 6, with some sort of the flu or even corona. Tired of sleeping all day, all night. I have no idea how they expect elderly, especially those who live alone, to remain in isolation for months.

Best of luck with whatever you caught. Hopefully, you have a runny nose 😉 as that seems to be a contra-indication for this corona virus.

[Slobodan Blagojevic]

Best of luck with whatever you caught. Hopefully, you have a runny nose 😉 as that seems to be a contra-indication for this corona virus.

Thanks, and no, it is quite dry

[Rob C]

Thanks, and no, it is quite dry

Silly question: have you been seen by a doctor about this?

Rob

[Slobodan Blagojevic]

Silly question: have you been seen by a doctor about this?...

No. The current advice is NOT to go to see anyone, but to self isolate and weather the storm. If you suspect corona, they will come to you, in special gear, to take a swab. Even if tested positive, you won't be admitted to a hospital unless you require intensive care.

[JoeKitchen]

There is over reaction and then Damn. 

Many states are implementing closure for all sit down patrons of bars and restaurants for about 15 days.  A few for three weeks, which I think is a little too long to commit to right now.  But Denver is having its bars and restaurants stay closed until May 11.  What? 

Unless there is a nation wide moratorium on commercial mortgage and rent payments, the entirety of Denver's restaurant scene will be out of business by then.  I've worked in the industry for a number of years, and unless people (and I mean young healthy people) really start dropping like flies, your looking at a full sector of Denver's economy loosing all trust in government (owners and workers) and will more then likely start operating with a big middle finger aimed at city hall. 

[Robert Roaldi]

I went to our city's largest supermarket Monday night -- normal hours are from 6 a.m. to midnight -- and found that it had closed at 9 p.m. because, according to an employee who was standing outside smoking a cigarette, of the corona virus. That strikes me as exactly backwards. People have to eat, they have to go to the supermarket, so instead of restricting hours, they should extend them, to spread the crowd, rather than compress it. If you're going to have 2,000 customers a day, do you really want to squeeze them into a shorter time period, with more people in the store all at once, or spread them? Apparently, the supermarket wizards disagree with my assessment.

This seems to be widespread. Friends in Toronto are reporting the same. I haven't noticed this in my local stores here in Ottawa yet. On the face of it, it appears to be a bizarre policy and I'd be interested to hear an explanation too.

[Rob C]

No. The current advice is NOT to go to see anyone, but to self isolate and weather the storm. If you suspect corona, they will come to you, in special gear, to take a swab. Even if tested positive, you won't be admitted to a hospital unless you require intensive care.

Some are more equal than others: military in masks and police not. Wot?

Stay warm, because my mother used to say that the cold kills the old. She made 93 or thereabouts, so perhaps she knew a thing or two. I'm not suggesting you're old, because to me you're still young. I owe that conceit to myself; it's my secret for keeping a good skin.

;-)

[Alan Goldhammer]

I went to our city's largest supermarket Monday night -- normal hours are from 6 a.m. to midnight -- and found that it had closed at 9 p.m. because, according to an employee who was standing outside smoking a cigarette, of the corona virus. That strikes me as exactly backwards. People have to eat, they have to go to the supermarket, so instead of restricting hours, they should extend them, to spread the crowd, rather than compress it. If you're going to have 2,000 customers a day, do you really want to squeeze them into a shorter time period, with more people in the store all at once, or spread them? Apparently, the supermarket wizards disagree with my assessment.

Some chains have announced closing at 9PM to restock shelves.  I went to the local Safeway this morning at 7AM.  Few people picking stuff up.  No meat or poultry at all.  Packaged fresh lettuce was all gone but most other produce was there.  I did get a pack of Hebrew National hot dogs but they didn't have hot dog buns.  Still no toilet paper (we still have some).  Just as I was leaving I saw a large semi pulling into the loading dock, presumably with stuff for re-stock.  I then went to our Whole Foods at 7:30.  Lots of people shopping and they were just unloading packaged poultry in bulk.  Meat counter did not have chopped meat but had lots of other choices so I picked up lamb chops.  No pasta at all but not a problem as I make my own.

I think with so many people furloughed from work in our area that people can spread out their shopping.  Whole Foods hours are 7am to 10pm; Safeway is open 24 hours.

[Alan Goldhammer]

A bit of good news from China.  https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3551767 discusses the impact of temperature and humidity on the transmission of COVID-19 (you can download the full paper but I'm posting the abstract).  We'll see if this holds up as the weather warms up.

Abstract:  This paper investigates how air temperature and humidity influence the transmission of COVID-19. After estimating the serial interval of COVID-19 from 105 pairs of the virus carrier and the infected, we calculate the daily effective reproductive number, R, for each of all 100 Chinese cities with more than 40 cases. Using the daily R values from January 21 to 23, 2020 as proxies of non-intervened transmission intensity, we find, under a linear regression framework for 100 Chinese cities, high temperature and high relative humidity significantly reduce the transmission of COVID-19, respectively, even after controlling for population density and GDP per capita of cities. One degree Celsius increase in temperature and one percent increase in relative humidity lower R by 0.0383 and 0.0224, respectively. This result is consistent with the fact that the high temperature and high humidity significantly reduce the transmission of influenza. It indicates that the arrival of summer and rainy season in the northern hemisphere can effectively reduce the transmission of the COVID-19.